D. N. Lobo, M. A. Memon, S. P. Allison and B. J. Rowlands (Section of Surgery and Clinical Nutrition Unit, University Hospital, Queen’s Medical Centre, Nottingham NG7 2UH, UK)
Evolution of Nutritional Support in Acute Pancreatitis
BJS June 2000 Vol. 87 (6), Pg. 695-707
Acute pancreatitis, a disease of varying severity, has been defined as an acute inflammatory process of the pancreas, with variable involvement of other regional tissues or remote organ systems. Mild disease is associated with minimal organ dysfunction and an uneventful recovery, while severe disease is associated with organ failure and local complications such as necrosis, abscess and pseudocyst formation.
Parenteral nutrition has no statistically significant benefit in mild disease, but it may be associated with an increased incidence of catheter-related sepsis if its duration is prolonged. On the other hand, it does not have a negative effect on outcome in severe disease and provides essential nutrients.
At the same time, the results of the studies claiming superiority of enteral over parenteral nutrition must be interpreted with caution, as the theoretical benefits of enteral feeding have not yet translated into improved outcome in patients with severe acute pancreatitis.
Two of the studies that included patients with mild pancreatitis show only a trend towards better outcome in patients fed enterally, while the study that included only patients with severe disease demonstrates a statistically significant reduction in total and septic complications in the enterally fed group.
What is clearly demonstrated by these trials is that enteral feeding is feasible and practical in these patients, apart from being much cheaper than parenteral feeding.
Parenteral nutrition, including fat, is well tolerated, does not stimulate pancreatic secretion and can minimize malnutrition when gastrointestinal dysfunction is prolonged. Similarly, nasojejunal or jejunostomy feeds are well tolerated and, unlike nasogastric or nasoduodenal feeding, do not stimulate the pancreas.
A diagnosis of acute pancreatitis is not, therefore, itself an indication for instituting artificial nutrition. Nevertheless, in severely affected patients who are hypercatabolic and/or unable to eat normally for more than 7-10 days, it is prudent to begin artificial nutrition either parenterally or via the jejunum, or both, in order to prevent the clinical consequences of malnutrition.
In those with acute on chronic pancreatitis and who are for this or other reasons malnourished on admission, nutritional support should be introduced as early as possible. Jejunal feeding may be preferred where practical and tolerated.
A combination of enteral and parenteral nutrition is therefore a reasonable way to meet metabolic demands in these patients; the amount of nutrients delivered parenterally can be progressively reduced as larger volumes are tolerated enterally.
TREM-1 in Sepsis
Lancet, Vol.358, September 8, 2001, Pg. 776-78
Summary: Sepsis is characterised by a dysregulated host response to microbial components, such as lipopolysaccharide (in the case of gram-negative bacteria) and peptidoglycan or extracellular toxins (from gram-positive bacteria).
Neutrophils and monocyte / macrophages exposed to lipopolysaccharide are activated and release proinflammatory cytokines, such as tumor-necrosis factor (TNF) a and interleukin – 1b. Excessive production of these cytokines is believed to contribute to the multiorgan failure that is seen in septic patients.
Until recently little was known of the mechanism that linked bacteria on the outside of the cell with transcription of genes for cytokines in the cell nucleus. Triggering receptor expressed on myeloid cells (TREM)-1 is the most recent of a series of discoveries that have begun to open this particular black box.
TREM-1 is a member of the immunoglobulin super-family and is expressed on the cell surface of neutrophils and certain subpopulations of monocytes. It triggers secretion of proinflammatory cytokines. Expression of TREM-1 is greatly upregulated in presence of extracellular bacteria such as Pseudomonas aeruginosa and Staphylococcus aureus. It amplifies host response to bacterial stimulus. When infected mice were treated with a fusion protein containing the extracellular domain of murine TREM-1 and human IgG Fc, TNF-a and interleukin-1b production was significantly reduced and mortality fell from 94% to 24%.
This protection was still effective when started up to 4 h after infection. TREM-1 is thus a mechanism by which innate immunity responds to the presence of bacterial components.
Some of these pathways represent potential therapeutic targets. Molecules such as E5531 that appear to interfere with lipopolysaccharide binding are already in clinical development, and blocking TREM-1 deserves further study because it seems to be active even after bacterial challenge.
A better understanding of the processes that cause bacteria to activate cells may shed light on why patients respond so differently to what seems to be the same insult.
Stephen J. Lewis, Matthias Egger, et al
Early Enteral Feeding Versus Nil By Mouth After Gastrointestinal Surgery: Systematic Review and Meta-analysis of Controlled Trials
BMJ, Vol.323 (7316), October 6, 2001, Pg. 773-776
Summary : The objective was to determine whether a period of starvation (nil by mouth) after gastrointestinal surgery is beneficial in terms of specific outcome. The design of the study consisted of systematic review and meta-analysis of randomized controlled trials comparing any type of enteral feeding started within 24 hours after surgery with nil by mouth management in elective gastrointestinal surgery. Three electronic databases were searched and details of other trials (unpublished) were also requested.
The main measures of outcome were anastomotic dehiscence, infection of any type, wound infection, pneumonia, intra-abdominal abscess, length of hospital stay and mortality.
The conclusions were that there seems to be no clear advantage to keeping patients nil by mouth after elective gastrointestinal resection. Early feeding may be of benefit. An adequately powered trial is required to confirm or refute the benefits seen in small trials.
Editorial – DBA Silk and N. Menzies Gow
Postoperative Starvation After Gastrointestinal Surgery
BMJ, Vol.323 (7316), October 6, 2001, Pg. 761-762
Summary : Nil by mouth after gastrointestinal surgery may not be beneficial. The apparently beneficial effects of early postoperative feeding on infection rates and length of stay in hospital are compelling arguments in favour of change in clinical practice.
Indeed, one study has found that supplementing normal oral diet in hospital wards with as little as 300 kcal and 12 g of protein per day resulted in reduction of postoperative complications in patients undergoing gastrointestinal surgery. In the 2 studies, in which patients underwent major upper gastrointestinal surgery, early postoperative enteral nutrition either afforded no advantage over standard care or seemed to have deleterious effect.
One explanation of these results might be that the surgical injury is less and the metabolic response to it relatively modest in patients undergoing lower gastrointestinal surgery, compared with patients undergoing major upper gastrointestinal injury. Only in patients undergoing lower gastrointestinal surgery does enteral nutrition in the early postoperative period have an important impact.
R. Saadia and E. Degiannis (Departments of Surgery, University of Manitoba and Health Sciences Centre, et al)
Non-operative Treatment of Abdominal Gunshot Injuries
BJS April 2000 Vol. 87 (4), Pg. 393-397
The authors have retrospectively studied all published relevant clinical reports by searching through the Medline database and manually. The theoretical arguments in favour of non-operative management as well as the results of the reviewed reports are analysed and evaluated.
Mandatory laparotomy has traditionally been advocated for gun shot wounds of the abdomen. The 1960s marked a turning point in favour of the policy of the selective conservation for the abdominal gun shot wounds.
This approach appears to be a logical development of a conservative trend in the treatment of all abdominal trauma. It is suggested that conservative treatment can be offered at least for an initial observation period to patients who have no signs of peritoneal irritation or blood loss.
This policy has succeeded in lowering the rate of therapeutic laparotomy as also being a safe method of treatment. With the advent of diagnostic peritoneal lavage and radiological imaging this method has now become widely accepted.
Patients with non penetrating injuries can be offered non operative treatment with a satisfactory outcome. Greater caution should be exercised in the presence of a visceral injury until the safety of this option has been established by further clinical trials.
V. Speirs and M. J. Kerin (Medical Research Laboratory and Academic Surgical Unit, University of Hull, Hull, UK)
Prognostic Significance of Oestrogen Receptor b in Breast Cancer
BJS April 2000 Vol. 87 (4), Pg. 405-409
This study evaluates the significance of ERb (oestrogen receptor b) in breast cancer management. An up-to-date review of the current literature concerning the role and the possible implications of ERb in human breast cancer was undertaken.
Human breast tumours express wild-type and variant ERb. Expression of ERb correlates with accepted prognostic indications including lymph node status and tumour grade. Furthermore levels of ERb messenger RNA alter during carcinogenesis and are upregulated in breast tumours that develop antioestrogen resistance.
ERb clearly has prognostic implications in the management of breast cancer. The presence of ERb in breast tumours helps to explain the differential tissue and gene specific effects that have been observed with oestrogens and antioestrogens. The possible alteration in the balance of expression of ER subtypes during tumour evolution may influence the action of antioestrogens as antagonists or agonists particularly in view of opposing downstream effects mediated by ligand bound receptor signaling via the classical ERE and from API.
In the future this feature may be exploited as a tool for the development of selective oestrogen-responsive modulations to target tumours with a particular ER phenotype.
K. S. Ho, K. W. Eu, et al (Departments of Colorectal Surgery and Anaesthesia, Singapore General Hospital, Singapore)
Randomized Clinical Trial of Haemorrhoidectomy Under a Mixture of Local Anaesthesia Versus General Anaesthesia
BJS April 2000 Vol. 87 (4), Pg. 410-413
A randomized clinical trial of 53 consecutive elective haemorrhoidectomies was carried out. One group was operated under general anaesthesia, while the second group had topical anaesthetic cream applied followed by local anaesthetic infiltration for surgical anaesthesia.
There was no difference between the two groups in terms of operating time, postoperative pain, nausea or vomiting pain free postoperative period, analgesic requirements or patient satisfaction with the method of anaesthesia. Postoperative oxygen saturation and pulse rates were similar in the two groups.
Topical and local anaesthesia can be used as effectively as general anaesthesia for haemorrhoidectomy.
K. S. Mainprize, S. W. T Gould, et al (Department of General Surgery, Wexham Park Hospital, et al)
Surgical Management of Polypoid Lesions of the Gallbladder
BJS April 2000 Vol. 87 (4), Pg. 414-417
The demographic, radiological and pathological data of 38 patients with ultrasonographically detected polypoid lesions of the gall bladder (PLG) have been reviewed. A Medline search for such lesions was performed and a review of literature is presented.
34 patients underwent cholecystectomy but 4 were advised against or declined surgery. Of those operated upon 11 had macroscopic and microscopically proven PLGs. Of these 7 had cholesterol polyps, 2 had adenomas one had a carcinoid tumour and one had an adenocarcinoma of the gall bladder.
One had a histopathologically normal gall bladder. The remainder had chronic cholecystitis with or without gallstones. All the neoplastic lesions had solitary polyps greater than 1.0 cm diameter.
The authors suggest that in patients with ultrasonographically detected PLG surgery should be advocated if they are symptomatic or if the PLG is 1.0 cm or more in diameter.
S. Kondo, Y. Nimura, et al (First Department of Surgrey, Nagoya University School of Medicine, Nagoya, Japan)
Regional and Para-aortic Lymphadenectomy in Radical Surgery for Advanced Gallbladder Carcinoma
BJS April 2000 Vol. 87 (4), Pg. 418-422
This study aims to elucidate the nodal status, its prognostic influence and the efficacy of lymphadenectomy. It is a retrospective study of 60 cases, which underwent radical resection and routine regional and para-aortic lymphadenectomy for gallbladder carcinoma.
73% were node positive and 38% had positive para-aortic nodes. The postoperative survival was extremely poor in the presence of minimal metastases and in para-aortic disease. In cases with only regional nodes positive, the survival was much better, as also in cases with no metastases.
It is concluded that regional and para-aortic lymphadenectomy provides no survival benefits in patients with para-aortic disease or with distant metastases. It potentially may improve survival in selected patients with regional node involvement. A sampling biopsy of the para-aortic nodes is recommended before starting radical surgery.
S. Takano, Y. Ito, et al (Third Department of Surgery, Nihon University School of Medicine, Tokyo, Japan)
Pancreaticojejunostomy Versus Pancreaticogastrostomy in Reconstruction Following Pacreaticoduodenectomy
BJS April 2000 Vol. 87 (4), Pg. 423-427
Different methods of reconstruction after pancreaticoduodenectomy have been used – PJ (pancreaticojejunostomy) (n=69) in one hospital and pancreaticogastrostomy (n=73) (PG) in another hospital.
The operations were performed by the same team in each hospital. The anastomoses were done in 2 layers with pancreatic duct stents.
Pancreatic fistula was identified by the presence of more than 1000 units/L of amylase rich fluid in the drains. 7 days or more postoperatively, by radiography from the pancreatic duct stent and by water-soluble contrast upper gastrointestinal studies.
The 2 groups were similar in terms of age, sex, preoperative assessment, disease status, operative time, intraoperative blood loss and nature of non- tumorous pancreatic tissue.
The ascitic amylase, 7 days after surgery was significantly lower after PG than PJ. The PG group had no pancreatic fistula but 13% had a fistula in the PG group.
Intra-abdominal abscess and haemorrhage was 3% (PG) and 4% (PJ) with 2 hospital deaths 3% in the PJ group. This supports the hypothesis that PG is safer than PJ.
M. Falconi, A. Valerio, et al (Department of Surgery, Pancreatic Unit and Endoscopy Service, Verona University, Verona, Italy)
Changes in Pancreatic Resection for Chronic Pancreatitis Over 28 Years in a Single Institution
BJS April 2000 Vol. 87 (4), Pg. 428-433
This study includes 547 patients who underwent surgery for chronic pancreatitis (1971-1998). In 80% of cases only anastomoses were performed and in 20% of cases resections had to be done. The indications, mortality and morbidity with the type of operative procedure and their long-term follow-up have been analysed.
In the second 14 year period there was a significant reduction in the percentage of resections compared with anastomoses (28% vs 13%) and a significant change in the type of resection with a substantial increase in the resections of the head with those of the body and tail.
Statistically significant reductions occurred in operating times, number of units of blood transfused and mean hospital stay. The mortality and morbidity rates also tended to decrease though not significantly.
The improvements in the ability to diagnose more accurately the extent of the disease has resulted in the reduction in the number of pancreatic resections. Resection has proved effective in relieving pain associated with pancreatitis.
E. Lemaire, P. Ruszniewski, et al (Medico-Surgical Federation of Hepato-Gastroenterology, Beaujon Hospital, Clichy, France)
Functional and Morphological Changes in the Pancreatic Remnant Following Pancreaticoduodenectomy with Pancreaticogastric Anastomosis
BJS April 2000 Vol. 87 (4), Pg. 434-438
Nineteen patients who underwent pancreaticoduodenectomy and pancreaticogastrostomy for pancreatic tumours (benign or malignant) with a histologically normal pancreatic resection margin were studied. The median interval between the surgery and evaluation was 32 months (12-120 months).
The following tests were performed: 72 hour faecal fact concentration and faecal-1 elastase (for exocrine function); fasting blood glucose, haemoglobin A1c, serum peptide C and insulin levels (endocrine function); pancreatic parenchymal thickness and pancreatic duct diameter using CT scan.
Faecal fat excretion was raised in 16 out of 17 patients and faecal 1 elastase was reduced in all 17 patients.
None of the patients developed diabetes at follow-up. There was a significant decrease in pancreatic thickness and a dilatation of the pancreatic duct on CT scan. Pancreatic atrophy developed over time but at the limit of statistical significance.
Pancreatic exocrine function decreased but endocrine function remained unaltered.
N. P. Woodcock, J. MacFie, et al (Department of Surgery, Scarborough Hospital, Woodlands Drive, Scarborough, UK)
Bacterial Translocation in Patients Undergoing Abdominal Aortic Aneurysm Repair
BJS April 2000 Vol. 87 (4), Pg. 439-442
This is a prospective study in which patients undergoing surgery for abdominal aorta aneurysm (AAA) were assessed for evidence of bacterial translocation by culture of a mesenteric lymph node (MLN), small bowel serosal exudate and thrombus within the aneurysm. All septic complications were recorded.
51 patients (40 male, 11 female; median age 72 years) were studied. Enteric bacteria were isolated from MLN of 5 patients (10%), one of whom also yielded growth from the serosal exudate. Septic morbidity occurred in four of these patients, compared with 9 of 46 patients without evidence of translocation.
One patient who showed Escherichia coli in the MLN developed an aortoenteric fistula, with a coliform species isolated from the graft.
A. J. Lloyd, J. Boyle, et al (Oxford Center for Health Care Research and Development, Oxford Brookes University, Oxford and Department of Surgery, Leicester University, Leicester, UK)
Comparison of Cognitive Function and Quality of Life After Endovascular or Conventional Aortic Aneurysm Repair
BJS April 2000 Vol. 87 (4), Pg. 443-447
82 patients undergoing aortic aneurysm repair (34 endovascular and 48 conventional procedures) were assessed before and after 6 months for cognitive function and quality of life (by psychometric tests and the Medical Outcomes Short Form 36 (SF-36) questionnaire).
Data at 6 months was available in 78% of patients. As a group, the patients showed a significant decline on one cognitive function test (visual search) and on two domains of the SF-36 (physical function and vitality) when they were reassessed. There were no significant differences for the two procedures.
B. Kavuklu, M. O. Guc, et al (Department of General Surgery and Pharmacology, Faculty of Medicine, Hacettepe University, Turkey)
Aminoguanidine Attenuates Endotoxin-induced Mesenteric Vascular Hyporeactivity
BJS April 2000 Vol. 87 (4), Pg. 448-453
Twenty Sprague-Dawley rats (180-230 gm) were divided into 4 groups and were administered either Escherichia coli endotoxin (1 mg/kg intraperitoneally) or its solvent saline and were pretreated with aminoguanidine (15 mg/kg intraperitoneally 20 minutes before and 2 hours after endotoxin injection or saline).
4 hours after endotoxin injection, the animals were anaesthetized, their blood pressure and mesenteric blood flow were measured and the resistance in the mesenteric vascular beds was then calculated. The effect of phenylephrine (1-30 mg/kg I.V.) on these parameters was also investigated.
The endotoxin did not alter the blood pressure, but decreased mesenteric blood flow by increasing the vascular resistance. Aminoguanidine alone had no effect on either the blood pressure or mesenteric blood flow (it completely blocked the effects of endotoxin).
On the other hand, endotoxin significantly attenuated the responsiveness to phenylephrine which was restored by aminoguanidine.
M. Luther, I. Kantonen, et al for the ‘FINNVASC Study Group
Arterial Intervention and Reduction an Amputation for Chronic Critical Leg Ischaemia
BJS April 2000 Vol. 87 (4), Pg. 454-458
Untreated chronic critical leg ischaemia (CLI) usually leads to gangrene and amputation or death. Endovascular intervention may improve arterial flow and prevent amputation.
A nationwide survey of the incidence of major amputations and reconstructions for CLI was undertaken in Finland.
The overall amputation incidence was 216 per million inhabitants per year. The corresponding incidence of arterial reconstructions was 203 per million per year. There were large variations in the incidence of amputations and reconstructions; 20-fold differences in infrapopliteal surgical reconstructions and 30-fold differences in endovascular procedures were found.
There was a correlation between a high incidence of infrapopliteal surgical reconstructions and a low incidence of amputations. This correlation was found for below-knee amputations only.
The authors feel that long surgical reconstructions, which improve peripheral blood flow directly to the ischaemic area can improve leg salvage.
T. Komiyama, H. Shigematsu, et al (Division of Vascular Surgery, Department of Surgery, University of Tokyo, Tokyo, Japan)
Near-Infrared Spectroscopy Grades the Severity of Intermittent Claudication in Diabetes More Accurately than Ankle Pressure Measurement
BJS April 2000 Vol. 87 (4), Pg. 459-466
208 symptomatic legs in 153 patients who complained of calf intermittent claudication (IC) due to atherosclerotic disease were studied with near-infrared spectroscopy (NIRS) and resting ankle:brachial pressure index (ABPI).
Three distinct types of IC were detected by NIRS. ABPI was significantly different between these 3 types in non-diabetics, but could not grade the severity of IC in diabetics.
Recovery time (RT) of muscle oxygenation differentiated more accurately between severe and moderate claudication than ABPI in diabetics, although in non-diabetics this difference was not evident.
Measurement of muscle oxygenation during exercise by NIRS graded the severity of IC in diabetics more accurately than resting ABPI.
A. A. van der Krabben, H. van Goor, et al (Department of Surgery, University Hospital, St. Radboud, Nijmegen and Comprehensive Cancer Centre, North Groningen, The Netherlands)
Morbidity and Mortality of Inadvertent Enterotomy During Adhesiotomy
BJS April 2000 Vol. 87 (4), Pg. 467-471
This is a retrospective study of 270 reoperations for inadvertent enterotomy. The risk factors, postoperative morbidity and mortality are assessed.
Inadvertent enterotomy occurred in 52 (19%) of these cases. Dividing adhesions in the lower abdomen and pelvis, in particular, caused bowel injury. In univariate analysis, body mass index was significantly higher in patients with inadvertent enterotomy than in those without enterotomy.
Age and 3 or more previous laparotomies appeared to be independent parameters predicting inadvertent enterotomy. Patients with inadvertent enterotomy had significantly more postoperative complications and urgent relaparotomies, a higher rate of admission to the ICU and parenteral nutrition usage, and a longer postoperative hospital stay.
L. Jansen, O. E. Nieweg, et al (Departments of Surgery, Pathology and Nuclear Medicine, The Netherlands Cancer Institute, The Netherlands)
Reliability of Sentinel Lymph Node Biopsy for Staging Melanoma
BJS April 2000 Vol. 87 (4), Pg. 484-489
This study evaluates the reliability of sentinel lymph node biopsy for staging melanoma. 200 patients with a cutaneous melanoma of at least 1.0 mm Breslow thickness, without palpable regional lymph nodes, were included in this study.
One day after lymphoscintigraphy, a sentinel lymph node biopsy was performed, guided by a g probe and patent blue dye. Lymph node dissection was performed only if metastasis was found in a sentinel lymph node. The median follow-up was 32 months.
The sentinel node was removed in 199 of the 200 patients (mean 2.2 nodes per patient). 48 patients (24%) had sentinel lymph node metastasis. 15 patients developed recurrence after removal of a tumour-negative sentinel node; six relapsed in the previously mapped basin (false-negative rate 11%).
The overall survival at 3 years was 93% if the sentinel node was negative and 67% if the node was positive. Sentinel node status and Breslow thickness were strong predictors of recurrence and survival.
H. J. Stein, M. Feith, et al (Chirurgische Klinik und Poliklinik, and the Institut fur Pathologie und Pathologische Anatomie, et al)
Limited Resection for Early Adenocarcinoma in Barrett’s Esophagus
Annals of Surgery December 2000 Vol. 232 (6), Pg. 733-742
Radical esophagectomy with systematic lymphadenectomy is widely advocated as the treatment of choice in patients with early adenocarcinoma of the distal esophagus. This is associated with substantial complications and long-term side effects. The authors evaluate the feasibility and outcomes of a limited surgical approach.
71 patients with pT1 adenocarcinoma of the distal esophagus underwent transmediastinal or transthoracic esophagectomy with two-field lymphadenectomy. 24 patients with uT1N0 tumors underwent a limited resection of the distal esophagus and esophagogastric junction, regional lymphadenectomy, and reconstruction by jejunal (iso peristaltic pedicled) interposition.
The two groups were compared for extent and multicentricity of the primary tumor, associated high-grade dysplasia, pattern of lymphatic node metastases, complications, deaths, and outcomes. 60.6% had multicentricity of the primary tumour or associated high-grade dysplasia.
A complete resection was possible in all cases irrespective of the surgical approach. Patients undergoing limited resection had fewer complications. pT1a tumors (38 patients) showed no lymph node metastases or micro metastases while 17.9% of 56 pT1b patients showed metastases.
Distal lymph node metastases occurred only if 3 or more regional nodes were positive. Lymph node metastases were prognostic but the stage or surgical approach was not. The mean Gastrointestinal Quality of Life Index did not differ in the two groups.
Limited surgical resection with regional lymphadenectomy with jejunal interposition is an attractive surgical alternative to radical esophagectomy.
T. Lerut, P. Flamen, et al (Departments of Thoracic Surgery, Nuclear Medicine, Pathology, Internal Medicine, and Radiology, University Hospital Gasthuisberg, Leuven, Belgium)
Histopathologic Validation of Lymph Node Staging with FDG-PET Scan in Cancer of the Esophagus And Gastroesophageal Junction – A Prospective Study Based on Primary Surgery with Extensive Lymphadenectomy
Annals of Surgery December 2000 Vol. 232 (6), Pg. 743-752
This article evaluates the value of positron emission tomography with “fluorodeoxyglucose” (FDG-PET) for preoperative lymph node staging of patients with primary cancer of the esophagus and esophagogastric junction.
42 patients were evaluated. All underwent attenuation-corrected FDG-PET imaging of the neck, thorax, and upper abdomen. A spiral computed tomography (CT) scan and an endoscopic ultrasound.
The gold standard consisted exclusively of the histology of sampled nodes obtained by extensive two-field or three-field lymphadenectomies (n=39) or from guided biopsies of suspicious distant nodes indicated by imaging (n=3).
FDG-PET scan had lower accuracy for the diagnosis of locoregional nodes than combined tomography and endoscopic ultrasound (48% vs. 69%) because of a significant lack of sensitivity (22% vs. 83%). The accuracy for distant nodal metastasis was significantly higher for FDG-PET than the combined use of CT and endosonography (86% vs. 62%).
Sensitivity was not significantly different, but specificity was greater (90% vs. 69%). FDG-PET scanning improves the clinical staging of lymph node involvement based on detection of distant nodal metastases and on the superior specificity compared with conventional imaging modalities.
D. Cherqui, E. Husson, et al (The Departments of General and Digestive Surgery and Anesthesiology, Hopital Henri Mondor-Universite Paris XII, Creteil, France)
Laparoscopic Liver Resections: A Feasibility Study in 30 Patients
Annals of Surgery December 2000 Vol. 232 (6), Pg. 753-762
This article assesses the safety and feasibility of laparoscopic liver resections. The following criteria were followed.
A preoperative diagnosis was made – benign lesions, hepatocellular carcinoma with compensated cirrhosis, and metastasis of noncolorectal origin. The hepatic involvement had to be limited and located in the left or peripheral right segments (segments 2-6) and the tumor size had to be 5 cm or smaller.
The technique included CO2 pneumoperitoneum. The resection was done with a harmonic scalpel with or without portal triad clamping or hepatic vein control. Portal pedicles and large hepatic veins were stapled.
The resected specimen was placed in a bag and removed through a separate incision, without fragmentation. There were 18 benign lesions and 12 malignancies, including 8 hepatocellular carcinomas.
The resection included 1 left hepatectomy, 8 bisegmentectomies (2 and 3), 9 segmentectomies and 11 atypical resections. Mean blood loss was 300 cc. Mean surgical time 214 minutes. There were no deaths, but there were 2 conversions to laparotomy.
20% had complications. Only one cirrhotic developed postoperative ascites. Laparoscopic hepatic resections are feasible and safe in selected patients.
S. M. Beard, M. Holmes, et al (The School of Health and Related Research, The Department of Public Health, Sheffield Health Authority, et al)
Hepatic Resection for Colorectal Liver Metastases: A Cost-Effectiveness Analysis
Annals of Surgery December 2000 Vol. 232 (6), Pg. 763-776
The cost effectiveness of resection is important from the perspective of managed care in the United States and for the commissioning of health services in the United Kingdom.
A simple decision-based model was developed to evaluate the marginal costs and health benefits of hepatic resection. The results of 100 hepatic resections were used for the cost calculation. Survival data from published series were compiled to estimate the incremental cost per life-year gained (LYG) because of the short period of follow-up.
Hepatic resection for colorectal metastases provides an estimated marginal benefit of 1.6 life-years (undiscounted) at a marginal cost of £6,742. If 17% of patients have only palliative resections, the overall cost per LYG is approximately £5,236 (£5,985 with discounted benefits). If potential benefits are extended to include 20-year survival rates, these figures fall to approximately £1,821 (£2,793 with discounted benefits).
Further univariate sensitivity of analysis of key model parameters showed the cost per LYG to be consistently less than £15,000.
The authors conclude that hepatic resections for colorectal metastases is highly cost-effective as compared to non surgical treatment.
R. Adam, A. Laurent, et al (The Centre Hepato-Biliaire, Hopital Paul Brousse, Villejuif, and Universite Paris-Sud, France)
Two-Stage Hepatectomy: A Planned Strategy to treat Irresectable Liver Tumors
Annals of Surgery December 2000 Vol. 232 (6), Pg. 777-785
The authors assess the feasibility risks and patient outcomes in the treatment of colorectal metastases with two-stage hepatectomy.
Multiple colorectal hepatic metastases are not amenable to a hepatectomy (single) even if downstaged by chemotherapy, portal embolization, or combined with a locally destructive technique. In such cases a two-stage hepatectomy, might offer a chance of long term remission.
Of 308 cases of irresectable hepatic metastases from colorectal carcinoma, 16 cases became eligible for curative two stage hepatectomy combined with chemotherapy and adjuvant non surgical interventions as indicated.
Out of the selected cases, 13 cases were found to be feasible for two-stage hepatectomy. There were no surgical deaths. There were no deaths after the first procedure but 15% died after the second procedure. The postoperative complication rates were 31% and 45% respectively.
The 3 year survival rate was 35% with 4 patients (31%) being disease free at 7, 22, 36 and 54 months. Median survival was 31 months from the second procedure and 44 months from the diagnosis of metastases.
Two-stage hepatectomy combined with chemotherapy has good results. It increases the proportion of patients with resectable metastasis.
D. J. Gouma, R. C. I. van Geenen, et al (The Departments of Surgery and Clinical Epidemiology, Academic Medical Center, Amsterdam, The Netherlands)
Rates of Complications and Death After Pancreaticoduodenectomy: Risk Factors and the Impact of Hospital Volume
Annals of Surgery December 2000 Vol. 232 (6), Pg. 786-795
This study was performed in two-phases. In phase A, 300 consecutive patients undergoing pancreaticoduodenectomy in a single institution were divided into two equal halves.
The overall complications, deaths, hospital stay and risk factors were analyzed in the two periods (two halves) and compared with a historical reference group.
In phase B, the Netherlands Medical Registry data on age and postoperative deaths of patients who underwent pancreaticoduodenectomy from 1994-1998 were analyzed for the influence of hospital volume on death.
Between the two time periods (two halves) the death rate decreased from 4.9% to 0.7%. The complication rate decreased from 60% to 41%. The mean hospital stay decreased from 24 to 15 days. The death rate was not related to age or to the surgeon performing the operation.
Serum creatinine levels, need for blood transfusion and operative time were independent risk factors. The mortality rate for pancreaticoduodenectomy in the Netherlands dropped from 12.6% to 10.1% (1994 to 1998). It was greater in patients over 65 years of age. 40% of procedures were performed in hospitals performing less than five resections per year.
The death rate in these hospitals was greater than in those hospitals performing more than 25 resections per year. Pancreaticoduodenectomy should be performed in centers with sufficient experience and resources for support.
H. J. Bonjer, V. Sorm, et al (The Departments of Surgery and Internal Medicine, University Hospital Dijkzigt, and the Department of Public Health, Erasmus University, Rotterdam, The Netherlands)
Endoscopic Retroperitoneal Adrenalectomy: Lessons Learned From 111 Consecutive Cases
Annals of Surgery December 2000 Vol. 232 (6), Pg. 796-803
Minimally invasive adrenalectomy has become the procedure of choice for benign adrenal pathology. The transperitoneal route is preferred for laparoscopy.
This article presents the clinical characteristics and outcomes of 111 Endoscopic Retroperitoneal Adrenalectomies (ERA). 95 patients underwent 111 ERA (79 unilateral and 16 bilateral). The indications were Cushing’s syndrome (n=22), Cushing’s disease (n=8), ectopic adrenocorticotrophic hormone syndrome (n=6), Conn’s adenoma (n=25), pheochromocytoma (n=19), incidentaloma (n=11), and other (n=4).
Tumor size varied from 0.1 cm – 8 cm. Median age was 50 years. Unilateral ERA took 114 men with a mean blood loss of 65 ml. Bilateral ERA lasted 214 minutes with a median blood loss of 121 ml.
The conversion rate to open surgery was 4.5%. The complication rate was 11%. The median hospital stay (postoperative) was 2 days for ERA and 5 days for bilateral ERA. The death rate was 0.9%. At a median follow-up of 14 months the recurrence rate of disease was 0.9%.
ERA is recommended for benign adrenal tumor.
J. A. B. van der Hoeven, G. J. T. Horst, et al (The Departments of Surgery, Biological Psychiatry, and Clinical Immunology, Groningen University Hospital, Groningen, The Netherlands)
Effects of Brain Death and Hemodynamic Status on Function and Immunologic Activation of the Potential Donor Liver in the Rat
Annals of Surgery December 2000 Vol. 232 (6), Pg. 804-813
This article assesses the effect on the function and immunologic status of potential donor livers of the duration of brain death with presence and absence of hemodynamic instability in the donor.
Brain death was induced in Wistar rats. Short or long periods of brain death in the presence or absence of hemodynamic instability were applied. Sham- operated rats served as controls.
Organ function was studied by monitoring standard serum parameters. The inflammatory status of the liver was assessed by determining the early gene products, the expression of cell adhesion molecules, and the influx of leukocytes in the liver.
Progressive organ dysfunction was most pronounced in hemodynamically unstable brain-dead donors. Irrespective of hemodynamic status, a progressive inflammatory activation could be observed in brain-dead rats compared to controls.
The changes observed may predispose the graft to additional damage from ischemia and reperfusion in the transplant procedure.
W. K. de Roos, J. H. W. de Wilt, et al (The Department of Surgical Oncology, University Hospital Rotterdam/Daniel den Hoed Cancer Center, Rotterdam, and IntroGene B. V., Leiden, The Netherlands)
Isolated Limb Perfusion for Local Gene Delivery
Efficient and Targeted Adenovirus-Mediated Gene Transfer Into Soft Tissue Sarcomas
Annals of Surgery December 2000 Vol. 232 (6), Pg. 814-821
This article evaluates the potential of isolated limb perfusion (ILP) for efficient and tumor-specific adenovirus-mediated gene transfer in sarcoma-bearing rats.
A major concern in adenovirus-mediated gene therapy in cancer is the transfer of genes to organs other than the tumor, especially organs with a rapid cell turnover. Adjustment of the vector delivery route might be an option creating tumor specificity in the therapeutic gene expression.
Rat limb sarcomas (5-10 mm) were transfected with recombinant adenoviruses. Intratumoral luciferase expression after ILP was compared with systemic administration, regional infusion, or intratumoral injection using a similar dose of adenoviruses carrying the luciferase marker gene.
Localization studies using lacZ as a marker gene were performed to evaluate the intratumoral distribution of transfected cells after both ILP and intratumoral injection.
Intratumoral luciferase activity after ILP or intratumoral administration was significantly higher compared with regional infusion or systemic administration. After ILP, luciferase gene expression was minimal in extratumoral organs, whether outside or inside the isolated circuit.
Localization studies demonstrated that transfection was confined to tumor cells lying along the needle track after intratumoral injection, whereas after ILP, lacZ expression was found in viable tumor cells and in the tumor- associated vasculature.
The ILP technique is a good method for the delivery of recombinant adenoviruses carrying therapeutic gene constructs to enhance tumor control.
Toni Lerut (The Department of Thoracic Surgery, U.Z. Gasthuisberg, Katholieke Universiteit, Leuven, Belgium)
The Surgeon as a Prognostic Factor
Annals of Surgery December 2000 Vol. 232 (6), Pg. 729-732
According to the author the choice of this title ‘The Surgeon as a Prognostic Factor’ is based on the rapidly emerging literature on case volume and outcome per surgeon and on the differences between surgeons in postoperative mortality, morbidity and survival.
The notion that a surgeon is an important variable that can influence patient outcome is receiving increasing attention in the mass media. The lack of surgical interest in the use of randomized clinical trials has led to criticism, particularly in the case of surgeons using new modes of surgical therapy without any proof of long-term efficiency or safety.
An analysis of new high quality journals (175 articles describing results of original research) showed only 7% reported data derived from randomized trials.
In the field of surgical practice, much attention has been paid to the relation between case volume and outcome. Several studies report a clear impact of volume on mortality after esophageal resection. Many similar studies dealing with other pathologies have also been published.
This would mean that those hospitals, which have small case volume, should discontinue performing complex surgical procedures and refer such cases to centers of excellence. Although this seems right in principle, it may be difficult to put it into practice.
Most surgeons, who are involved in high volume practice, had at an earlier date started out with low volume practice. Moreover there is sufficient evidence in literature to indicate that equally good results can be obtained in smaller hospitals. The National Health Service Center for Reviews and Dissemination at York University has said, “it would be incautious to argue for the existence of a clear cut positive volume-outcome relationship”.
Obviously surgical skills and quality are not related only to volume but also to specific training and interest in a particular pathology. Specialist training must, eventually reduce or prevent extreme variation in surgical outcomes.
What then are the options? Centralization is one certainly. Another option is professional networking between surgeons. This may provide an attractive way to improve quality and outcome.
Bellantone R, Lombardi CP, Raffaelli M, et al (Universita Cattolica del Sacro Cuore, Rome)
Minimally Invasive, Totally Gasless Video-Assisted Thyroid Lobectomy
Am J Surg 177: 342-343, 1999
An original technique for minimally invasive, totally gasless, video-assisted thyroid lobectomy has been described.
A 9-mm solid hyperechoic solid nodule of the inferior pole of the thyroid was removed by this technique.
The technique has been described. The procedure was easily and safely performed and should be considered an alternative to other minimally invasive methods.
Meurisse M, Hamoir EM, Defechereux T, et al (Univ of Liege, Belgium)
Bilateral Neck Exploration Under Hypnosedation : A New Standard of Care in Primary Hyperparathyroidsm?
Ann Surg 229: 401-408, 1999
The conventional “four gland exploration” requires general anesthesia with its risks. Image guided unilateral techniques expose the patients to the risk of missing multiple adenomas or asymmetric hyperplasia.
The efficacy of local anesthesia and hypnosedation has been assessed in patients undergoing bilateral neck exploration for primary hyperparathyroidism. Of 121 patients of hyperparathyroidism, 31 agreed to undertake local anesthesia and hypnosedation.
A hypnotic state was induced in 10 minutes and were given local anesthesia and minimal intravenous sedation. No patients required conversion to general anesthesia. The mean operating time was less than one hour. All four glands could be identified in 84% of cases, 3 glands in 9.7%.
Adenomas (6 of which were ectopic) were detected in 26 cases. 5 cases had hyperplasia requiring subtotal parathyroidectomy and thymectomy (undetected by localization studies). 4 patients underwent concomitant thyroid lobectomies.
The patient comfort recovery and surgical technique was excellent. The mean hospital stay was 1.5 days.
Harman CR, Grant CS, Hay ID, et al (Mayo Clinic, Rochester, Minn)
Indications, Technique, and Efficacy of Alcohol Injection of Enlarged Parathyroid Glands in Patients With Primary Hyperparathyroidism
Surgery 124: 1011-1020, 1998
Patients with hyperparathyroidism (HPT) who are unsuitable for surgery can be treated with percutaneous alcohol ablation of the parathyroid (PAAP). The indications, results, and morbidity of this procedure are evaluated.
PAAP was performed on 36 patients (12 men) aged 20 to 93 years with primary HPT. The indications were co-existing medical morbidity, unsuitable for surgery, surgery declined or partial ablation of the remaining gland.
The follow-up was for a median of 16 months, 12 (33%) remained eucalcemic. Of 29 patients with complete ablation there were 4 failures, 4 partial responses, 11 initial cures and final failures and 10 (34%) cures. In the partial ablation group, 2 were cured and the remaining five had adequately controlled calcium levels. 2 patients in the partial ablation group required multiple treatments.
PAAP is an effective technique for HPT cases, not suitable for surgery. Calcium levels must be followed closely. Multiple treatments may be required.
Stracke S, Jehle PM, Sturm D, et al (Univ of Ulm, Germany)
Clinical Course After Total Parathyroidectomy Without Autotransplantation in Patients With End-Stage Renal Failure
Am J Kidney Dis 33: 304-311, 1999
Patients with chronic renal failure and severe osteitis fibrosa require subtotal parathyroidectomy (PTX), total PTX with autotransplantation of parathyroid tissue, or PTX (total).
Total PTX may be curative, but patients may require long-term calcium and vitamin D supplements. Bone metabolism and calcium homeostasis with vitamin D analogues and calcium were prospectively assessed.
20 patients (23-74 years) underwent total PTX. The median time from dialysis to PTX was 6.5 years. Biochemistry and parathyroid hormone (PTH) levels were studied for a period of 20 months. All patients received vitamin D supplements after surgery.
There was complete relief of bone pain within one week. Most patients had temporary hypocalcemia easily controlled by therapy. 6 cases had recurrent hypocalcemia (5 because of poor compliance), 5 patients were asymptomatic but one had recurrent hypocalcemic seizures. PTH levels were subnormal in 6 patients, normal in 7 and increased in 7.
Total PTX should be considered for patients with severe renal hyperparathyroid bone disease.
Burney RE, Jones KR, Christy B, et al (Univ of Michigan, Ann Arbor)
Health Status Improvement After Surgical Correction of Primary Hyperparathyroidism in Patients With High and Low Preoperative Calcium Levels
Surgery 125: 608-614, 1999
This is a prospective cohort study comparing the patients health status before and after correction of primary hyperparathyroidism (HPT) with high and low preoperative levels of serum calcium.
155 patients with primary HPT with serum calcium levels < 10.9 mg/dL (n=86) or with serum calcium levels of 10.9 mg/dL or greater (n=69) completed the SF-36 Health Survey before and 2 and 6 months after surgery.
Preoperatively both groups had profound functional status deficits. At 2 months, both groups had improved similarly in 7 of 8 domains. At 5 months, both groups had returned to normal or near normal in 5 and 6 of the 8 domains.
The high calcium group had more pain and a persistently abnormal pain score compared with the low calcium group. Fatigue was reduced in the low calcium group from 71% to 30% and in the high calcium group from 81% to 42%. The corresponding reductions in confusion were 27% to 6% and from 33% to 10% respectively.
Patients with HPT have significant health status deficits that are independent of calcium levels. Surgery results in significant improvement.
Burney RE, Jones KR, Peterson M, et al (Univ of Michigan, Ann Arbor)
Surgical Correction of Primary Hyperparathyroidism Improves Quality of Life
Surgery 124: 987-992, 1998
The SF-36 health status assessment tool was used to measure improvement in functional status and well-being in patients after surgery to correct hyperparathyroidism (HPT).
The SF-36 was administered to 140 patients with HPT aged 21 to 85 years before surgery and at 2 and 6 months after surgery. Scores were compared with those of controls from the normal population.
110 patients completed the SF-36 tool at 2 months and 82 patients at 6 months. Baseline scores were significantly lower in all 8 domains. At 2 months postoperatively all scores had improved and scores in 6 domains had improved significantly. At 6 months postoperatively there was significant improvement in all 8 domains except for general health perception.
Surgical correction of HPT improves functional health status.
Pasieka JL, Parsons LL (Univ of Calgary, Alta, Canada)
Prospective Surgical Outcome Study of Relief of Symptoms Following Surgery in Patients With Primary Hyperparathyroidism
World J Surg 22: 513-519, 1998
This article studies the effect of surgery on symptoms of HPT. It is a 2-year study on 63 patients with HPT and 54 patients (controls) undergoing surgery for non toxic nodular goiter.
Both groups completed a visual analogue scale-based symptom questionnaire at baseline, 7 to 10 days postoperatively and after 3 and 12 months. The one-year assessment also included a general health assessment and a quality-of-life index.
For patients with HPT there was significant symptomatic relief at first postoperative assessment. No further reduction in symptoms was documented at subsequent follow-ups. The comparison group had no significant change in the postoperative follow-up.
The main symptom of weakness and easy fatiguability, followed by bone pain, joint pain, forgetfulness, mood swings, thirst and irritability. All except depression and itchiness were significantly improved at 1-year follow-up. The HPT reported a 60% increase in general health at 1-year, compared with no significant change in the comparison group.
Surgery provides significant relief of symptoms in HPT – most of the improvement occurs within 1 week and thereafter there may be a slow continuous improvement.
Silverberg SJ, Shane E, Jacobs TP, et al (Columbia Univ, New York)
A 10-Year Prospective Study of Primary Hyperparathyroidism With or Without Parathyroid Surgery
N Engl J Med 341: 1249-1255, 1999
Most patients with primary HPT have no symptoms. The criteria for surgery the effects of the disease on multiple systems, the assessment of long-term incidence, and complications are studied. The results of a 10-year follow-up of 2 cohorts of patients treated with surgery and with no intervention are presented.
Of 137 patients enrolled, 121 (88%) participated for at least 1-year. Biochemical studies were performed at baseline and every 4-6 months thereafter. The change in bone mineral density of the lumbar spine, femoral neck, and distal third of the nondominant radius were determined annually and compared in the two groups.
61 patients underwent parathyroidectimy. They were generally younger had higher serum calcium levels and urinary calcium excretion and had significantly lower 2 scores for bone mineral density at the lumbar spine and femoral neck. 49 (80%) had adenomas, 7 (11%) had hyperplasia and 5 (8%) had a combination of the two. Bone mineral density increased in these sites during the follow-up period.
After 1-year the increase was significant only in the femoral neck at 4.7 and 10 years. There was no recurrence of kidney stones. In the non-intervention group, the biochemical values and bone mineral density remained unchanged in 29 symptom free postmenopausal women during the follow-up period. Bone mineral density decreased more than 10% during follow-up in 11 patients (21%).
In 14 symptom-free patients, the disease progressed, and hypercalcemia developed in 2, and hypercalciuria in 8, and low cortical bone density in 6.
None of these patients had kidney stones. However, in 8 nonintervention patients with kidney stones at baseline, 6 had recurrent stones and 3 had new surgical indications.
Lundgren E, Ljunghall S, Akerstrom G, et al (Univ Hosp, Uppsala, Sweden)
Case-Control Study on Symptoms and Signs of “Asymptomatic” Primary Hyperparathyroidism
Surgery 124: 980-986, 1998
Hyperparathyroidism (HPT) may have no symptoms. Postmenopausal women are at increased risk of primary HPT and hence this case control study in postmenopausal women who did not know they had HPT.
Serum calcium and parathyroid hormone levels were studied in 5202 patients (55-75 years) – this showed HPT in 102 cases. They were age matched to 95 controls. In the controls the total serum calcium levels were 9.48 mg/dL as against 10.40 mg/dL in the patients. PTH values in the controls were 29.8 ng/L as against 58.1 ng/L in patients.
The patients had lassitude, lack of initiative, fatiguability, daytime sleepiness, feeling of weakness, irritability, and lack of sexual and emotional interest more commonly than controls. They also had lower bone density and higher alkaline phosphatase values than controls. They were less likely to have had estrogen replacement therapy.
Asymptomatic postmenopausal women with HPT manifest psychic symptoms and bone loss and are at increased risk of cardiovascular complications.
Hundahl SA, Fleming ID, Fremgen AM, et al (Queens Med Ctr, Honolulu, Hawaii; Univ of Tennessee, Memphis; American College of Surgeons, Chicago)
A National Cancer Data Base Report on 53,856 Cases of Thyroid Carcinoma Treated in the U.S., 1985-1995
Cancer 83: 2638-2648, 1998
This is an analysis of voluntarily submitted data of 53,856 thyroid cancer patients (1% of total NCDB cases).
There were 42,686 cases of papillary carcinoma, 6764 cases of follicular carcinoma 1585 with Hurthle cell carcinoma, 1928 with medullary carcinoma, and 893 undifferentiated/anaplastic carcinoma.
Most patients had total thyroidectomy with or without lymph node sampling and with or without radiotherapy usually with iodine-131. Anaplastic carcinoma had 14% 10-year survival but most others had excellent survivals (75%-93%).
Patients with stage III/IV follicular cancer had a slightly worse 5-year stage stratified survival rate than patients with papillary cancer. The type of surgery had no effect on the survival rate.
5-year survival for Hurthle cell cancer and follicular carcinoma are similar but 10-year survivals are quite different (76% vs 85%). Patients below 45 years of age had better prognosis than older patients.
Sanders LE, Cady B (Lahey Hitchcock Med Ctr, Burlington, Mass; New England Deaconess Hosp, Boston)
Differentiated Thyroid Cancer: Reexamination of Risk Groups and Outcome of Treatment
Arch Surg 133: 419-425, 1998
Tailoring surgery to a thyroid cancer patients risk of recurrence or death minimizes the morbidity of the disease. The validity of age metastases, extent and size (AMES) risk factors have been re-examined in an expanded cohort of 1019 patients (1940-1990).
This is a retrospective study divided into 3 periods (before 1960, 1960-1979, and 1980-1990). Actuarial curves were generated using life table analysis. Follow-up was for a mean period of 13 years. There were 730 women (72% – median age 41 years) and 289 men (28% – median age 47 years).
76% were papillary or mixed papillary with follicular tumors, 20% were follicular and 4% Hurthle cell tumors. The median size was 2-29 cm. The percentage of tumor >5cm declined (15% to 5%) after 1960. 22% patients were deemed high risk (26% pre 1960 cohort and 18% – 19% after 1960).
The AMES criteria accurately predicted recurrence and death. 20-year survival rates were significantly higher in the low-risk group (50% vs 96% in high-risk group). The risk of recurrence in the low-risk group was 5%. Of the 44 such (low-risk group recurrences) 58% died. The risk of recurrence in the high-risk group was 31% (75% died).
Bilateral surgery and use of radiolabeled iodine did not affect survival or recurrence. The use of thyroid hormones increased 20-year survival. The AMES criteria accurately stratify thyroid cancer patients by risk group.
Ulchaker JC, Goldfarb DA, Bravo EL, et al (Cleveland Clinic Found, Ohio)
Successful Outcomes in Pheochromocytoma Surgery in the Modern Era
J Urol 161: 764-767, 1999
The surgical management of pheochromocytoma at the Cleveland Clinic Foundation is reviewed.
The surgical management, complications, and treatment outcomes of 113 patients (60 women) aged 14-84 years has been retrospectively reviewed. The average tumor size was 6 cm. There were 92 adrenal and 21 extra-adrenal tumors. 52 tumors were on the right side, 33 on the left and 7 were bilateral. Sodium nitroprusside was the initial antihypertensive used and esmolol was the preferred b-blocker.
The mean stay in the ICU was 1.2 days and mean hospital stay was 8.9 days. 86 patients were discharged without antihypertensive medication. Major complications like pulmonary edema were seen in 3 and CCF in 2 cases and stroke in 1. Minor complications like fever was seen in 21, atelectasis in 19, pleural effusion in 2, pneumonia in 2 deep venous thrombosis and hyperglycemia in one each.
a-Adrenergic agents were not used at all and calcium channel blockers were the antihypertensive of choice.
Lee JE, Evans DB, Hickey RC, et al (Univ of Texas, Houston)
Unknown Primary Cancer Presenting as an Adrenal Mass: Frequency and Implications for Diagnostic Evaluation of Adrenal Incidentalomas
Surgery 124: 1115-1122, 1998
The frequency and natural history of adrenal involvement at presentation in patients referred to Unknown Primary Tumor Clinic, Houston, Texas were retrospectively reviewed for suspected primary cancer.
1715 patients were referred for evaluation of a suspected unknown primary cancer. Cancer was diagnosed in 1639 patients, 95 (5.8%) of whom had adrenal gland involvement. The most common primary tumor site was the lung. Patients without adrenal involvement had a lower incidence of primary lung cancer (33% vs 71%).
Only 4 patients (0.2%) had disease limited to the adrenal gland (size of 6 cm or more) and all were symptomatic. Three of the four had bilateral involvement. Patients with unknown primary and adrenal incidentalomas had a median survival of 7 months.
True isolated adrenal involvement is rare in patients with unknown primary cancer and does not merit fine-needle aspiration cytology. Patients with localized cancer (localized to adrenal) are usually symptomatic and have large (> 6 cm) tumors.
Helen Segal, and Beverly J Hunt
Aprotinin: pharmacological reduction of perioperative bleeding
The Lancet, vol.355, April 15,2000,pg.1289
Perioperative bleeding, despite advances in surgical technique, is still a significant complication of major surgery and is associated with increased morbidity and mortality.
After the report in 1987 by Royston and colleagues about the efficacy of aprotinin in reducing bleeding in open cardiac surgery, use of and interest in aprotinin has been sustained. Many clinical trials using the original high-dose regimen have shown a decreased blood loss, and a reduction in the use of blood products by at least 30%, in open cardiac surgery. High-dose aprotinin is licensed for use in high-risk cardiac surgery.
Aprotinin is a broad-spectrum serine-protease inhibitor and has the highest affinity for trypsin. Among the haemostatic proteins, plasmin is strongly inhibited, and kallikrein less so, by aprotinin. Studies of perioperative haemostasis have shown that plasma markers of fibrinolytic activity, such as D-dimers, are suppressed during the use of aprotinin. This finding led to the conclusion that aprotinin reduces perioperative bleeding by acting as a powerful antifibrinolytic, mainly through plasmin inhibition.
One of the remarkable effects of aprotinin is its ability to produce dry surgical fields. It may be that the effects of aprotinin at local sites are different from what is measured systemically.
The fact that other antifibrinolytic drugs, such as tranexamic acid, can also reduce bleeding in cardiac surgery, suggests that perioperative activation of fibrinolysis is important. However, aprotinin is a more potent antiplasmin agent than the lysine analogues (tranexamic acid, Î aminocaproic acid) and thus should theoretically have greater clinical efficacy. Aprotinin was associated with a greater reduction in blood loss than were the lysine analogues, although there was no difference in blood-transfusion requirements.
Aprotinin is obtained from bovine lung tissue and there is a risk of allergic reaction with repeated exposure. Recombinant human aprotinin would be ideal.
Robert J Porte, I Quintus Molenaar, et al
Aprotinin and transfusion requirements in orthotopic liver transplantation: a multicentre randomised double-blind study.
Lancet, vol.355, 15 April 2000, pg.1303-1309
Intraoperative hyperfibrinolysis contributes to bleeding during adult orthotopic liver transplantation. Authors aimed to find out whether aprotinin, a potent antifibrinolytic agent, reduces blood loss and transfusion requirements.
A randomised, double blind, placebo-controlled trial was done in which six liver-transplant centres participated. Patients undergoing primary liver transplantation were randomly assigned intraoperative high-dose aprotinin, regular-dose aprotinin, or placebo. Primary endpoints were intraoperative blood loss and transfusion requirements. Secondary endpoints were perioperative fluid requirements, postoperative blood transfusions, complications and mortality.
Intraoperative use of aprotinin in adult patients undergoing orthotopic liver transplantation significantly reduces blood-transfusion requirements and should be routinely used in patients without contraindications.
Pittet D, Dharan S, Touveneau S, et al (Univ of Geneva)
Bacterial Contamination of the Hands of Hospital Staff During Routine Patient Care
Arch Intern Med 159: 821-826, 1999
The dynamics of bacterial contamination of the hands of health care workers (HCWs) during daily hospital practice has been examined in a large teaching hospital.
Structured observations of 417 episodes of care were scrutinized by 2 infection control observers in a predetermined sample of hospital wards.
Each observation started with the hand-cleansing procedure and ended when the HCW cleaned hands again or at the end of a coherent episode of care. At completion, an imprint of the 5 fingers of the dominant hand was obtained and bacterial colony counts were quantified.
The intensity of bacterial infection as a function of method of hand cleansing, use of gloves, duration and type of care and hospital ward were examined. Bacterial infection rose linearly with time on ungloved hands (average, 16 colony-forming units [CFUs] per minute). Patient care activities independently correlated with higher contamination levels included direct patient contact, respiratory care, handling of body fluid secretions, and rupture in the sequence of patient care.
Contamination levels varied by location within the hospital. The medical rehabilitation ward had the highest levels (49 CFUs), compared with all other wards. Simple hand washing without hand antisepsis before patient care was correlated with higher colony counts (52 CFUs).
This information helps identifying patient care situations related to high contamination levels and may lead to improved hand cleansing procedures.
Sands K, Vineyard G, Livingston J, et al (Harvard Med School, Boston)
Efficient Identification of Postdischarge Surgical Site Infections: Use of Automated Pharmacy Dispensing Information, Administrative Data, and Medical Record Information
J Infect Dis 179: 434-441, 1999
A large number of surgical site infections (SSIs) may occur after discharge from hospital and hence leads to problems in routine surveillance. Hence new algorithms for identifying SSIs from automated claims and electronic medical record data have been investigated.
4086 nonobstetric surgical procedures performed over 1 year period were evaluated.
Automated medical and pharmacy records were screened for possible SSI and claims records were screened for possible SSI and claims records were screened for rehospitalization and emergency department visits.
30 day postoperative records were reviewed to confirm SSIs using the National Nosocomial Infection Surveillance classification system of the Centers for Disease Control and Prevention. Predictors of SSI were assessed by means of binary recursive partitioning, with 10-fold cross-validation, and logistic regression with bootstrap resampling.
96 postdischarge SSIs were identified (2.3%). 69% of these were managed outside the hospital. With the use of specific codes and code combinations, it was possible to identify a 2% subset of procedures in which 74% of SSIs occurred.
At a specificity of 92%, this sensitivity value was improved to 92%. Sensitivity was 77% with a specificity of 94%, when only hospital discharge diagnosis codes and pharmacy dispensing data were used.
However, information on outpatient tests and diagnoses was required to create a model with sensitivity greater than 80% or predictive value greater than 35%. All study models provided better performance characteristics than responses to questionnaires from patients or surgeons.
Mularski RA, Ciccolo ML, Rappaport WD (Univ of Arizona, Tucson)
Nonsurgical Causes of Pneumoperitoneum
West J Med 170: 41-46, 1999
Pneumoperitoneum is a radiographic manifestation of free air in the peritoneal cavity and usually indicates serious intra-abdominal disease and an urgent need for a laparotomy. However, pneumoperitoneum without evidence of visceral perforation has been reported in 5% to 14% of patients. 8 such patients have been reported (managed medically).
Medical records of patients from 2 teaching hospitals have been reviewed retrospectively. Successful medical (non-operative) management or failure to find a cause after laparotomy was considered as the diagnostic feature of nonperforation. A list of such causes has been given. 8 cases (6 male, 2 female) were studied.
2 patients had a negative laparotomy and 6 were managed medically. A review of literature revealed that 61 of 139 patients underwent surgery without evidence of a perforated viscus.
It is important that all physicians recognize nonsurgical causes of pneumoperitoneum.
Velmahos GC, Kamel E, Berne TV, et al (Univ of Southern California, Los Angeles)
Abdominal Computed Tomography for the Diagnosis of Intra-abdominal Sepsis in Critically Injured Patients: Fishing in Murky Waters
Arch Surg 134: 831-838, 1999
Abdominal CT of critically ill patients is associated with considerable risks and costs. The authors assess the value of abdominal CT in identifying intra-abdominal sepsis in such cases.
85 such patients were prospectively studied. They had developed sepsis of unknown origin after major trauma.
A total of 161 CT scans (abdominal) were ordered for evaluation of sepsis. The sensitivity and specificity of this investigation was assessed. It identified an intra-abdominal focus of infection in 58% of cases (most commonly an intra-abdominal abscess). Abnormalities were detected in 53% of initial scans (on an average at 9 days after admission).
However, 77% of repeat scans were abnormal when the first scan had yielded positive results; but only 27% of repeat scans were positive of the first scan was negative. The only factors independently associated with an abnormal scan were penetrating trauma and emergency laparotomy.
Abdominal CT had a sensitivity of 97.5% and a specificity of 61.5% for diagnosis of intra-abdominal sepsis. The scans led to a change of treatment in 69% of patients.
Isenmann R, Rau B, Beger HG (Univ of Ulm, Germany)
Bacterial Infection and Extent of Necrosis Are Determinants of Organ Failure in Patients With Acute Necrotizing Pancreatitis
Br J Surg 86: 1020-1024, 1999
Patients with necrotizing pancreatitis are at risk for organ failure and death, although the risk factors are not well known. The authors have studied the relationship between infection, extent of necrosis and organ failure in such patients.
This is a retrospective study of 273 patients with necrotizing pancreatitis. The evaluation included the incidence of pulmonary and renal insufficiency, sepsis and sepsis-like syndrome, shock, and coagulopathy.
The patients were divided into 3 groups – Group 1 with <30% necrotic tissue, group 2 with 30%-50% necrosis and group 3 with >50% necrosis. Intra-operative smears were used to assess the bacterial status of the necrotic tissue for 201 patients. In 82 patients, bacterial cultures of abdominal aspirates were used.
Statistical analysis of the data by means of the Cochran-Armitage trend test was used to decide the relationship between organ failure, extent of pancreatic necrosis, as well as the relationship between the incidence of bacterial infection and extent of necrosis. Organ failure occurred in 89% of infected necrosis as against 73% of sterile necrosis.
Organ failure increased with the extent of necrosis, however the bacterial status was a significant factor. Organ failure was highest in group 3 and patients with infected necrosis were at high risk, no matter how extensive the necrosis.
Lipka JM, Zibari GB, Dies DF, et al (Louisiana State Univ, Shreveport)
Spontaneous Bacterial Peritonitis in Liver Failure
Am Surg 64: 1155-1157, 1998
SBP-Spontaneous Bacterial Peritonitis is a potentially fatal complication of cirrhotic ascites and is difficult to diagnose because of paucity of clinical signs. Even if promptly treated SBP has a high rate of mortality and recurrence.
This study is a 5-year review of 26 patients (13 male and 13 female; mean age, 44 years) with SBP associated with chronic liver disease. All had Childs class C liver disease (46% alcoholic, 30% viral hepatitis and 19% cryptogenic). At diagnosis the mean polymorphonuclear (PMN) cell count in the ascitic fluid was 775 PMN/mm3. E. coli and K. pneumoniae were the commonest organisms (no organism was cultured in 19% of cases). When an organism was identified the infection was monomicrobial.
The only factor significantly associated with mortality was ascitic PMN count – 88% with counts >1000 PMN/mm3 died versus 22% with counts of <500 PMN/mm3. 54% died during their initial hospitalization or during a subsequent episode of SBP. Only 2 patients underwent liver transplantation.
Eggimann P, Francioli P, Bille J, et al (Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Universtatsspital Zurich, Switzerland)
Fluconazole Prophylaxis Prevents Intra-abdominal Candidiasis in High-risk Surgical Patients
Crit Care Med 27: 1066-1072, 1999
Candida species have emerged as an important cause of nosocomial infections especially amongst surgical patients. This article evaluates the role of IV fluconazole in the prophylaxis of candidiasis in high-risk surgical patients.
This is a randomized, double-blind trial (49 patients) on those who had undergone recent abdominal surgery, with suspected or confirmed perforative peritonitis. Those with probable or confirmed fungal infection were excluded.
Patients were randomly assigned to group 1 i.e. IV fluconazole 400 mg once daily or group 2 i.e. placebo therapy – both given over 30 minutes. The treatment continued till the infection resolved or till an adverse reaction developed. Monitoring included thrice weekly specimens for culture.
Among those with no colonization at baseline surveillance culture revealed Candida in 15% of group 1 versus 62% of group 2 (relative risk 0.25; 95% confidence interval, 0.07-0.96). The rate of candidal peritonitis was 4% in group 1 versus 35% in group 2 (relative risk 0.12; 95% confidence interval, 0.02-0.93). One patient in group 1 developed catheter related Candida albicans sepsis. In total 2 patients from group 1 developed candidiasis versus 7 patients from group 2.
87% of candidal sepsis isolated in either group were C. albicans and all 25 strains were susceptible to fluconazole. Both groups had comparable rates of adverse effects. Fluconazole effectively prevents candidal colonization or infection. Its use should be limited to patients at high risk for candidiases.
Schaffer MR, Tantry U, et al (Univ Hosp of Tubingen, Germany; Johns Hopkins Med Institutions, Baltimore, Md)
Inhibition of Nitric Oxide Synthesis in Wounds: Pharmacology and Effect on Accumulation of Collagen in Wounds in Mice
Eur J Surg 165: 262-267, 1999
The efficacy of nitric oxide (NO) inhibition on collagen accumulation in wounds was assessed to study the importance of NO in the normal wound repair process.
Dorsal skin incisions were made in Balb/C mice, and polyvinyl alcohol sponges were inserted subcutaneously. Starting on the day of wounding, the mice were treated orally or intraperitoneally with the following NO synthase inhibitors: Nw-nitro-L-arginine-methylester (L-NAME), NG-L-monoethyl-arginine acetate (L-NMMA), aminoguadine hemisulfate (AGU), or S-methyl isothiouronium (MITU).
The animals were sacrificed after 10 days. Concentrations of the stable NO end products, nitrite and nitrate were measured in wound fluid. Collagen deposition was assessed by measuring the hydroxyproline content of the sponges.
When NO synthesis inhibitors were given orally or intraperitoneally, they had no effect on wound nitrite/nitrate concentrations or collagen deposition. Both AGU and MITU reduced nitrite/nitrate concentrations in dose dependent fashion when given via mini-osmotic pumps implanted intraperitoneally. As these levels decreased, collagen deposition in the wound also decreased.
NO assists wound healing. The mechanism of action needs further investigation.
McGilvray ID, Rotstein OD (Univ of Toronto)
Antioxidant Modulation of Skin Inflammation: Preventing Inflammatory Progression by Inhibiting Neutrophil Influx
Can J Surg 42: 109-115, 1999
In vitro studies suggest that antioxidant therapy may interrupt the inflammatory response by altering expression of endothelial cell surface proteins that is, intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1). The effect of antioxidants on inflammatory cell influx was studied in a mouse model of local inflammation.
Swiss-Webster mice were injected with Salmonella minnesota endotoxin (LPS) to produce a local inflammatory reaction (increase in vascular permeability and neutrophil influx). The mice were pretreated with intraperitoneal administration of pyrrolidine dithiocarbamate (PDTC), 2 mmol/kg, an inhibitor of free radical generation, or the free radical scavenger dimethylthiourea (DMTU) 450 mg/kg.
Assessment included iodine-125 albumin injection to determine local changes in tissue vascular permeability (PI); measurement of tissue myeloperoxidase as an indicator of neutrophil accumulation and measurement of tissue ICAM-1 and VCAM-1 levels.
The initial increase in PI was unaffected by either PDTC or DMTU. However, both antioxidants reduced the late increase in PI and reduced neutrophil influx.
Endotoxin (LPS) injection was followed by upregulation of both ICAM-1 and VCAM-1. Treatment with PDTC or DMTU limited the increase in VCAM-1, but not of ICAM-1. Tissue myeloperoxidase levels, an indicator of neutrophil influx was not increased until 24 hours after LPS injection.
Antioxidant pretreatment inhibits the inflammatory response through prevention of neutrophil influx. It can be used to manipulate endothelial vascular adhesion molecules may provide a valuable new approach to attenuating the initial inflammatory response.
Sofer D, Gurevitch J, et al (Tel Aviv Univ, Israel)
Sternal Wound Infections in Patients After Coronary Bypass Grafting Using Bilateral Skeletonized Internal Mammary Arteries
Ann Surg 229: 585-590, 1999
An experience with bilateral skeletonized IMAs was analyzed to assess the frequency and risk factors for sternal complications and wound infections.
It includes 545 patients (average age 65 years) undergoing coronary artery bypass grafting (CABG) with bilateral skeletonized IMAs. There were 431 men and 114 women. About one third had diabetes and the same number was more than 70 years of age. The right gastroepiploic artery was used as a third arterial conduit in 18%. 60% had a composite graft prepared before connection to cardiopulmonary bypass. An average of 3.2 grafts were used per patient.
The perioperative mortality was 2%. Other perioperative complications included stroke (1.1%), sternal infection (1.7%) and superficial infection (2.8%). At a follow-up of 14 months late mortality was 1.5%. The rate of severe sternal complications was 2.2%, the risk factors being chronic obstructive pulmonary disease (COPD) and emergency CABG.
Female patients and those with COPD, renal failure, or peripheral vascular disease were more likely to have superficial wound sepsis. One-year actuarial survival was 97%. Combined early and late mortality was 33% for those with sternal complications as against 2.7% for those without sternal complications.
This technique offers low morbidity and mortality; but is not recommended in patients with COPD or in emergency surgery.
Brown RE, McCall TE, Neumeister MW (Southern Illinois Univ, Springfield)
Use of Free-Tissue Transfer in the Treatment of Median Sternotomy Wound Infections: Retrospective Review
J Reconstr Microsurg 15: 171-175, 1999
Free tissue transfer techniques may avoid the debilitating, disfiguring muscle losses of local/regional flaps. The results of a 4-year study have been presented.
The study included 12 free-flap procedures in 11 patients requiring closure of a large median sternotomy wound (6 M and 5 F) (average age 58 years). Most patients required 2 debridements. The free tissue transfer was performed when circumstances prohibited the use of a pedicled rectus abdominis flap.
Of the 12 flaps, 10 were rectus abdominus myocutaneous flaps. The average operating time was 6 hours 37 minutes and the average blood loss was 644 ml. The average postoperative hospital stay was 20 days. There was 1 case of total flap loss closed by secondary intention. There were 3 cases of marginal donor-site breakdown, which also healed secondarily. 2 flaps were associated with abdominal hernias.
Radice E, Nelson H, et al (Mayo Clinic and Mayo Found, Rochester, Minn)
Primary Myocutaneous Flap Closure Following Resection of Locally Advanced Pelvic Malignancies
Br J Surg 86: 349-354, 1999
The efficacy of routine primary myocutaneous flap closure for patients with large pelvic defects after surgery for locally advanced pelvic malignancies has been assessed.
The study includes 57 patients undergoing multimodality therapy and pelvic resection for locally advanced primary or locally recurrent anorectal cancer. Surgery consisted of proctectomy, leaving a perineal wound, in 35 patients; and sacrectomy, leaving a posterior wound, in 22.
20 patients comprising Group 1 underwent primary skin and pelvic closure. Group 2 included 24 patients who underwent primary skin and omental pelvic closure. The remaining 13 patients (Group 3) underwent immediate myocutaneous flap closure.
The 3 groups were comparable in age and sex, but Group 1 patients had more primary tumors and underwent less radical surgery and chemoradiation than those in the other 2 groups.
Complication rates were 40% (Group 1), 37.5% (Group 2) and 23% (Group 3). Rates of acute wound complications were 35% (Group 1), 25% (Group 2), and 7.6% (Group 3).
Reoperation for perineal wound complications was required by 25%, 29.2% and 0% respectively. Patients in Group 3 had no significant increase in length of stay. Overall routine primary flap closure replaced the wound complication rate from 38.5% to 25.8%. The length of hospital stay decreased from 17 to 13 days respectively.
Immediate myocutaneous flap closure reduces the need for readmission and reoperation. Delayed myocutaneous flap closure is an important technique in patients with perineal wound failure after attempted primary wound approximation.
Peschen M, Lahaye T, et al (Univ of Freiburg, Germany)
Expression of the Adhesion Molecules ICAM-1, VCAM-1, LFA-1 and VLA-4 in the Skin Is Modulated in Progressing Stages of Chronic Venous Insufficiency
Acta Derm Venereol 79: 27-32, 1999
Chronic venous insufficiency (CVI) provides a useful model for the study of factors involved in disturbed wound healing. Patients at various stages of progressive CVI were studied to assess modulation of the adhesion molecules ICAM-1, VCAM-1, LFA-1 and VLA-4 and their pathologic role in disease progression.
The study included 60 patients representing 5 different clinical stages of CVI telangiectases, stasis, dermatitis, hyperpigmentation, lipodermatosclerosis and venous leg ulcer. Skin biopsies were obtained for immunohistochemical staining to assess expression of ICAM-1/VCAM-1 on endothelial cells and their ligands LFA-1/VLA-2 on leukocytes.
Stasis dermatitis and other early stages CVI were associated with increased expression of ICAM-1 and VCAM-1 on endothelial cells. Levels of the corresponding mRNA were increased at the same time.
In addition there was significant perivascular infiltration of leukocytes, which expressed elevated levels of LFA-1 and VLA-4. Upregulation of CAMs persisted through the hyperpigmentation and lipodermatosclerosis stages of CVI, before the development of ulcers.
Herndon DN, Ramzy PI, et al (Univ of Texas, Galveston)
Muscle Protein Catabolism After Severe Burn: Effects of IGF-1/IGFBP-3 Treatment
Ann Surg 229: 713-722, 1999
A new complex of human insulin-like growth factor-1 (IGF-1) plus IGF binding protein-3 (IGFBP-3), its major binding protein, was studied for its clinical effects on skeletal muscle metabolism in children with severe burns.
29 children with more than 40% burns of total body surface area were included in this study. Net protein balance across the leg, muscle protein fractional synthesis rates, and glucose metabolism were studied before and after treatment with IGF-1/IGFBP-3, at dosages of 0.5, 1.0, 2.0 or 4.0 mg/kg per day. Another group was managed without IGF-1/IGFBP-3 (controls).
At baseline 59% of the children were catabolic. Serum IGF-1 increased significantly with IGF-1/IGFBP-3 given at the 1.0 mg/kg per day infusion rate. No further improvement in IGF-1 was achieved with higher doses of IGF-1/IGFBP-3.
Net protein balance was improved and muscle protein fractional synthetic rates were increased at dosages of 1.0 mg/kg/day or higher, particularly in children who were catabolic at baseline. The study treatment had no effect on glucose uptake across the leg or substrate usage.
Initial studies suggest that IGF-1 complexed with IGFBP-3 can reduce muscle protein catabolism in severely burned children who are catabolic at baseline.
Ferrando AA, Chinkes DL, et al (Univ of Texas, Galveston)
A Submaximal Dose of Insulin Promotes Net Skeletal Muscle Protein Synthesis in Patients With Severe Burns
Ann Surg 229: 11-18, 1999
The efficacy of a submaximal dose of insulin on skeletal muscle protein synthesis in patients with severe burns was assessed, along with its effects on amino acids.
This randomized trial included 13 adults with severe burns (>60% of total body surface area). They were randomly assigned to standard care or exogenous insulin given at an average rate of 2.6 mU/kg/men. Assessment included analysis of data from an arteriovenous model with primed-continuous infusions of stable isotopes and findings of vastus lateralis muscle biopsies.
The insulin group showed significant improvement in net amino acid balance and skeletal muscle protein synthesis. Breakdown of muscle protein was similar for both groups. The insulin dose given had no effect on glucose or amino acid uptake. Patients did not require increased calorie intake to prevent hypoglycemia.
This submaximal insulin dosage promotes net skeletal muscle protein synthesis without unduly increasing caloric requirements. This effect occurs through efficient reuse of intracellular amino acids.
Berman RS, Harrison LE, et al (Mem Sloan-Kettering Cancer Ctr, New York City)
Growth Hormone Alone and in Combination With Insulin, Increases Whole Body and Skeletal Muscle Protein Kinetics in Cancer Patients After Surgery
Ann Surg 229: 1-10, 1999
The efficacy of growth hormone (GH) with or without insulin was assessed in patients undergoing surgery for upper gastrointestinal (GI) cancers followed by Total Parental Nutrition (TPN).
This randomized trial included 30 patients undergoing surgery for upper GI cancers. After surgery, 10 patients were assigned to standard TPN; 10 to TPN plus daily injections of GH; 10 to TPN, daily injections of GH and systemic insulin. On postoperative day 5, whole-body and skeletal muscle protein kinetics were assessed in a radiotracer protein kinetic study.
Skeletal muscle protein net balance was negative for patients on TPN only. GH plus insulin significantly improved the skeletal muscle net protein balance while GH with or without insulin was associated with improvement in whole body protein net balance compared with TPN alone.
Patients receiving GH had markedly increased serum TGF-1 and GH levels while those receiving insulin had increased serum insulin and an increased insulin/glucagon ratio.
A larger trial assessing the effects of GH with or without insulin is indicated.
Belachew M, Legrand M, et al (Centre Hospitalier Hutois, Huy, Belgium; BioEnterics Corp, Carpinteria, Calif)
Laparoscopic Adjustable Gastric Banding
World J Surg 22: 955-963, 1998
Solid food intolerance and staple line disruptions are important problems in patients undergoing vertical banded gastroplasty for morbid obesity. The authors present their experience with laparoscopic adjustable silicone gastric banding (LASGB) for severe obesity which they feel offers several advantages.
The technique of LASGB was worked out in the laboratory including the development of an implantable adjustable silicone band. Initial trials were in easy cases. Later on it was performed on superobese patients. As many sutures as necessary were taken to embed the band although no suture was placed over the buckle. The patients underwent a Gastrografin study on the 4th day and were discharged on the 6th day. Stomal size was adjusted on an outpatient basis and other decisions on the basis of weight loss curves and radiological studies.
350 morbidly obese patients underwent LASGB over a 4-year period. The rate of conversion to laparotomy was 1.4%. 46 cases had late complications (related to pouch enlargement), mostly in the initial cases. After modifications in the technique (pouch size less than 15 mL), suture fixation of the anterior wall with complete embedding of the silicone band and partial deflation of the band at surgery – the complications reduced drastically.
The authors report good results with LASGB for morbid obesity.
Tackett LD, Breuer CK, et al (Brown Univ, Providence, RI)
Incidence of Contralateral Inguinal Hernia: A Prospective Analysis
J Pediatr Surg 34: 684-688, 1999
The incidence of contralateral hernias by age and sex was prospectively studied to identify risk factors for metachronous contralateral inguinal hernias.
554 boys and 102 girls (2 days to 18 years of age) underwent unilateral or bilateral inguinal hernia repair. All patients with unilateral hernias underwent ipsilateral repair only and were then followed up for a mean of 25.5 months for the occurrence of a metachronous contralateral hernia.
The incidence of synchronous bilateral hernias was 16.5% overall (28% in premature infants, 33.8% in infants less than 6 months old, and 27.4% in children below 2 years). The incidence of metachronous contralateral hernia.was 8.8% (median time 6 months and mean follow-up of 13 months). By 24 months 94% of contralateral hernias had appeared.
Proper counseling of parents may reduce anxiety and promote detection of contralateral hernias.
Watson DI, Davies N, et al (Univ of Adelaide, South Australia)
Importance of Dissection of the Hernial Sac in Laparoscopic Surgery for Large Hiatal Hernias
Arch Surg 134: 1069-1073, 1999
An experience with an alternative operative procedure that has greatly improved the reliability of laparoscopic repair of large hiatal hernias is reported. Two strategies are discussed.
Upto early 1996, the sac of the hiatal hernia was left in the mediastinum. This has now been altered, the hernial sac is first dissected from the mediastinum and then the contents were reduced to define the oesophagus.
The peritoneum is first divided at the edge of the oesophageal hiatus before isolating the sac by blunt dissection. The sac is then reduced into the abdomen and the oesophagus comes into view.
86 patients with large hiatal hernias were repaired laparoscopically (30 sliding, 10 paraoesophageal, 46 mixed hernias). 20 cases were converted to open surgery but it progressively dropped to 9% in the later operations.
The median operating time was 90 minutes. The repair of the defect was with posteriorly placed sutures in 72 cases, an anterior repair in 3 cases and the rest had both anterior and posterior repairs. The overall satisfaction outcome was 91%.
Large hiatal hernias may be treated effectively by a laparoscopic approach.
Hunter JG, Smith CD, et al (Emory Univ, Atlanta)
Laparoscopic Fundoplication Failures: Patterns of Failure and Response to Fundoplication Revision
Ann Surg 230: 595-606, 1999
The cause of failure of laparoscopic surgery for gastrooesophageal reflux disease have been investigated.
100 patients undergoing 111 revision procedures (fundoplication) were studied. The patients recorded their symptoms (pre and postoperative) on a 4 point scale. Besides this the patient underwent endoscopy, barium swallow, oesophageal motility, 24 hour ambulatory pH monitoring and gastric emptying study. The surgical procedure chosen depended on preoperative oesophagogastric motility and intraoperative assessment of oesophageal length.
Transdiaphragmatic migration of the fundoplication was the principal cause of failure. The others were twisted, slipped, misplaced or herniated fundoplication; insufficient mobilisation of the stomach and inadequate crural closure were also seen as causes of failure. After a year or more only 11 patients required further operations to ease symptoms (absence of symptoms in about 80% of cases).
Failure of fundoplication is rare but the results could improve further by liberal oesophageal mobilisation and a secure crural closure.
Tsuruma T, Yagihashi A, et al (Sapporo Univ, Japan)
Heat-Shock Protein-73 Protects Against Small Intestinal Warm Ischemia-Reperfusion Injury in the Rat
Surgery 125: 385-395, 1999
Ischemia/reperfusion (I/R) injury poses a challenging problem in small intestinal transplantation. The protective effects of heat shock protein (hsp)-73 against warm I/R injury in the small intestine of the rat have been studied.
3 groups of rats undergoing small bowel I/R injury produced by ligation of the mesenteric artery were studied.
24 hours before ischemia, the rats underwent common carotid artery injection with 6 mg/kg of sodium arsenite which induces hsp; with phosphate buffered saline solution; or with SA plus 5 mg/kg of quercetin which blocks hsp synthesis.
After reperfusion animals receiving SA had higher mean peak plasma levels of tumor necrosis factor a (TNF a) and cytokine induced neutrophil chemoattractant than the control group.
Postperfusion tissue myeloperoxidase activity was lower in the SA group, whereas peak plasma interleukin-10 level was higher. The SA group also showed reduced levels of nitric oxide and less severe warm I/R injury of small bowel. Giving quercetin to inhibit hsp counteracted the protective effects of hsp.
Franke C , for the Acute Abdominal Pain Study Group (Heinrich-Heine Universitat, Moorenstrasse, Germany)
Ultrasonography for Diagnosis of Acute Appendicitis: Results of a Prospective Multicenter Trial
World J Surg 23: 141-146, 1999
The performance and clinical examination were assessed in a prospective multicenter trial.
2280 patients with acute abdominal pain within 1 week of admission were studied.
Acute appendicitis was diagnosed in 519 (23%) patients. US was performed on 870 (38%) patients. Of 217 patients with a clinical diagnosis of acute appendicitis, a US scan was positive in 120 (sensitivity of 55%). Among 600 patients without acute appendicitis US scan was negative in 571 (specificity 95%). The positive and negative predictive values were 81% and 95% respectively.
The lack of correlation between clinical and US findings does not support the use of US as routine diagnostic aid in appendicitis.
Hunerbein M, Ghadimi BM, et al (Humboldt Univ, Berlin)
Transesophageal Biopsy of Mediastinal and Pulmonary Tumors by Means of Endoscopic Ultrasound Guidance
J Thorac Cardiovasc Surg 116: 554-559, 1998
Recently researchers have reported the efficacy of biopsy guided by oesophageal ultrasound (EUS). The efficacy of EUS guided biopsy in identifying thoracic lesions was examined.
29 patients patients (17 M; 12 W; mean age 58 years) (25 mediastinal and 4 pulmonary tumors) were subjected to conventional diagnostic methods and a transoesophageal EUS biopsy. Results were confirmed at surgery by histologic examination.
A definite surgical diagnosis was not available in 3 cases of mediastinal tumors; of the remaining 26 patients EUS guided biopsy was successful in 23 (88%) even in mediastinal tumors < 1cm in diameter. Of these 17 cases had malignancy (74%) and 6 had benign lesions (26%). EUS biopsy gave incorrect results in 3 patients (2 were non diagnostic) – fibrotic and fatty tissue and 1 had recurrent oesophageal cancer.
For 15 of these 23 patients, the biopsy was confirmed by conventional studies. For 8 the diagnosis changed (3 patients with suspected lymphoma EUS biopsy revealed adenocarcinoma, small cell carcinoma and sarcoidosis respectively; 1 patient with suspected lung cancer EUS biopsy revealed recurrent gastric cancer; 1 patient with suspected renal cell carcinoma EUS biopsy revealed small cell carcinoma; 1 patient with suspected sarcoma EUS biopsy revealed complete necrosis EUS biopsy also avoided unnecessary surgery for 1 patient with suspected recurrent oesophageal cancer (shown to be a benign lymph node) and 1 patient suspected to have malignant melanoma (shown to have a goiter).
There were no complications. The sensitivity, specificity, positive predictive value and negative predictive value of EUS biopsy in diagnosing malignancy were 89%, 83%, 100% and 75% respectively.
Gharagozloo F, Trachiotis G, et al (Georgetown Univ, Washington, DC)
Pleural Space Irrigation and Modified Clagett Procedure for the Treatment of Early Postpneumonectomy Empyema
J Thorac Cardiovasc Surg 116: 943-948, 1998
Empyemas develop in about 5%-10% of patients after pneumonectomy usually within 4 weeks after surgery. 80% of cases have a bronchopleural fistula. The classical conservative approach is time consuming.
A new approach – viz. irrigation of the pleural space and a modified Clagget procedure has been tried out.
22 patients with PNE developing within 4 weeks postoperatively (16 M, 6F, mean age 62 years) with a bronchopleural fistula were studied.
Treatment was started with emergency pleural space drainage. This was followed by thoracotomy with debridement of necrotic tissue bronchial stamp closure with absorbable monofilament suture and pleural space irrigation.
When the pleural fluid Gram stain became negative, the pleural space was obliterated using 2L of Debridement Antibiotic (DAB) solution (Gentamein 80 mg/L, Neomycin 500 mg/L and Polymyxin B 100 mg/L). After obliteration, the irrigation and drainage catheters were removed. The patients were followed by radiological studies for 1 year.
In 20 out of 22 cases the Gram stain of pleural fluid became negative after 8 days and in the remaining 2 it took 16 days. The mean time to discharge was 13 days (fully functional). There were no recurrences at 1 year and 12 patients remained recurrence free at follow-up of more than 3 years.