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British Journal of Surgery
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Wiley Online Library : British Journal of Surgery
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Intraoperative, postoperative and reoperative problems with ileoanal pouches
Background:Proctocolectomy with ileal pouch?anal anastomosis (IPAA) has been developed and refined since its introduction in the late 1970s. Nonetheless, it is a procedure associated with significant morbidity. The aim of this review was to provide a structured approach to the challenges that surgeons and physicians encounter in the management of intraoperative, postoperative and reoperative problems associated with ileoanal pouches.Methods:The review was based on relevant studies identified from an electronic search of MEDLINE, Embase and PubMed databases from 1975 to April 2011. There were no language or publication year restrictions. Original references in published articles were reviewed.Results:Although the majority of patients experience long?term success with an ileoanal pouch, significant morbidity surrounds IPAA. Surgical intervention is often critical to achieve optimal control of the situation.Conclusion:A structured management plan will minimize the adverse consequences of the problems associated with pouches. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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Effect of Roux?en?Y gastric bypass on testosterone and prostate?specific antigen
Background:Obese men have lower serum levels of testosterone, dehydroepiandrosterone (DHEA) and prostate?specific antigen (PSA), but an increased risk of dying from prostate cancer. The aim of this study was to examine the effect of surgically induced weight loss on serum testosterone, DHEA and PSA levels in obese men.Methods:Consecutive men undergoing Roux?en?$\font\ss=cmss10 scaled 1000 \hbox{Y}$ gastric bypass (RYGB) participated in a prospective, longitudinal study. Main outcomes were changes were body mass index (BMI), percentage excess weight loss, serum levels of testosterone, DHEA and PSA, PSA mass and plasma volume, measured before operation and 3, 6 and 12 months later.Results:In 64 patients, mean BMI fell from 48·2 kg/m2 before operation to 39·2, 35·6 and 32·4 kg/m2 at 3, 6 and 12 months after RYGB. Testosterone levels rose significantly from 259 ng/dl to 386, 452 and 520 ng/dl respectively. Serum PSA levels increased significantly from 0·51 ng/ml to 0·67 ng/ml at 12 months. There were no significant changes in DHEA or PSA mass.Conclusion:RYGB normalizes the serum testosterone level. PSA levels increase with weight loss and may be inversely correlated with changes in plasma volume, indicating that PSA levels may be artificially low in obese men owing to haemodilution. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis
Background:The standard of care for acute uncomplicated diverticulitis today is antibiotic treatment, although there are no controlled studies supporting this management. The aim was to investigate the need for antibiotic treatment in acute uncomplicated diverticulitis, with the endpoint of recovery without complications after 12 months of follow?up.Methods:This multicentre randomized trial involving ten surgical departments in Sweden and one in Iceland recruited 623 patients with computed tomography?verified acute uncomplicated left?sided diverticulitis. Patients were randomized to treatment with (314 patients) or without (309 patients) antibiotics.Results:Age, sex, body mass index, co?morbidities, body temperature, white blood cell count and C?reactive protein level on admission were similar in the two groups. Complications such as perforation or abscess formation were found in six patients (1·9 per cent) who received no antibiotics and in three (1·0 per cent) who were treated with antibiotics (P = 0·302). The median hospital stay was 3 days in both groups. Recurrent diverticulitis necessitating readmission to hospital at the 1?year follow?up was similar in the two groups (16 per cent, P = 0·881).Conclusion:Antibiotic treatment for acute uncomplicated diverticulitis neither accelerates recovery nor prevents complications or recurrence. It should be reserved for the treatment of complicated diverticulitis. Registration number: NCT01008488 (http://www.clinicaltrials.gov). Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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Reoperative surgery for bilateral multinodular goitre in the era of total thyroidectomy
Background:Total thyroidectomy, rather than bilateral subtotal thyroidectomy, is now accepted as the preferred management for bilateral benign multinodular goitre (BMNG) in order to reduce the need for reoperative surgery. The aim of this study was to examine whether this approach has had an impact on presentation for bilateral reoperative thyroid surgery.Methods:This was a retrospective cohort study. The study group comprised patients presenting with recurrent BMNG who underwent bilateral reoperative thyroid surgery following previous bilateral subtotal or partial thyroidectomy. They were compared with patients undergoing unilateral reoperative thyroid surgery following previous lobectomy, and those undergoing primary total thyroidectomy for BMNG.Results:Between 1 January 1987 and 31 December 2009, 12 354 consecutive thyroid procedures were undertaken. Among those with BMNG, primary total thyroidectomy was undertaken in 3298 patients, unilateral reoperative thyroidectomy in 337 and bilateral reoperative thyroidectomy in 191. Presentations of patients with recurrent BMNG declined gradually over the study period following the change in policy from subtotal to total thyroidectomy; only five patients (representing less than 0·5 per cent of all thyroid surgery) underwent bilateral reoperative surgery for BMNG in the last year of the study. Four of these patients had their initial operation before 1987 and in another unit, whereas the remaining patient initially had surgery overseas.Conclusion:The introduction of a policy of initial total thyroidectomy for bilateral BMNG has essentially eliminated the need for bilateral reoperative surgery for recurrent goitre. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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Tissue engineering and the road to whole organs
A glimpse into the future of surgery
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Incidence, prevalence and risk factors for peritoneal carcinomatosis from colorectal cancer
Background:This was a population?based cohort study to determine the incidence, prevalence and risk factors for peritoneal carcinomatosis (PC) from colorectal cancer.Methods:Prospectively collected data were obtained from the Regional Quality Registry. The Cox proportional hazards regression model was used for multivariable analysis of clinicopathological factors to determine independent predictors of PC.Results:All 11 124 patients with colorectal cancer in Stockholm County during 1995?2007 were included and followed until 2010. In total, 924 patients (8·3 per cent) had synchronous or metachronous PC. PC was the first and only localization of metastases in 535 patients (4·8 per cent). The prevalence of synchronous PC was 4·3 per cent (477 of 11 124). The cumulative incidence of metachronous PC was 4·2 per cent (447 of 10 646). Independent predictors for metachronous PC were colonic cancer (hazard ratio (HR) 1·77, 95 per cent confidence interval 1·31 to 2·39; P = 0·002 for right?sided colonic cancer), advanced tumour (T) status (HR 9·98, 3·10 to 32·11; P < 0·001 for T4), advanced node (N) status (HR 7·41, 4·78 to 11·51; P < 0·001 for N2 with fewer than 12 lymph nodes examined), emergency surgery (HR 2·11, 1·66 to 2·69; P < 0·001) and non?radical resection of the primary tumour (HR 2·75, 2·10 to 3·61; P < 0·001 for R2 resection). Patients aged > 70 years had a decreased risk of metachronous PC (HR 0·69, 0·55 to 0·87; P = 0·003).Conclusion:PC is common in patients with colorectal cancer and is associated with identifiable risk factors. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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Randomized clinical trial of bilateral subtotal thyroidectomy versus total thyroidectomy for Graves' disease with a 5?year follow?up
Background:The extent of thyroid resection in Graves' disease remains controversial. The aim of this study was to evaluate long?term results of bilateral subtotal thyroidectomy (BST) compared with total thyroidectomy (TT) in patients with Graves' disease and mild active ophthalmopathy.Methods:Participants were assigned randomly to BST or TT, and followed for 5 years after surgery. The primary endpoints of the study were the prevalence of recurrent hyperthyroidism and changes in Graves' ophthalmopathy. Secondary endpoints were postoperative transient and permanent paresis of the recurrent laryngeal nerve, and postoperative hypocalcaemia and hypoparathyroidism.Results:Two hundred patients were included, of whom 191 (BST 95, TT 96) completed the 5?year follow?up. Recurrent hyperthyroidism occurred in nine patients after BST and in none after TT (P = 0·002). Progression of Graves' ophthalmopathy was observed in nine patients after BST compared with seven following TT (P = 0·586). Transient hypoparathyroidism occurred in 13 and 24 patients respectively (P = 0·047). Permanent hypoparathyroidism was diagnosed in no patient after BST and in one after TT (P = 0·318). No differences were noted in transient or permanent recurrent laryngeal nerve injury.Conclusion:TT for Graves' disease prevented recurrent hyperthyroidism but did not prevent the progression of ophthalmopathy compared with BST. Registration number: NCT01408368 (http://www.clinicaltrials.gov). Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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Use of models in identification and prediction of physiology in critically ill surgical patients
Background:With higher?throughput data acquisition and processing, increasing computational power, and advancing computer and mathematical techniques, modelling of clinical and biological data is advancing rapidly. Although exciting, the goal of recreating or surpassing in silico the clinical insight of the experienced clinician remains difficult. Advances toward this goal and a brief overview of various modelling and statistical techniques constitute the purpose of this review.Methods:A review of the literature and experience with models and physiological state representation and prediction after injury was undertaken.Results:A brief overview of models and the thinking behind their use for surgeons new to the field is presented, including an introduction to visualization and modelling work in surgical care, discussion of state identification and prediction, discussion of causal inference statistical approaches, and a brief introduction to new vital signs and waveform analysis.Conclusion:Modelling in surgical critical care can provide a useful adjunct to traditional reductionist biological and clinical analysis. Ultimately the goal is to model computationally the clinical acumen of the experienced clinician. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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Systematic review and meta?analysis of randomized clinical trials of self?expanding metallic stents as a bridge to surgery versus emergency surgery for malignant left?sided large bowel obstruction
Background:Use of self?expanding metallic stents (SEMS) as a bridge to surgery has been suggested as an alternative management for acute malignant left?sided colonic obstruction, as emergency surgery has a high risk of morbidity and mortality. This meta?analysis evaluated high?quality evidence comparing preoperative SEMS with emergency surgery.Methods:Relevant randomized clinical trials (RCTs) were identified from the Cochrane Central Register of Controlled Trials, MEDLINE, Embase and PubMed (1990?2011). Primary outcomes were primary anastomosis, stoma and in?hospital mortality rates. Secondary outcomes included anastomotic leak, 30?day reoperation and surgical?site infection rates.Results:Four RCTs with 234 patients were included. Technical and clinical success rates for stenting were 70·7 per cent (82 of 116) and 69·0 per cent (80 of 116) respectively. The clinical perforation rate was 6·9 per cent (8 of 116) and the silent perforation rate 14 per cent (11 of 77). SEMS intervention resulted in significantly higher successful primary anastomosis (risk ratio (RR) 1·58, 95 per cent confidence interval 1·22 to 2·04; P < 0·001) and lower overall stoma (RR 0·71, 0·56 to 0·89; P = 0·004) rates. There was no difference in primary anastomosis, permanent stoma, in?hospital mortality, anastomotic leak, 30?day reoperation and surgical?site infection rates. Three trials were stopped prematurely, one because the emergency surgery group had a significantly increased anastomotic leak rate, and two others because of stent?related complications and increased 30?day morbidity following SEMS management.Conclusion:Technical and clinical success rates for stenting were lower than expected. SEMS is associated with a high incidence of clinical and silent perforation. However, as a bridge to surgery, SEMS has higher successful primary anastomosis and lower overall stoma rates, with no significant difference in complications or mortality. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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Systematic review and meta?analysis of follow?up after hepatectomy for colorectal liver metastases
Background:The evidence surrounding optimal follow?up after liver resection for colorectal metastases remains unclear. A significant proportion of recurrences occur in the early postoperative period, and some groups advocate more intensive review at this time.Methods:A systematic review of literature published between January 2003 and May 2010 was performed. Studies that described potentially curative primary resection of colorectal liver metastases that involved a defined follow?up protocol and long?term survival data were included. For meta?analysis, studies were grouped into intensive (more frequent review in the first 5 years after resection) and uniform (same throughout) follow?up.Results:Thirty?five studies were identified that met the inclusion criteria, involving 7330 patients. Only five specifically addressed follow?up. Patients undergoing intensive early follow?up had a median survival of 39·8 (95 per cent confidence interval 34·3 to 45·3) months with a 5?year overall survival rate of 41·9 (34·4 to 49·4) per cent. Patients undergoing routine follow?up had a median survival of 40·2 (33·4 to 47·0) months, with a 5?year overall survival rate of 38·4 (32·6 to 44·3) months.Conclusion:Evidence regarding follow?up after liver resection is poor. Meta?analysis failed to identify a survival advantage for intensive early follow?up. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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