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British Journal of Surgery
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Wiley InterScience : British Journal of Surgery
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Critical appraisal of single port access cholecystectomy
Single port access (SPA) cholecystectomy is a new concept in laparoscopic surgery. A review of existing results was performed to evaluate critically the current state of SPA with specific reference to feasibility, safety, learning curve, indications and cost-effectiveness.All papers identified in MEDLINE until 15 February 2010 and all other relevant papers obtained from cited references were reviewed, without any language restriction. Case reports and series of fewer than three patients were excluded.After selection, 24 studies including 895 patients were analysed. None was randomized. Feasibility seems to be established, with a conversion rate of 2 per cent. SPA was not standardized and there was much technical variation. The learning curve could not be determined. Median follow-up time was 3 (range 0·25-12) months. The overall published complication rate was 5·4 per cent and the biliary complication rate 0·7 per cent. The rate of umbilical complications ranged from 2 to 10 per cent.SPA cholecystectomy seems feasible, but standardization, safety and the real benefits for patients need further assessment. Uncontrolled wide adoption of this approach may be responsible for a rise in biliary complications. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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Hepatic ischaemia-reperfusion injury from bench to bedside
Vascular occlusion to prevent haemorrhage during liver resection causes ischaemia-reperfusion (IR) injury. Insights into the mechanisms of IR injury gathered from experimental models have contributed to the development of therapeutic approaches, some of which have already been tested in randomized clinical trials.The review was based on a PubMed search using the terms 'ischemia AND hepatectomy', 'ischemia AND liver', 'hepatectomy AND drug treatment', 'liver AND intermittent clamping' and 'liver AND ischemic preconditioning'; only randomized controlled trials (RCTs) were included.Twelve RCTs reported on ischaemic preconditioning and intermittent clamping. Both strategies seem to confer protection and allow extension of ischaemia time. Fourteen RCTs evaluating pharmacological interventions, including antioxidants, anti-inflammatory drugs, vasodilators, pharmacological preconditioning and glucose infusion, were identified.Several strategies to prevent hepatic IR have been developed, but few have been incorporated into clinical practice. Although some pharmacological strategies showed promising results with improved clinical outcome there is not sufficient evidence to recommend them. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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Systematic review of the benefits and risks of neoadjuvant chemoradiation for oesophageal cancer
Surgery alone for locally advanced oesophageal cancer is associated with low cure rates. The benefits and risks of neoadjuvant chemoradiation for patients with oesophageal cancer were evaluated.A systematic review of publications between 2000 and 2008 on neoadjuvant chemoradiation for oesophageal cancer was undertaken.Thirty-eight papers comprising 3640 patients met the inclusion criteria. Chemoradiation regimens varied widely with a predominance of 5-fluorouracil/cisplatin chemotherapy. Chemoradiation-related toxicity was reported in only ten studies and consisted mainly of neutropenia. The chemoradiation-related mortality rate was 2·3 per cent. The mean R0 resection rate and pathological complete response (pCR) rate were 88·4 and 25·8 per cent respectively. Postoperative morbidity was not uniformly reported. The in-hospital mortality rate after oesophagectomy following chemoradiation was 5·2 per cent. Five-year survival rates varied from 16 to 59 per cent in all patients and from 34 to 62 per cent in those with a pCR. Chemoradiation had a temporary negative effect on quality of life.Neoadjuvant chemoradiation regimens for oesophageal cancer vary widely. Besides traditional outcome variables (such as survival), other parameters should be analysed (for example toxicity) to assess whether the risks of chemoradiation are sufficiently compensated for by the benefits. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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Randomized clinical trial of short-term outcomes following purse-string versus conventional closure of ileostomy wounds
Ileostomy closure is an operation with an underappreciated morbidity, including surgical-site infection, small bowel obstruction and anastomotic leakage. Surgical-site infections, in particular, are a frequent occurrence following closure of contaminated wounds. This randomized controlled trial compared a purse-string closure technique with conventional linear closure.Sixty-one patients were randomized to conventional or purse-string closure of ileostomy wounds. The primary endpoint was the incidence of surgical-site infection, including infections requiring hospital or community treatment.Purse-string closure resulted in fewer surgical-site infections than conventional closure: two of 30 versus 12 of 31 respectively (P = 0·005).The purse-string method results in a clinically relevant reduction in surgical-site infections after ileostomy closure. Registration number: ACTRN12609000021279 (Australian New Zealand Clinical Trials Registry: ). Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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Randomized clinical trial of mesh versus sutured wound closure after open abdominal aortic aneurysm surgery
Incisional herniation is a common complication of abdominal aortic aneurysm (AAA) repair. This study investigated whether prophylactic mesh placement could reduce the rate of postoperative incisional hernia after open repair of AAA.This randomized clinical trial was undertaken in three hospitals. Patients undergoing elective open AAA repair were randomized to routine abdominal mass closure after AAA repair or to prophylactic placement of polypropylene mesh in the preperitoneal plane.Eighty-five patients with a mean age of 73 (range 59-89) years were recruited, 77 (91 per cent) of whom were men. There were five perioperative deaths (6 per cent), two in the control group and three in the mesh group (P = 0·663), none related to the mesh. Sixteen patients in the control group and five in the mesh group developed a postoperative incisional hernia (hazard ratio 4·10, 95 per cent confidence interval 1·72 to 9·82; P = 0·002). Hernias developed between 170 and 585 days after surgery in the control group, and between 336 and 1122 days in the mesh group. Four patients in the control group and one in the mesh group underwent incisional hernia repair (P = 0·375). No mesh became infected, but one was subsequently removed owing to seroma formation during laparotomy for small bowel obstruction.Mesh placement significantly reduced the rate of postoperative incisional hernia after open AAA repair without increasing the rate of complications. Registration number: ISRCTN28485581 (). Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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Randomized double-blind placebo-controlled crossover study of caffeine in patients with intermittent claudication
Intermittent claudication is a disabling symptom of peripheral arterial disease for which few medical treatments are available. This study investigated the effect of caffeine on physical capacity in patients with intermittent claudication.This randomized double-blind placebo-controlled crossover study included 88 patients recruited by surgeons from outpatient clinics. The participants abstained from caffeine for 48 h before each test and then received either a placebo or oral caffeine (6 mg/kg). After 75 min, pain-free and maximal walking distance on a treadmill, perceived pain, reaction times, postural stability, maximal isometric knee extension strength, submaximal knee extension endurance and cognitive function were measured. The analysis was by intention to treat.Caffeine increased the pain-free walking distance by 20·0 (95 per cent confidence interval 3·7 to 38·8) per cent (P = 0·014), maximal walking distance by 26·6 (12·1 to 43·0) per cent (P < 0·001), muscle strength by 9·8 (3·0 to 17·0) per cent (P = 0·005) and endurance by 21·4 (1·2 to 45·7) per cent (P = 0·004). However, postural stability was reduced significantly, by 22·1 (11·7 to 33·4) per cent with eyes open (P < 0·001) and by 21·8 (7·6 to 37·8) per cent with eyes closed (P = 0·002). Neither reaction time nor cognition was affected.In patients with moderate intermittent claudication, caffeine increased walking distance, maximal strength and endurance, but affected balance adversely. Registration number: NCT00388128 (). Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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Randomized clinical trial of gut-specific nutrients in critically ill surgical patients
Inadequate gut function is common and may adversely affect prognosis. However, it is difficult to measure and treatment options are limited. This study evaluated whether gut-specific nutrients (GSNs) could stimulate the return of gut function in critically ill patients, and assessed what effect, if any, this would have on patient outcomes.Consecutive critically ill patients intolerant to enteral feeding were randomized to receive a cocktail of GSNs or placebo. Administration was for 1 month and patients were followed for 3 months. The primary endpoint was the time to return of normal gut function.Twenty-five patients were randomized to each group. GSN administration was associated with a quicker return of normal gut function (median 164 versus 214 h; P = 0·016), attenuation of the acute-phase response and a lower incidence of sepsis (4 versus 13 patients, P = 0·015) compared with placebo. There were fewer deaths by 3 months in the GSN group but this did not achieve significance (2 versus 7 deaths; P = 0·138).GSNs expedite the return of gut function in the critically ill and improve outcomes. Inadequate gut function may be associated with poor prognosis similar to that of other single organ failures. Registration number: ISRCTN61157513 (). Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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Five-year follow-up of the Medical Research Council CLASICC trial of laparoscopically assisted versus open surgery for colorectal cancer
The UK Medical Research Council CLASICC trial assessed the safety and efficacy of laparoscopically assisted surgery in comparison with open surgery for colorectal cancer. The results of the 5-year follow-up analysis are presented.Five-year outcomes were analysed and included overall and disease-free survival, and local, distant and wound/port-site recurrences. Two exploratory analyses were performed to evaluate the effect of age (70 years or less, or more than 70 years) on overall survival between the two groups, and the effect of the learning curve.No differences were found between laparoscopically assisted and open surgery in terms of overall survival, disease-free survival, and local and distant recurrence. Wound/port-site recurrence rates in the laparoscopic arm remained stable at 2·4 per cent. Conversion to open operation was associated with significantly worse overall but not disease-free survival, which was most marked in the early follow-up period. The effect of surgery did not differ between the age groups, and surgical experience did not impact on the 5-year results.The 5-year analyses confirm the oncological safety of laparoscopic surgery for both colonic and rectal cancer. The use of laparoscopic surgery to maximize short-term outcomes does not compromise the long-term oncological results. Registration number: ISRCTN74883561 (). Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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Predictors of permanent ileostomy after restorative proctocolectomy
Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is a surgical approach for ulcerative colitis and familial adenomatous polyposis. This study evaluated predictors of the need for a permanent ileostomy to identify patients at high risk of IPAA failure.This was a retrospective analysis of patients who underwent proctocolectomy and IPAA between 1997 and 2008. A logistic regression model was used for multivariable analysis of potential risk factors.Proctocolectomy was combined with IPAA in 185 patients, of whom 169 had a loop ileostomy formed. IPAA and ileostomy closure were successful in 162 patients (87·6 per cent). Reasons for not closing the ileostomy included pouch failure (16 patients), patient choice (5) and death (2). Thus one in eight patients had a permanent ileostomy after planned IPAA. Age was the major predictor of the need for a permanent ileostomy in multivariable analysis (P = 0·002) with a probability of more than 25 per cent in patients aged over 60 years. However, advancing age was associated with colitis, co-morbidity, obesity and corticosteroid use.The probability of the need for a permanent ileostomy after IPAA increases with age. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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Outcomes of intensive surveillance after resection of hepatic colorectal metastases
The impact of computed tomography (CT)-based follow-up for the detection of resectable disease recurrence following surgery for colorectal liver metastases (CRLM) was evaluated.Some 705 patients undergoing resection of CRLM between January 1993 and March 2007 were included. Surveillance comprised 3-monthly CT (thorax, abdomen and pelvis) in the first 2 years after surgery, 6 monthly for 3 years and annually from years 6 to 10. Survival differences following recurrence between patients managed surgically and palliatively were determined, and the cost was calculated.Five-year disease-free and overall survival rates were 28·3 and 32·3 per cent respectively. Of 402 patients who developed recurrence within 2 years, 88 were treated with liver resection alone and 36 with lung and/or liver resection. Their 5-year overall survival rates were 31 and 30 per cent respectively, compared with 3·9 per cent in 278 patients managed palliatively (P < 0·001). For each 3-month interval during the first year of follow-up, patients with recurrence treated surgically had better overall survival than those treated palliatively. The cost of surveillance that identified 124 patients amenable to further resection was £12 338 per operated recurrence. Assuming that patients with recurrence gained 5 years' survival, the mean survival gain was 4·28 years per resection and the cost per life-year gained was £2883.Intensive 3-monthly CT surveillance after liver resection for CRLM detects recurrence that is amenable to further resection in a considerable number of patients. These patients have significantly better survival with a reasonable cost per life-year gained. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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