Extended versus inpatient thromboprophylaxis with heparins following major open abdominopelvic surgery for malignancy: a systematic review of efficacy and safety.

BACKGROUND: Patients undergoing open abdominopelvic procedures for malignancy are at high risk of postoperative venous thromboembolism (VTE). This risk can be mitigated with prophylaxis; however, optimum duration in this population remains unknown. Our objective was to conduct a systematic review of contemporary literature on the use of heparin thromboprophylaxis following major open pelvic surgery for malignancy, comparing the efficacy and safety of extended duration to inpatient treatment. METHODS: A study protocol describing search strategy and inclusion and exclusion criteria was developed and registered with PROSPERO. A literature review was conducted in accordance with the protocol. RESULTS: Literature review identified only 4 studies directly comparing extended and inpatient duration prophylaxis, with a combined population of 3198 and 3135 patients for VTE rate and bleeding events, respectively. Despite many studies reporting lower VTE rates in patients receiving extended prophylaxis, no statistically significant difference in rates of postoperative VTE (p = 0.18) or bleeding complications (p = 0.43) was identified between patients receiving extended duration prophylaxis and those receiving inpatient only prophylaxis. CONCLUSION: On the review of contemporary literature, no significant difference was found in rates of postoperative VTE or bleeding complications between patients receiving extended duration heparin VTE prophylaxis and those receiving inpatient prophylaxis after open abdominopelvic surgery for malignancy.This raises the question of how extended duration prophylaxis has become common practice in this population, and whether this needs to be re-evaluated.

Evaluation of outcome after cardiomyotomy for achalasia using the Chicago classification.

BACKGROUND: Achalasia can be subdivided into manometric subtypes according to the Chicago classification. These subtypes are proposed to predict outcome after treatment. This hypothesis was tested using a database of patients who underwent laparoscopic Heller's cardiomyotomy with anterior fundoplication. METHODS: All patients who underwent Heller's cardiomyotomy for achalasia between June 1993 and March 2015 were identified from an institutional database. Manometry tracings were retrieved and re-reported according the Chicago classification. Outcome was assessed by a postal questionnaire, and designated a success if the modified Eckardt score was 3 or less, and the patient had not undergone subsequent surgery or pneumatic dilatation. Difference in outcome after cardiomyotomy was analysed with a mixed-effects logistic regression model. RESULTS: Sixty, 111 and 24 patients had type I, II and II achalasia respectively. Patients with type III achalasia were more likely to be older than those with type I or II (mean age 63 versus 50 and 49 years respectively; P = 0·001). Some 176 of 195 patients returned questionnaires after surgery. Type III achalasia was less likely to have a successful outcome than type II (odds ratio (OR) 0·38, 95 per cent c.i. 0·15 to 0·94; P = 0·035). There was no significant difference in outcome between types I and II achalasia (II versus I: OR 0·87, 0·47 to 1·60; P 0·663). The success rate at 3-year follow-up was 69 per cent (22 of 32) for type I, 66 per cent (33 of 50) for type II and 31 per cent (4 of 13) for type III. CONCLUSION: Type III achalasia is a predictor of poor outcome after cardiomyotomy. There was no difference in outcome between types I and II achalasia.

Rigid removable cover for dorsal wound protection and tube fixation in pigs.

OBJECTIVE: To report the design and benefits of a rigid polyethylene cover 'shell' for the protection of dorsal torso wounds and tube fixation in pigs. METHODS: Open C-shaped polyethylene shells were designed to protect wounds and dressings on the dorsum of pigs used in research into negative pressure dressing-assisted wound healing. The shells were designed to resist trauma and contamination, to be comfortable and expansible, and to facilitate tube fixation and management. Strap fixation was optimised during experimentation. Efficacy was assessed by direct observation of dressing and wound protection, tube integrity and by macroscopic and microscopic assessments of wound healing. RESULTS: The shells effectively protected the wounds against blunt and sharp trauma, were simple to remove and reapply, were well tolerated and allowed for growth of the pigs. Circumferential neck straps attached by lateral straps to the shells proved critical. There was no wound infection or inflammation underlying the shells. Porting tubing via mid-dorsal holes in the shells and affixing the tubing just cranial to these holes prevented tube damage and traction, permitted tube management from outside the cages and allowed the pigs to move freely without becoming entangled. CONCLUSION: These shells effectively protected dorsal skin wounds and dressings, prevented tube damage and facilitated tube management in pigs. Similar systems may be useful for other production animals for wound management and for tube management with negative pressure wound healing, drain tubes or the delivery of nutrition, fluids or medications.

Comparative study on acute pancreatitis management.

BACKGROUND: Guidelines have been published regarding the management of acute pancreatitis by the British Society of Gastroenterology (BSG). The aim of the present paper is to compare the management of patients with acute pancreatitis in a tertiary referral medical centre and a regional health centre in Australia during 2001, evaluate compliance with the published BSG guidelines, and compare our data with those of a similar UK study. METHODS: Patients with a primary diagnosis of acute pancreatitis were identified retrospectively. Eighty-four admissions from the Austin Hospital (AH), a tertiary referral centre, and 83 from The Geelong Hospital (TGH), a regional health centre, were treated in these two hospitals. The histories were collected and examined for compliance with the guidelines recommended by the BSG. We compared our data with the data from the two UK hospitals in a previous study. RESULTS: Only 38% of patients from these two centres had all the investigations performed for severity stratification as recommended by BSG. In other respects, AH and TGH managed these patients with acute pancreatitis according to the recommendations. The overall mortality rate from acute pancreatitis was 3.0%, and within the group of severe acute pancreatitis the mortality rate was 22.7%. 65.5% of patients from AH with gallstone related acute pancreatitis had a cholecystectomy or sphincterotomy and extraction of gallstones within 4 weeks of presentation. There were five re-admissions to AH in 2001 due to non-operated gallstone-related acute pancreatitis. In contrast, 84.3% of patients from TGH had definitive treatment within 4 weeks and there were three re-admissions to TGH. CONCLUSION: Overall, both a tertiary referral centre and smaller regional hospital in Australia managed acute pancreatitis according to recently published BSG guidelines. The guidelines emphasized the importance of expertise in hepatopancreatobiliary surgery, availability of intensive care unit/high dependency unit and dynamic CT scanning. The recommendations for definitive treatment of patients with gallstone-related pancreatitis within 4 weeks of presentation reduced the morbidity and mortality in this group. Although compliance with the guidelines on investigation for severity stratification of acute pancreatitis was poor, this lack of formal severity assessment did not appear to influence the outcome.

Ablation of Barrett's epithelium: the promise and the problems.

The incidence of adenocarcinoma of the esophagus has increased dramatically over recent years. Because Barrett's epithelium is recognized as a risk factor for adenocarcinoma there is an interest in reversing this metaplasia. A number of endoscopic methods of destruction of esophageal columnar epithelium have been described. The purpose of this article is to review the currently available methods of managing Barrett's epithelium with particular reference to the role of ablative therapy in reducing the risk of adenocarcinoma.

Systematic review of dynamic graciloplasty in the treatment of faecal incontinence.

BACKGROUND: The aim of this systematic review was to compare the safety and efficacy of dynamic graciloplasty with colostomy for the treatment of faecal incontinence. METHODS: Two search strategies were devised to retrieve literature from the Medline, Current Contents, Embase and Cochrane Library databases up until November 1999. Inclusion of papers depended on a predetermined protocol, independent assessments by two reviewers and a final consensus decision. English language papers were selected. Acceptable study designs included randomized controlled trials, controlled clinical trials and case series. Forty papers met the inclusion criteria. They were tabulated and critically appraised in terms of methodology and design, outcomes, and the possible influence of bias, confounding and chance. RESULTS: No high-level evidence was available and there were no comparative studies. Mortality rates were around 2 per cent for both graciloplasty and colostomy. Morbidity rates reported for graciloplasty appear to be higher than those for colostomy. Dynamic graciloplasty was clearly effective at restoring continence in between 42 and 85 per cent of patients, whereas colostomy is, by its design, incapable of restoring continence. However, dynamic graciloplasty is associated with a significant risk of reoperation. CONCLUSION: While dynamic graciloplasty appears to be associated with a higher rate of complications than colostomy, it is clearly a superior intervention for restoring continence in some patients. It is recommended that a comparative, but non-randomized, study be undertaken to evaluate the safety of dynamic graciloplasty in comparison to colostomy, and that the procedure should be performed only in centres where it is carried out routinely.

Minimal residual marrow disease: detection and significance of isolated tumour cells in bone marrow.

BACKGROUND: Detection of malignant cells in bone marrow and peripheral blood of patients with solid tumours at the time of surgery is increasingly emerging as a prognostic factor for disease progression and a way of monitoring adjuvant therapies. Furthermore, isolation and characterization of these cells provide insight into the early metastatic process, with potential therapeutic implications. This article reviews the current knowledge about the clinical significance of minimal residual marrow disease (MRMD) and its methods of detection, outlining some of their specific technical problems. METHODS: A comprehensive review of articles cited in the largest medical databases was conducted. RESULTS: The sensitivity of the methods of detecting MRMD has improved substantially in the past decade, resulting in higher detection rates. In many solid tumours MRMD has been found to correlate with disease-free and overall survival; however, the importance of this as an independent prognostic variable remains contentious. CONCLUSIONS: There is a need for a standardized approach to the detection of these cells before they become integrated into the current staging systems. The challenge remains to establish which of these tumour cells have the capacity to progress and develop metastatic disease, what are the early genetic and molecular mechanisms underlying this process and to apply novel, better targeted therapies against them.

Ultrasound-assisted lipoplasty.

BACKGROUND: Ultrasound-assisted lipoplasty (UAL) has been associated with particular types of complications and uncertain long-term effects arising from interactions between ultrasonic energy and living tissue. The present review seeks to address these issues. METHODS: Search strategy Three search strategies were devised to retrieve literature from Medline, Current Contents, Embase and Cochrane Library databases up until April 2000. Study selection Inclusion of papers was largely determined using a predetermined protocol. English language papers were selected. Acceptable study designs included randomized controlled trials, controlled clinical trials, case series or case reports. Data collection and analysis Thirty-six papers met the inclusion criteria. They were tabulated and critically appraised in terms of methodology and design, outcomes, and the possible influence of bias, confounding and chance. Other papers were also included to provide background material. RESULTS: There was little high-level evidence available comparing UAL and suction-assisted lipoplasty (SAL), with no conclusive evidence that UAL has a safety benefit, although low-quality evidence suggests that UAL is associated with reduced surgeon fatigue as well as increased operating times, slower aspiration rates and an increased learning curve. There is inadequate evidence to determine whether the theoretical potential for DNA damage from ultrasound is realized in the clinical setting. CONCLUSIONS: The evidence base for UAL is inadequate to determine the procedure's safety and efficacy. The potential for DNA damage must be investigated with appropriate in vivo animal models. Recommendations for the safe use of UAL are discussed.

Publication bias in presentations to the Annual Scientific Congress.

BACKGROUND: Free papers presented to the Annual Scientific Congress (ASC) of the Royal Australasian College of Surgeons (RACS) were reviewed for the years 1994, 1995 and 1996. Reports were examined for evidence of publication bias. METHODS: Suitable free papers were identified from the proceedings of the meetings and authors were contacted to obtain information about the research reported and any publications resulting from it. RESULTS: Responses were obtained from 302 of 576 presentations considered suitable. A total of 55% of responding authors reported publication of their paper. Basic science papers were most likely to be published. There was a significant bias in favour of publication of positive results (98 of 139 positive vs 76 of 159 inconclusive or negative reports; P < 0.01). Retrospective data were as likely to be published as prospective (51% and 57%, respectively). Reports describing studies of high-level evidence were more likely to be published in journals with a high impact factor. CONCLUSION: The ASC is a comprehensive meeting that attracts a wide range of free papers from most sections of the RACS. There appears to be no evidence of bias in selection of papers for inclusion in the meeting but there is bias in the subsequent publication, which favours positive reports.

The introduction of patient-controlled analgesia into an isolated rural hospital.

This study investigated the feasibility of using patient-controlled analgesia (PCA) effectively in a small 70 bed isolated rural hospital. The first 50 patients to use a Bard PCA 1, in the Port Lincoln Hospital, South Australia, were studied. The patients consumed morphine at a mean rate of 1.24 mg/h and used PCA for a mean of 48 h. Thirty-eight per cent of patients required treatment for nausea and other complications which is similar to the rate of those in other published series. Visual analogue pain scores showed excellent pain control, generally without evidence of oversedation; however, there was one episode of respiratory depression. Seventy-eight per cent of patients reported that their pain was relieved most or all of the time. The study demonstrated that a PCA service provided by nursing staff, the GP anaesthetist and rural surgeons is feasible in an isolated rural hospital.

Cervical or thoracic anastomosis for esophagectomy for carcinoma.

A prospective trial was conducted to compare intrathoracic and cervical anastomoses after esophagectomy for squamous cell carcinoma of the middle or lower one-third of the esophagus. One hundred and twenty-three patients were randomized to have either a cervical or thoracic anastomosis. Thirty-one patients were subsequently excluded either because esophagectomy was performed without thoracotomy or the tumor was unresectable or because the randomization protocol was not complied with. Transfusion requirements and operating time were similar for the 49 patients having esophagectomy by way of the laparotomy and right thoracotomy (TA) and the 43 patients who underwent laparotomy, right thoracotomy and cervicotomy (CA). Forty-three per cent of the CA and 49 per cent of the TA patients had involved lymph nodes. An esophagectomy incorporating a cervical anastomosis resulted in a significantly greater margin of macroscopically normal esophagus above the tumor (median of 4.0 versus 1.5 centimeters for TA). A leak was significantly more frequent after cervical anastomosis (26 per cent) than thoracic (4 per cent) (p less than 0.002). Respiratory complications were more frequent with a thoracic anastomosis, but this was not statistically significant. Thirty day mortality rates were similar for the two groups: 14.3 per cent, TA, and 9.3 per cent, CA (p = N.S.). Postoperative strictures occurred in 14 per cent of TA and 23 per cent of CA patients and were most common after an anastomotic leak. The survival patterns of the two groups were similar. The median survival time for CA patients was 23 months and for TA, 20 months. Excluding hospital mortality, 47 per cent of patients were alive at two years and 30 per cent at 40 months. Survival was related to extent of disease. The greater length of tumor-free esophagus removed with a cervical anastomosis did not result in an improved long term survival period, but was associated with a significantly higher incidence of anastomotic fistula.

Repair of suprahepatic caval lesions under extracorporeal circulation in major liver trauma.

A case of major hepatic injury with associated juxtahepatic trauma is reported. Repair of the injuries was effected with the aid of extracorporeal circulation. This aided exposure of the bleeding site while at the same time minimizing blood loss. Hypothermia is an added benefit of this approach, decreasing the risk of hepatic ischaemia.

Peripheral blood leucocyte subpopulations in patients splenectomized for trauma.

Monoclonal antibodies were used to type leucocyte subpopulations in peripheral blood mononuclear leucocytes (MNL) from patients who had had spleens removed following trauma. The proportion of OKT3+ (T) cell and OKT4+ ('T helper/inducer') cell was significantly decreased in splenectomized subjects. While a decrease was also observed for the OKT8+ ('T suppressor/cytotoxic') cells, this was not significant. The ratio of OKT4+/OKT8+ cells was significantly decreased in the splenectomized group. Interestingly, the absolute numbers of OKT3+, OKT4+ and OKT8+ cells were increased. The % of B lymphocytes (identified as Ig+ and FMC1+ cells) was significantly increased in patients. The proportion of MHC Class II+ cells (FMC4+) was also increased although not significantly. A marked increase in % of monocytes (FMC33+) was observed in patients. The changes in proportion of regulatory T cells and monocytes may in part explain the depressed mitogen responses of MNL from splenectomized subjects.

Bile salt-induced injury of rabbit oesophageal mucosa measured by hydrogen ion disappearance.

Oesophageal injury secondary to gastro-oesophageal reflux is unlikely to be due to the effects of hydrochloric acid alone. The present authors have investigated the development of acid and bile salt-induced oesophageal mucosal injury in a rabbit model. Solutions of hydrochloric acid and sodium taurocholate (ST) were perfused through an isolated oesophageal preparation and mucosal injury was determined by measuring the rate of H+ disappearance. Perfusion with acid alone in concentrations up to 10 mmol/l did not affect the H+ disappearance rate. Addition of 1 mmol/l ST to an acid perfusate resulted in loss of H+ from the system. The increase in H+ disappearance rate was associated with loss of ST from the perfusate. Sodium taurocholate was only lost from the system when in an acid medium. Increased rate of H+ disappearance occurred even after the bile salt had been washed out of the perfused oesophagus. The mechanism of bile salt-induced mucosal injury was unlikely to be due to mucosal disruption secondary to micelle formation since the critical micellar concentration of taurocholate was found to be greater than that used in the perfusate. These findings indicate that bile salts may be an important factor in hydrochloric acid-related damage to oesophageal mucosa, by acting through mechanisms unrelated to micelle formation.

Morphological changes caused by exposure of rabbit oesophageal mucosa to hydrochloric acid and sodium taurocholate.

The present authors have studied the light and electron microscopic changes in rabbit oesophageal mucosa which has been exposed to solutions of hydrochloric acid and sodium taurocholate (ST). In an in vivo model the oesophagus was perfused with saline, acid (0.1-40 mmol/l of H+) or taurocholate (0.1-1.0 mmol/l at pH 2.0 or 1.0 mmol/l at neutral pH). At the end of each perfusion experiment the oesophagus was removed and assessed by the naked eye, light and electron microscopy. Some desquamation of superficial stratum corneum cells occurred in all specimens perfused for 5 h. Injury was more evident to the stratum spinosum and basal cell layers. Damage was more severe in the bile salt plus acid perfused specimens, varying between margination of nuclear chromatin in the basal cells to complete necrosis and separation of the overlying layers. Taurocholate in neutral solution did not damage the oesophageal epithelium. Electron microscopy revealed that damage to cells in the basal layers and stratum granulosum occurred within 30 min of exposure to acidified taurocholate, this damage increasing with time. It is concluded that taurocholate is able to damage oesophageal mucosa, that the damage first occurs in the deeper layers of the oesophageal mucosa and that the damage may occur in the absence of gross or light microscopic changes in the mucosa.