Peri-operative administration of tranexamic acid in lower limb arthroplasty: a multicentre, prospective cohort study.

In the UK, tranexamic acid is recommended for all surgical procedures where expected blood loss exceeds 500 ml. However, the optimal dose, route and timing of administration are not known. This study aimed to evaluate current practice of peri-operative tranexamic acid administration. Patients undergoing primary total hip arthroplasty, total knee arthroplasty or unicompartmental knee arthroplasty during a 2-week period were eligible for inclusion in this prospective study. The primary outcome was the proportion of patients receiving tranexamic acid in the peri-operative period. Secondary outcomes included: dose, route and timing of tranexamic acid administration; prevalence of pre- and postoperative anaemia; estimated blood loss; and red blood cell transfusion rates. In total, we recruited 1701 patients from 56 NHS hospitals. Out of these, 1523 (89.5%) patients received tranexamic acid and of those, 1052 (69.1%) received a single dose of 1000 mg intravenously either pre- or intra-operatively. Out of the 1701 patients, 571 (33.6%) and 1386 (81.5%) patients were anaemic (haemoglobin < 130 g.l-1 ) in the pre- and postoperative period, respectively. Mean (SD) estimated blood loss for all included patients was 792 (453) ml and 54 patients (3.1%) received a red blood cell transfusion postoperatively. The transfusion rate for patients with pre-operative anaemia was 6.5%, compared with 1.5% in patients without anaemia. Current standard of care in the UK is to administer 1000 mg of tranexamic intravenously either pre- or intra-operatively. Approximately one-third of patients present for surgery with anaemia, although the overall red blood cell transfusion rate is low. These data provide useful comparators when assessing the efficacy of tranexamic acid and other patient blood management interventions in future studies.

The role of intra-operative cell salvage in patient blood management for revision hip arthroplasty: a prospective cohort study.

Cell salvage is an important component of blood management in patients undergoing revision hip arthroplasty surgery. However concerns regarding efficacy and patient selection remain. The aims of this study were to describe intra-operative blood loss, cell salvage re-infusion volumes and red blood cell transfusion rates for revision hip procedures and to identify factors associated with the ability to salvage sufficient blood intra-operatively to permit processing and re-infusion. Data were collected from a prospective cohort of 664 consecutive patients undergoing revision hip surgery at a single tertiary centre from 31 March 2015 to 1 April 2018. Indications for revision surgery were aseptic (n = 393 (59%)) fracture (n = 160 (24%)) and infection (n = 111 (17%)). Salvaged blood was processed and re-infused when blood loss exceeded 500 ml. Mean (SD) intra-operative blood loss was 1038 (778) ml across all procedures. Salvaged blood was re-infused in 505 of 664 (76%) patients. Mean (SD) re-infusion volume was 253 (169) ml. In total, 246 of 664 (37%) patients received an allogeneic red blood cell transfusion within 72 h of surgery. Patients undergoing femoral component revision only (OR (95%CI) 0.41 (0.23-0.73)) or acetabular component revision only (0.53 (0.32-0.87)) were less likely to generate sufficient blood salvage volume for re-infusion compared with revision of both components. Compared with aseptic indications, patients undergoing revision surgery for infection (1.87 (1.04-3.36)) or fracture (4.43 (2.30-8.55)) were more likely to generate sufficient blood salvage volume for re-infusion. Our data suggest that cell salvage is efficacious in this population. Cases where the indication is infection or fracture and where both femoral and acetabular components are to be revised should be prioritised.

Women presenting with lower abdominal pain: a missed opportunity for chlamydia screening?

INTRODUCTION: Many young women presenting with lower abdominal pain are referred to general surgeons with possible appendicitis. For some of these patients there will be a gynaecological cause for their pain. There has been a steady increase in the incidence of Chlamydia infections and pelvic inflammatory disease (PID) among the general population. Therefore, are general surgeons considering this as a diagnosis for lower abdominal pain in women? METHODS: One hundred and ninety three women who had been admitted with lower abdominal pain to a single hospital between 1999 and 2001 were identified using computerised records and the notes were examined. One hundred and eighty six women were included in the audit. Investigations and treatments instigated for these patients were then carefully recorded. RESULTS: Seventy-four patients underwent appendicectomy, of which 59 were histologically confirmed. Eighty-nine patients (47.8%) of admissions had no final diagnosis and were not screened for Chlamydia trachomatis. Sexual history was recorded in only 51% of admissions. Vaginal swabs were sent in only 7.3% of admissions. CONCLUSION: Current guidelines for Chlamydia trachomatis screening produced by the Chief Medical Officer (CMO) include screening in women presenting with lower abdominal pain as well as those with post-coital or intermenstrual bleeding. Most women who present with classical symptoms of PID will present to gynaecological specialities for further management. However, a significant number of women presenting atypically will be referred to surgeons to exclude gastrointestinal causes for their lower abdominal pain. These women could and probably should be screened for Chlamydia trachomatis.

The emergent role of focal liver ablation techniques in the treatment of primary and secondary liver tumours.

Only 20% of patients with primary or secondary liver tumours are suitable for resection because of extrahepatic disease or the anatomical distribution of their disease. These patients could be treated by ablation of the tumour, thus preserving functioning liver. This study presents a detailed review of established and experimental ablation procedures. The relative merits of each technique will be discussed and clinical data regarding the efficacy of the techniques evaluated. A literature search from 1966 to 2003 was undertaken using Medline, Pubmed and Web of Science databases. Keywords were Hepatocellular carcinoma, liver metastases, percutaneous ethanol injection, cryotherapy, microwave coagulation therapy, radiofrequency ablation, interstitial laser photocoagulation, focused high-intensity ultrasound, hot saline injection, electrolysis and acetic acid injection. Ablative techniques offer a promising therapeutic modality to treat unresectable tumours. Large-scale randomised controlled trials are required before widespread acceptance of these techniques can occur.

Angiogenesis of gastrointestinal tumours and their metastases--a target for intervention?

Angiogenesis is an obligatory event for the growth of tumours beyond 2 mm in diameter, above which simple oxygen diffusion can no longer support the rapid proliferation of malignant cells. Angiogenesis is a fine balance between inhibitory and stimulatory factors, the knowledge of which offers novel targets for the treatment of gastrointestinal neoplasia. A literature search of Pubmed and Medline databases was undertaken, using the keywords colorectal cancer, pancreatic cancer, gastrointestinal cancer, angiogenesis and anti-angiogenesis therapy. It was found that angiogenesis in primary tumours is a sequential and highly complex cascade of molecular events resulting in the rapid exponential growth of the tumour. Hepatic metastases of primary tumours may be less reliant on traditional angiogenic pathways, by co-opting pre-existing hepatic vasculature. Research into angiogenesis has revealed many different sites that can be targeted by agents such as tyrosine kinase inhibitors. Many anti-angiogenic agents are undergoing preclinical evaluation, with only a few entering phase I and phase III clinical trials. However, early results suggest that anti-angiogenic therapy could be an important adjunct to conventional chemotherapy treatment of gastrointestinal neoplasia.

Two-stage liver resection and chemotherapy for bilobar colorectal liver metastases.

BACKGROUND: A significant number of patients with colorectal metastatic disease confined to the liver are inoperable at assessment. For these patients, the outlook is poor. Chemotherapy can 'down-stage' some tumours and render them operable. The authors present a series of patients with inoperable disease despite down-staging with chemotherapy, who underwent a two-stage resection to clear their metastatic disease. METHODS: The case-notes of 11 patients who were found to have inoperable hepatic metastatic disease were identified using computerised medical records and mean hospital stay, survival and long-term follow-up data was noted. RESULTS: The mean follow-up from initial resection was 13.5 months (range of 5-20 months). Three deaths were recorded in the follow-up interval. Causes of death included recurrence of hepatic disease following completion of two-stage resection, progression of original hepatic disease leading to inoperability at second stage operation and recurrence of original primary colorectal tumour. The mean survival in the patients who died was 17 months (range of 15-19 months). The remaining patients are alive to date with six patients showing no evidence of hepatic recurrence, follow-up period of 13 months (range of 8-20 months). One patient developed de novo prostate cancer and is awaiting his second liver resection, and one patient has stable hepatic disease with no evidence of progression. CONCLUSION: Two-stage liver resection can prolong survival when compared to chemotherapy alone, with a recurrence rate equivalent to ablation techniques. Longer-term studies are needed for further evaluation.

How valuable is ascitic cytology in the detection and management of malignancy?

INTRODUCTION: Ascitic cytology is often requested in the early stages of ascitic assessment. A review of this practice in a major English teaching hospital is presented. METHOD: Patients were retrospectively identified using the histopathology and patient administration system between January 1999 and May 2001. RESULTS: Of 276 samples sent for assessment 35 cases were found to be negative when on further review an intra-abdominal malignancy was present. The malignancy was diagnosed using a radiological modality. The sensitivity of ascitic cytology was found to be 60% with 100% specificity. A delay of up to five days could be incurred awaiting the cytology results before further radiological examinations were undertaken. CONCLUSION: Too much hope is placed on ascitic cytology to provide the diagnosis at the expense of other investigations. It is recommended that the initial assessment should concentrate on history, examination, and basic tests on ascitic fluid to assess the serum-ascites albumin gradient. Ovarian malignancy is the only tumour type yielding a significant rate of detection from cytology with some prognostic impact. Results should not be awaited before abdominal ultrasound is undertaken. This more directed practice would help reduce unnecessary workload for the pathologist and has resource implications.

Validation of electrode placement in neonatal electrogastrography.

Electrogastrography (EGG) is the transcutaneous measurement of gastric electrical activity. The aims of this study were to validate the electrode placement position in neonatal electrogastrography using ultrasonography to localise the stomach, and to describe the observed EGG frequency characteristics. Fifteen neonates with no known abdominal disorder were studied. Two bipolar EGG recordings were obtained from each subject, the first from electrodes placed at sites localized by ultrasound and the second from electrodes placed at the currently recommended sites. Paired sample t tests were used to compare electrode positioning and electrogastrographic data. There were 15 subjects with a mean age of 36 days (range 1-95). While there was a significant difference in the position of electrodes at each site, the EGG recordings did not differ. The 3-cycle/minute (2.6-3.7cpm) activity ranged from 30% to 84% of recorded time (mean at sites localized with ultrasound was 53%, and at currently recommended sites it was 50%; difference not significant, P = 0.155). Bradygastria (<2.6 cpm) was observed in the range of 2-29% of recorded time (mean at sites localised with ultrasound was 12.9%, and at currently recommended sites it was 11.7%; difference not significant, P = 0.40). Tachygastria (3.2-10 cpm) was shown to be in the range of 10-58% of recorded time (mean at sites localized with ultrasound was 33.3%, and at currently recommended sites it was 38.7%; difference not significant; P = 0.044). In conclusion, there was no significant difference between EGG recordings taken from electrode sites localized by ultrasound and those recommended by manufacturers of the electrogastrogram, thus confirming the validity of the manufacturer's recommended electrode positioning. The pattern of electrical control activity in the normal neonatal stomach appears to be different from that demonstrated in adults. Bradygastria and tachygastria are seen more frequently, with fewer periods of 3 cpm activity.

Management of benign rectal strictures: a review of present therapeutic procedures.

PURPOSE: A significant benign stricture of the rectum is uncommon but can be a recalcitrant condition to treat. Case reports detailing a particular treatment option abound in the surgical literature. An overall précis of the different techniques available is presented, with a comparison of their relative strengths and weaknesses. METHODS: A literature search was undertaken from 1963 to the present day, using MEDLINE. Keywords were benign, strictures, and rectum. RESULTS: Balloon dilation is the most frequent intervention described in the literature. Repeated dilation with time often is required to achieve normal bowel function. Electrocautery resection or incision combined with dilation increases the success rate without increasing the complication rate. Transanal strictureplasty with mechanical staplers is reported as achieving the best success with the smallest complication rate; however, only a minority of strictures are suitable to be managed in this way, and therefore, the numbers treated are small. CONCLUSIONS: All of the techniques reviewed compared favorably with formal stricture resection in terms of success rate and complications.

A snapshot of MDT working and patient mapping in the UK colorectal cancer centres in 2002.

OBJECTIVES: To ascertain the position nationally of Colorectal Multi-Disciplinary Team (MDT) implementation as part of the NHS cancer plan. Also to define nationally patterns of 'bottlenecks' in the patient journey from referral to treatment. METHODS: A simple questionnaire was sent to the lead clinician at all 183 cancer networks asking about their current MDT organization, and whether they had undertaken a mapping exercise of the patient journey. RESULTS: Ninety-one percent (n = 166) of the questionnaires were returned, and of these 90% (n = 150) stated that their MDT meeting was up and running. Sixty-two percent (n = 102) stated they were having problems running their MDT meeting and of these 32% (n = 33) did not have a dedicated MDT clerk. Several of the Calman-Hine identified 'core personnel' are attending infrequently. Sixty-four percent (n = 107) of respondents have carried out a patient mapping process with 65% (n = 70) claiming it was a success, leaving 27% (n = 32) with no immediate plans to undertake the process. CONCLUSIONS: Although MDT activity is near-universal, the survey has highlighted a wide variation in MDT meeting implementation across England, with the same problems being experienced by most centres. Organizational problems are common, and we feel that a dedicated MDT clerk is essential for smooth running. Further areas that require development have been identified by most respondents as radiological, oncological and endoscopic services. It is anticipated that true collaboration nationally will develop, and contact with the nine pilot sites is encouraged to explore solutions to difficulties.

Effect of patient, operative and isolation factors on subsequent yield and viability of human hepatocytes for research use.

It is widely accepted that the model of choice for pharmacotoxicological studies are human hepatocytes. There is therefore a demand for these cells, but quality must be maintained for their widespread use. We present a retrospective review of the isolation of hepatocytes from both surgically resected tissue and livers rejected for transplantation, and evaluated patient, operative and isolation variables to ascertain which may affect the viability and yield of cells. Seven clinically rejected whole livers and 60 surgically resected specimens (from two distinct operating centres) were isolated. For surgically resected tissue we found that decreasing age, securing the perfusing cannulae with suture rather than reforming Glissons capsule with glue and steatotic livers improved viability. No significant correlation could be found with pre-operative blood results, disease, type of operation, presence or absence of Pringle manoeuvre, weight of tissue isolated, time of digestion with collagenase and cold ischaemic time. There was a reduction in mean yield and viability when hepatocyte isolations were performed in livers rejected for transplant, compared to surgically resected tissue although this did not reach significance. Human hepatocytes can be successfully and consistently isolated from surgically resected tissue and appear to be superior to those isolated from rejected for transplant livers. From our study, there are few parameters that significantly affect the quality of isolated hepatocytes, which increases the possible pool of tissue that hepatocytes can be isolated from.