Systematic review and meta-analysis of hepatic resection versus transarterial chemoembolization for solitary large hepatocellular carcinoma.

BACKGROUND: Surgical techniques and pre-operative patient evaluation have improved since the initial development of the Barcelona clinic liver cancer staging system. The optimal treatment for solitary hepatocellular carcinoma ≥5 cm remains unclear. The aim of this study was to review the long-term survival outcomes of hepatic resection versus transarterial chemoembolisation (TACE) for solitary large tumours. METHODS: EMBASE, MEDLINE, Pubmed and the Cochrane database were searched for studies comparing resection with TACE for solitary HCC ≥5 cm. The primary outcome was overall survival at 1, 3 and 5 years. RESULTS: The meta-analysis combined the results of four cohort studies including 861 patients where 452 underwent hepatic resection and 409 were treated with TACE to an absence of viable tumour. The pooled HR for 3 year OS rate calculated using the random effects model was 0.60 (95% CI 0.46-0.79, p < 0.001; I2 = 54%, P = 0.087). The pooled HR for 5 year OS rate calculated using the random effects model was 0.59 (95% CI 0.43-0.81, p = 0.001; I2 = 80%, P = 0.002). CONCLUSION: Hepatic resection has been shown to result in greater survivability and time to disease progression than TACE for solitary HCC ≥5 cm. Where a patient is fit for surgery, has adequate liver function and a favourable tumour, resection should be considered.

How Does Cholecystectomy Influence Recurrence of Idiopathic Acute Pancreatitis?

BACKGROUND: Idiopathic acute pancreatitis is diagnosed in approximately 10-30 % of cases of acute pancreatitis. While there is evidence to suggest that the cause in many of these patients is microlithiasis, this fact has not been translated into a resource efficient treatment strategy that is proven to reduce recurrence rates. The aim of this study was to examine the value of prophylactic cholecystectomy following an episode of acute pancreatitis in patients with no history of alcohol abuse and no stones found on ultrasound. METHODS: This was a retrospective study of 2236 patients who presented to a regional Australian hospital. Patients were included when diagnosed with acute pancreatitis with no confirmed cause. Recurrence of acute pancreatitis was compared between those that did and did not undergo cholecystectomy. RESULTS: One hundred ninety-five consecutive patients met the study definition of "idiopathic" acute pancreatitis. 33.8 % (66/195) underwent cholecystectomy. The patients who had cholecystectomy had a recurrence rate of 19.7 % (13/66) whereas, of those managed expectantly, 42.8 % (68/159) had at least one recurrence of acute pancreatitis (P = 0.001). CONCLUSIONS: Following an episode of acute pancreatitis with no identifiable cause, in patients fit for surgery, cholecystectomy should be considered to reduce the risk of recurrent episodes of pancreatitis.

The Simple Prognostic Index (SPI)--a pathophysiologic prognostic scoring tool for emergency laparotomy.

BACKGROUND: Laparotomy is commonly performed as an emergency operation. It is often performed on elderly patients with high risks of mortality and morbidity. Currently, there is no accurate scoring system to predict mortality and morbidity, preoperatively, in these circumstances. This study was conducted to develop a scoring system that can accurately predict the risk of in-hospital mortality and complications for these patients in the emergency department prior to surgery. PATIENTS AND METHODS: Middlemore Hospital data were searched for patients who underwent emergency laparotomy for an acute abdominal condition between January 1997 and December 2006. Data collected included age, gender, presenting diagnosis, indications for surgery, acute physiologic parameters, and also data on associated comorbidities. We categorized patients for the risk of morbidity and 30-d mortality. The risk categorization was based on preoperative existing comorbidities and acute disturbances of physiologic parameters. Regression analysis was used to correlate between acute laboratory parameters, patients age and gender, clinical premorbid conditions, and surgical procedures with the risk of mortality and rates of complications. RESULTS: Emergency laparotomy was performed on 1712 patients. The median age was 58 and there were 896 male patients. Patients with one or two minor comorbidities had comparable mortality and complication rate to those with no comorbidities. There was high correlation between factors that denoted the onset of multiple organ failure with in-hospital mortality and complication rates. This allowed us to divide patients into four prognostic groups with increasing mortality and morbidity. CONCLUSIONS: Mortality and morbidity after emergency laparotomy are closely related to the presence or absence of acute physiologic impairment and the presence or absence of chronic organ system failure. The Simple Prognostic Index (SPI) is a simple scoring system for prediction of mortality and morbidity prior to emergency laparotomy.

Use of statins in adhesive small bowel obstruction.

BACKGROUND: Adhesive small bowel obstruction (ASBO) causes considerable morbidity and may require surgical intervention. The role of statins in adhesion prevention is of increasing interest, though no investigation of its impact on ASBO and operative rates has been conducted. This study investigates the impact of statin use on operative rates in ASBO. METHODS: A retrospective review of all patients with ASBO within our institution from January 1997 to December 2007 was conducted. Demographic data, potential confounders, and treatment received (conservative/operative) were recorded. Statistical significance was determined using the two-tailed Fisher's exact test for categorical data and the Mann-Whitney U test for continuous data. Univariate and logistic regression were conducted to control for potential known confounders. RESULTS: There were 419 cases of ASBO with 253 (60.4%) females. The median age of diagnosis was 62 (15-93) years and the median ASA score was 2 (1-4). Forty-nine (11.7%) patients required operative management, the median day-stay was three (1-154) d and 151 (36%) patients were taking statins. On univariate analysis, statin use was associated with decreased operative rates (P = 0.02). The relative risk was 0.46 with an absolute risk reduction of 7.9% (95% CI: 2.1%-13.7%). The number needed to treat was 13 (NNT = 13; 95% CI: 7.3-46.8). Statin use was associated with decreased operative rates using a logistic regression model (P = 0.04). CONCLUSION: Statin use is independently associated with decreased operative rates in ASBO.

Smoking is a major risk factor for wound dehiscence after midline abdominal incision; case-control study.

BACKGROUND: The incidence of acute fascial wound dehiscence (AFWD) after major abdominal operations is as high as 3%. AFWD is associated with mortality rates of 15-20%. Male gender, advanced age and numerous systemic factors including malignancy hypoproteinemia and steroid use have been associated with increased risk. The aim of the present study was to investigate the association between smoking prevalence and AFWD. METHODS: Middlemore Hospital records were retrieved from the 1997-2006 period for patients who had undergone midline abdominal surgery and developed AFWD. A return to the operating theatre for closure of the fascial dehiscence was required for study group inclusion. Each patient in the study group was matched to two control patients who had been admitted in the same year for surgery and who had a similar initial surgical intervention. Conditional logistic regression was used to calculate odds ratios with 95% confidence intervals, representing the risk of developing fascial wound dehiscence in smokers compared with the non-smoking group. RESULTS: There were 52 patients (32 male, 20 female) and 104 controls (64 male, 40 female). Median age for both groups was 63 years. A history of heavy tobacco use (> or =20 pack-years) was more prevalent in those who had AFWD (46%) compared with the control group (16%; P = 0.0002; odds ratio 3.7). CONCLUSIONS: Smoking is associated with an increased incidence of acute fascial wound dehiscence following laparotomy. It is not known whether smoking is a causal or a surrogate factor.

What happens to the external carotid artery following carotid endarterectomy?

AIMS: The effect of carotid endarterectomy on the patency of the external carotid artery is unknown. We conducted a retrospective study to evaluate the long-term changes in the external carotid artery following carotid endarterectomy. METHODS: Data was prospectively recorded for all patients who had carotid endarterectomy between 1997 and 2006 in our vascular surgical unit. These patients had follow-up with carotid duplex ultrasound to assess the patency of the internal and external carotid artery. The data were retrieved and evaluated for patency and flow characteristic in both arteries before and after surgery. RESULTS: Carotid endarterectomy was performed on 255 occasions in 236 patients over the ten year study period. Immediate and long-term outcome of carotid endarterectomy is comparable to results at other major centers. Stenosis of the external carotid artery as detected by duplex scan occurred in 5.5% of patients and was totally asymptomatic. CONCLUSION: Our results of carotid endarterectomy are comparable to other centers. Long-term follow up of the external carotid artery with duplex scan showed asymptomatic stenosis in a small percentage of patients.

Resection of peritoneal metastases causing malignant small bowel obstruction.

BACKGROUND: Resection of peritoneal metastases has been shown to improve survival in patients with abdominal metastatic disease from abdominal or extra abdominal malignancy. This study evaluates the benefit of peritoneal metastatic resection in patients with malignant small bowel obstruction and a past history of treated cancer. PATIENTS AND METHODS: Patients undergoing laparotomy for resection of peritoneal metastases from recurrence of previous cancer between 1992-2003 were reviewed retrospectively. Data were collected about type of primary cancer, interval to recurrence, extent of the disease and completeness of resection, morbidity and mortality and long-term survival. RESULTS: Between 1992 and 2003 there were 79 patients (median age 62, range 19-91) who had laparotomy for small bowel obstruction due to recurrent cancer. The primary cancer was colorectal (31), gynaecologic cancer (19), melanoma (16) and others (13). Overall, the rate of complications was 35% and mortality was 10%. Median survival was 5 months; patients with history of colorectal cancer had better survival than other cancer (median survival 7 months vs. 4 months; p = 0.02). Multivariate analysis showed that the extent of recurrent disease was the only factor that affected overall survival. CONCLUSION: Laparotomy for small bowel obstruction is a worthwhile option for patients with malignant small bowel obstruction. Although it is associated with significant morbidity and mortality it offers a reasonable survival benefit in particular for patients with completely resectable disease.

What clinical and laboratory parameters determine significant intra abdominal pathology for patients assessed in hospital with acute abdominal pain?

BACKGROUND: Abdominal pain is a common cause for emergency admission. While some patients have serious abdominal pathology, a significant group of those patients have no specific cause for the pain. This study was conducted to identify those who have non-specific abdominal pain who can be either admitted short term for observation or reassured and discharged for outpatient management. PATIENTS AND METHODS: A prospective documentation of clinical and laboratory data was obtained on a consecutive cohort of 286 patients who were admitted to a surgical unit over a nine month period with symptoms of abdominal pain regarded severe enough for full assessment in the casualty department and admission to a surgical ward. The patients were followed until a definite diagnosis was made or the patient's condition and abdominal pain improved and the patient discharged. The hospital where the study took place is a small peripheral general hospital draining a population of 120,000 people in a rural area in New Zealand. RESULTS: There were 286 admissions to the emergency department. Logistic regression multivariate statistical analysis showed that guarding raised white cells count, tachycardia and vomiting were the only variables associated with significant pathology. CONCLUSION: Patients with no vomiting, no guarding, who have normal pulse rates and normal white cell counts are unlikely to have significant pathology requiring further active intervention either medical or surgical.

Hollow viscus injury in children: Starship Hospital experience.

Starship Children's Hospital in Auckland, New Zealand, serves a population of 1.2 million people and is a tertiary institution for pediatric trauma. This study is designed to review all cases of abdominal injury (blunt and penetrating) that resulted in injury of a hollow abdominal viscus including the stomach, duodenum, small intestine, large intestine and urinary bladder. The mechanism of injury; diagnosis and outcome were studied. This was done by retrospective chart review of patients admitted from January 1995 to December 2001. Thirty two injuries were found in 29 children. The age ranged from 7 months to 15 years with boys represented more commonly. Small bowel was the most frequently injured hollow viscus. Computerized Tomography (CT scan) is an extremely useful tool for the diagnosis of HVI.

Clinical variables associated with positive angiographic localization of lower gastrointestinal bleeding.

BACKGROUND: Localizing the source of severe lower gastrointestinal (GI) bleeding is often difficult but is important to plan the extent of colonic resection. The purpose of the present paper was to audit the Auckland Hospital experience of selective angiography, in localizing lower GI bleeding. METHODS: Patients admitted to Auckland Hospital with rectal bleeding and who subsequently had angiography were evaluated by reviewing their clinical notes and radiological results during a 7-year period (1997-2003). Data collected included demographic details, haemodynamic parameters, change in haemoglobin level, requirement of blood transfusion within 24 h before the procedure, site of the bleeding and pathology. RESULTS: The notes of 88 patients (male, n = 51; median age 69 years, range 8-99 years) were available for review and analysis. The site of bleeding was localized in 38 (51%); 30 of them had bleeding in the right colon or small bowel and eight in the left colon. Positive localization correlated with: haemodynamic instability P < 0.0001; drop in haemoglobin level of > or =50 from previous admission (P = 0.02); transfusion requirement of > or =5 units of blood within 24 h (P < 0.0001). Logistic regression analysis showed transfusion requirement of > or =5 units to achieve haemodynamic stability to be the most powerful predictor of accurate localization (odds ratio, 40). CONCLUSION: Catheter angiography for acute lower GI bleeding will successfully localize a point of bleeding in approximately 50% of patients. The most useful clinical indicator for positive angiography was haemodynamic instability particularly in those who require transfusion of > or =5 units of blood to achieve haemodynamic stability.

Long-term outcome of postanal repair in the treatment of faecal incontinence.

BACKGROUND: Idiopathic faecal incontinence is a common debilitating problem; the results of surgical treatment are variable with only a small proportion of patients achieving full continence. OBJECTIVES: The aim of this study was to evaluate the long-term outcome of postanal repair in idiopathic faecal incontinence. PATIENTS AND METHODS: Patients who had postanal repair in Auckland between 1994 and 2001 were identified and mailed faecal incontinence severity index (FISI) and faecal incontinence quality of life (FIQOL) questionnaires. Preoperative and postoperative incontinence scores were compared and postoperative quality of life scores were calculated. RESULTS: Forty-seven of the 66 patients who had undergone postanal repair from 1994 to 2001 completed the FIQOL questionnaire. FISI scores were complete on 44 patients. Comparison of preoperative and postoperative FISI scores revealed an improvement with mean scores of 34 and 23, respectively (P = 0.0001). Thirty (68%) patients had improved, including four who were fully continent. Fourteen patients were the same or worse. CONCLUSIONS: Postanal repair provides lasting benefit for the majority of patients with faecal incontinence.

Randomized controlled trial of Gastrografin in adhesive small bowel obstruction.

BACKGROUND: Several previous studies have shown that Gastrografin can be utilized to triage patients with adhesive small bowel obstruction (ASBO) to an operative or a non-operative course. Previous studies assessing the therapeutic effect of Gastrografin have been confounded by post-administration radiology alerting the physician to the treatment group of the patient. Therefore the aim of the present paper was to test the hypothesis that Gastrografin hastens the non-operative resolution of (ASBO). METHODS: Patients, diagnosed with ASBO on clinical and radiological grounds, were randomized to receive Gastrografin or placebo in a double-blinded fashion. Patients did not undergo further radiological investigation. If the patient required subsequent radiological intervention or surgical intervention they were excluded from the study. End-points were passage of time to resolution of ASBO (flatus and bowel motion), length of hospital stay and complications. RESULTS: Forty-five patients with ASBO were randomized to receive either Gastrografin or placebo. Two patients were excluded due to protocol violations. Four patients in each group required surgery. Eighteen of the remaining patients received Gastrografin and 17 received placebo. Patients who received Gastrografin had complete resolution of their ASBO significantly earlier than placebo patients (12 vs 21 h, P = 0.009) and this translated into a median of a 1-day saving in time in hospital (3 vs 4 days, P = 0.03). CONCLUSIONS: Gastrografin accelerates resolution of ASBO by a specific therapeutic effect.

Correlation between the current TNM staging and long-term survival after curative D1 lymphadenectomy for stomach cancer.

BACKGROUND AND AIMS: This study aims to assess the tumour-related factors that influence long-term survival after curative gastrectomy with standard D1 lymphadenectomy for patients with stomach cancer. PATIENTS AND METHODS: Patients who had undergone curative gastrectomy for carcinoma of the stomach at North Shore Hospital between 1990 and 2000 were identified from theatre records and the hospital database. Medical records were reviewed and included tumour location, type of operation, in-hospital mortality, gross morphology of tumour, histological type, and Helicobacter status; pathology slides were reviewed, and tumours were staged according to the new TNM staging. Patients were followed-up for 2-11 years. Length of survival was obtained for each patient from medical records or from family doctors. RESULTS: R0 gastrectomy was performed on 70 patients; median survival was 23 months, and all patients with early gastric cancer are currently still alive. T stage, nodal stage and histological type correlated significantly with survival, but multivariate analysis showed that T stage is the most significant predictor. Five-year survival was 26%. Significant survival difference was seen between T2a and T2b. CONCLUSION: Histological subtype, lymph node metastases and depth of invasion are factors that affect survival of patients with gastric cancer; however, depth of invasion is more important than other variables. Tumour location and type of gastrectomy has no effect on survival. The latest TNM classification (sixth edition) gives a better prognostication than the previous classification.