How Well Planned Urgency Class Come True in The Emergency Surgery? Timing of Acute Care Surgery.

BACKGROUND AND AIMS: Emergency surgery represents an essential aspect of surgical care, but little is known about realization of the planned emergency class. Different systems such as NCEPOD classification and Timing of Acute Care Surgery classification have been developed for the timing of the emergency surgery. The aim of the study was to find out how well planned urgency class is being implemented. MATERIALS AND METHODS: The planned and realized waiting times for all emergency surgeries were studied during the 6-month period in the Oulu University Hospital. The catchment area of the hospital includes a population of 742,000. The urgency in the hospital is planned in a four-step scale: an extremely urgent (E) patient should be taken immediately to the operating theater. Class I urgency surgery should start within 3 h (180 min), class II within 8 h (480 min), and class III within 24 h (1440 min). Surgeon plans urgency at his discretion, and no specific urgency has been imposed on certain diagnoses thus the surgeon's perceptions of the illness or trauma affects the assessment. RESULTS: Extreme urgent patients had an average waiting time of 26 min. For class I patient, the average waiting time was 59 min, while 93% of surgeries were started within the target time. For class II and class III patients, these figures were 337 min and 86% and 830 min and 78%, respectively. CONCLUSION: With regard to urgency, the higher the degree of urgency, the greater the chance of the surgery being realized within the planned time.

Strong claudin 5 expression is a poor prognostic sign in pancreatic adenocarcinoma.

We investigated the expression of claudin 5 in 88 ductal adenocarcinomas of the pancreas. The results were correlated with patient prognosis, with claudin 5 expression in blood vessels, with the expression level of bcl2 and bax and with apoptosis. Claudin 5 expression was detected in 24 (38%) cases. It was not associated with tumour size or spread, but strong claudin 5 expression correlated with a worse survival (p = 0.005). Claudin 5 also associated with a higher extent of apoptosis and greater expression of bax protein. In the tumour vasculature, some vessels displayed a loss of claudin 5 expression. The presence of this loss was associated with tumour grade and the presence of nodal metastases (p = 0.02, p = 0.022, respectively). These results indicate that claudin 5 is upregulated in a proportion of pancreatic ductal adenocarcinomas. The association of strong claudin 5 expression with a worse survival is in line with some earlier reports indicating that this protein is involved with increased locomotion and more aggressive spread of carcinomas. The association of claudin 5 with apoptosis and bax might be due to stronger cellular kinetics found in such tumours. The loss of claudin 5 expression in the tumour vasculature points to a leaky vessel type; this might also ease the access of tumours to vessels and be reflected in its association with the presence of nodal metastases.

Nuclear Nrf2 expression is related to a poor survival in pancreatic adenocarcinoma.

The aim of this study was to investigate the expression of Nrf2, sulfiredoxin and DJ1 in pancreatic cancer. The expression of Nrf2, sulfiredoxin and DJ1 was studied immunohistochemically in a large set of pancreatic adenocarcinomas consisting of 103 cases. Eighty six percent of the cases showed cytoplasmic Nrf2 and 24% nuclear Nrf2 positivity. Sulfiredoxin positivity was observed in 54% and DJ1 positivity in all cases. Nuclear Nrf2 positivity had an association with sulfiredoxin (p=0.019) and was associated with a poor survival (p=0.010). Stage IV tumors tended to have a more nuclear Nrf2 expression (p=0.080). DJ1 expression was more often found in well-differentiated tumors (p=0.012), and DJ1 expression was associated with better survival (p=0.020). According to the results, nuclear Nrf2 expression predicts a worse survival in pancreatic adenocarcinoma, which is in keeping with its protection of cells against oxidative or xenobiotic stress. In accordance with Nrf2's regulation of the synthesis of sulfiredoxin, there was an association between them (p=0.019). DJ1 had no association with Nrf2, and its expression predicted a better survival of patients.

Wire-guided excision of non-palpable breast cancer: determinants and correlations between radiologic and histologic margins and residual disease in re-excisions.

In cases of wire-guided excision of non-palpable breast cancer (WGE), data concerning the determinants and correlations between radiologic and histologic margins and residual cancer in re-excisions are sparse. A total of 21 variables in 66 WGE followed by 49 re-excisions were prospectively analyzed. In multivariate analysis, only large mammographic lesions were clearly related to positive margins in specimen radiography (P<0.05). Multifocality (P<0.001), large pathologic size (P<0.05) and superficial excision (P<0.05) were related to positive histologic margins and multifocality (P=0.001) to residual disease in re-excisions. The sensitivity, specificity and positive predictive values of specimen radiography for predicting histologic margins were 33%, 79% and 53%, and those for predicting residual disease 30%, 80% and 38%, respectively. The ability of histologic margins to predict residual disease was 91%, 58% and 38%, respectively. In WGE, large mammographic lesions carry a significant risk for radiologically incomplete excision, while pathologically large and multifocal tumors may be histologically incompletely excised, especially if the excision does not extend down to the pectoral fascia. The excision sites of multifocal tumors should be re-excised because of the considerable risk of residual disease. The radiologic and histologic margins of the specimen may be misleading.

Adenoma of the papillae of Vater. Report of eleven cases.

Eleven patients with a preoperative diagnosis of adenoma of the papillae of Vater were followed up during the fifteen-year period from 1984 till 1998 in the Oulu University Hospital. Seven patients were treated primarily by transduodenal excision without any recurrences so far. One of these seven patients was found to have adenocarcinoma in a histological examination. Active surgery for adenoma of the papillae of Vater is recommended because of the precancerous nature of the lesion, and because malignancy cannot always be detected by endoscopic biopsies. Transduodenal excision could be recommend for patients at high operative risk, especially in cases with small adenomas and low-grade dysplasia, where histologically free resection margins can be achieved, but pancreaticoduodenectomy should still be performed on patients at low operative risk.

Self organization of a massive document collection.

This article describes the implementation of a system that is able to organize vast document collections according to textual similarities. It is based on the self-organizing map (SOM) algorithm. As the feature vectors for the documents statistical representations of their vocabularies are used. The main goal in our work has been to scale up the SOM algorithm to be able to deal with large amounts of high-dimensional data. In a practical experiment we mapped 6,840,568 patent abstracts onto a 1,002,240-node SOM. As the feature vectors we used 500-dimensional vectors of stochastic figures obtained as random projections of weighted word histograms.

Cosmetic results after wire-guided biopsy of benign breast lesions.

BACKGROUND: There are surprisingly few reports about the cosmetic results of wire-guided biopsy of benign breast lesions as opposed to breast-conserving surgery and irradiation of early breast cancer (BCT). STUDY DESIGN: Twenty potential perioperative risk factors for adverse cosmetic results after wire-guided breast biopsy were prospectively evaluated in 101 patients undergoing the first single biopsy after suspicion of a malignant lesion that subsequently proved to be benign. The overall cosmetic result was evaluated by using 6 specific cosmetic indices individually scored 6 months after the breast biopsy. RESULTS: The overall cosmesis was excellent, good, fair, or poor in 48.5%, 26.7%, 12.9%, and 11.9% of cases, respectively. The corresponding figures according to appraisal by the patients were 22.8%, 58.4%, 17.8%, and 1.0%, respectively. Unsatisfactory (fair or poor) overall cosmetic results were related to excisions extending down to the fascia (p = 0.001) and postoperative complications (p = 0.018) in multivariate analysis. Notably, specimen volume had no significant impact on overall cosmesis, as opposed to cosmesis after BCT. CONCLUSIONS: Cosmetic outcomes after wire-guided biopsy of benign breast lesions were excellent or good in at least 75% of cases. Excisions extending down to the pectoralis fascia and complications were associated with poor aesthetic outcomes.

Liver resection of noncolorectal secondaries.

BACKGROUND AND OBJECTIVES: Hepatic resection of noncolorectal metastases appears to be performed with increasing frequency. Reported experience is limited and indications are controversial. METHODS: Retrospective review of curative hepatic resection in 32 patients (median age 58 years) during 1970-1995. The primary tumor was a carcinoid in seven patients, other endocrine tumor in five patients, malignant melanoma in three patients, stomach cancer in three patients, exocrine pancreatic cancer in two patients, gynecological cancer in two patients, sarcoma in two patients, and miscellaneous in eight patients. Seven patients (22%) had bilobar disease and 12 patients (38%) had extrahepatic growth. RESULTS: Median survival was 32 months, and 5-year actuarial survival rate was 36% (including operative mortality). Median survival in the endocrine (n = 12) and nonendocrine (n = 20) groups was 72 and 18 months, respectively (corresponding 5-year survival rates were 56 and 25%) (P = 0.16). Prognostic factors could not be established in either group. It is, however, noteworthy that no patient with nonendocrine secondaries and more than one liver tumor or extrahepatic disease survived for 5 years. Major complications were seen in eight patients (25%), including three postoperative deaths (operative mortality 9%) occurring during the first 5 years of the study period. CONCLUSIONS: Hepatic resection of metastases from endocrine primary tumors was followed by long-term survival in a substantial proportion of patients. Long-term survival for patients with nonendocrine tumors was observed only when there was a single liver tumor and no extrahepatic growth. Further experience is needed for definition of resection criteria.

Mammographic and ultrasonographic findings in bilateral breast cancer: a comparative study.

To compare the results of mammographic and US examinations in unilateral and bilateral breast cancers in routine clinical work, the files of all patients with 825 preoperative mammograms and 525 preoperative US examinations operated on for primary breast cancer in the Oulu University Hospital from 1983 through 1993 were retrospectively reviewed. The only statistically significant difference noted in the mammographic findings was the false-negative rates in unilateral, bilateral and metachronous second breast cancers (6.8, 16.3 and 23.3 %, respectively). The differences were mainly due to the lower sensitivity of mammography in the detection of palpable bilateral breast cancers. The false-negative rate of US was also significantly higher in bilateral breast cancers (23 %) than in unilateral cancers (11 %), and significantly higher for nonpalpable than palpable cancers in both the bilateral and the unilateral groups. The mammographic failure rates and the difference between these two groups were most pronounced during the early study period, which underscores the importance of experience and dedicated imaging technique. The smaller tumour size at the time of diagnosis and probably the loss of the opposite breast for comparison have contributed to the higher false-negative rates in bilateral breast cancer.

Preoperative methylene blue staining of galactographically suspicious breast lesions.

Microdochectomy is the standard treatment of galactographically suspicious breast lesions. Precise preoperative marking of the suspicious duct and intraductal lesions facilitates selective minimal-volume microdochectomy. Methylene blue dye staining fulfills this criterion. A retrospective review of our experience of preoperative methylene blue staining in 30 patients with unilateral spontaneous nonlactiferous single duct nipple discharge operated on during 1986-1995 in the Oulu University Hospital for galactographically suspicious breast lesions. Galactography was successful in 29 out of 30 (93.3%) cases. Preoperative methylene blue staining was attempted in all cases on the day of surgery and it was successful in 22 (73.3%) cases making subsequent selective minimal-volume microdochectomy easy to perform. The failure of methylene blue staining led to quadrantectomy in 4 cases and smaller breast resections in the remaining 4 cases. Preoperative methylene blue dye staining crucially facilitates selective minimal-volume microdochectomy. An interval between primary galactography and later methylene blue staining leads to failures in approximately one quarter of the cases. A higher success rate would necessitate scheduling the microdochectomy on the same day as the primary galactography (and the subsequent methylene blue staining in suspicious cases).

Determinants of positive histologic margins and residual tumor after lumpectomy for early breast cancer: a prospective study with special reference to touch preparation cytology.

BACKGROUND AND OBJECTIVES: Removal of the entire tumor by breast-conserving surgery is important, but the determinants of adequate excision have not been established. METHODS: A prospective study of 55 consecutive lumpectomies for early breast cancer was performed to study the correlation between touch preparation cytology and histologic margins and the determinants of positive histologic margins and residual disease after the initial excision. RESULTS: The correlation between touch preparation cytology and histologic margins was poor: sensitivity and specificity were 37.5% and 85.1%, respectively. The histologic margins were positive in 8 cases (14.5%) and were related to the presence of intraductal carcinoma and to the large pathologic size of the index tumor. Re-excision specimen of the tumor bed (34 of 55 cases) contained residual cancer in seven cases (20.6%). Multifocal and nonpalpable index tumors predicted residual cancer. Residual disease was found in 37.5% of the cases (3 of 8) with positive and in 15.4% of the cases (4 of 26) with negative histologic margins. CONCLUSIONS: Touch preparation cytology cannot be recommended as a method of assessing lumpectomy margins for early breast cancer. Histologic margins are misleading in predicting residual cancer in re-excision specimens. To minimize the risk of residual cancer, wide excision or mastectomy should be considered in the management of multifocal and nonpalpable tumors.

Radiological findings in biliary fistula and gallstone ileus.

PURPOSE: Biliary fistula and gallstone ileus are rarely found. The diagnosis is difficult and may be delayed until operation. We reviewed the radiological findings in a retrospective material. MATERIAL AND METHODS: The cases of 16 patients treated for biliary fistula were analyzed with respect to findings at imaging. Ten patients had a spontaneous fistula. Nine of them had an internal bilioduodenal fistula and one had an external fistula with stones passing through a subcutaneous abscess. Five patients also had gallstone ileus and one patient a rare gastric outlet obstruction caused by a gallstone (Bouveret's syndrome). Six patients had an iatrogenic fistula. One of them had internal bile ascites and 5 an external fistula, one of which was a biliocystic fistula resulting from attempted hepatic cyst sclerotherapy. RESULTS: Various imaging modalities were used and there was often a delay in the diagnosis. Imaging did not show the fistula itself in any of the spontaneous cases. However, a nonvisualized or shrunken gallbladder seen at US often coexisted in these cases. CT yielded the diagnosis in one case of gallstone ileus, and a Gastrografin meal yielded it in the case of Bouveret's syndrome. Fistulography and cholangiography provided a correct diagnosis of fistula in all cases of iatrogenic biliocutaneous fistulas. CONCLUSION: Patients with biliary fistula usually undergo examinations with nonspecific results. The imaging findings could be more specific if the possibility of this diagnosis were remembered.

Nonpalpable breast lesions: pathologic correlation of ultrasonographically guided fine-needle aspiration biopsy.

To evaluate the usefulness of ultrasonographically guided fine-needle aspiration biopsy in routine clinical use, we evaluated retrospectively all of the 781 nonpalpable breast lesions operated on in the Oulu University Hospital during the period 1986 to 1993. There were 86 patients with 90 nonpalpable breast lesions, of which samples were taken by ultrasonographically guided fine-needle aspiration biopsy. Open wire-guided surgical biopsy was obtained in all cases for a histologic diagnosis. Two false-negative results and one insufficient cytologic sample occurred in the 26 malignancies and one false-positive result and two insufficient cytologic samples were found in the 73 benign breast lesions, giving sensitivity, specificity, positive predictive value, negative predictive value, and overall diagnostic accuracy values of 84%, 93%, 94%, 95%, and 90%, respectively. The calculations include the insufficient samples. We conclude that ultrasonographically guided fine-needle aspiration biopsy is a method comparable to mammographic and stereotactic fine-needle aspiration biopsy methods.

Intraabdominal abscess formation after major liver resection.

A series of 138 major liver resections undertaken between 1971 and 1987 were reviewed. Intrabdominal abscesses developed in 11 (8%) patients, a mean of 23 days (range 10-42) after operation and two died (mortality 18%). Eight developed after 63 right hepatectomies, two after 24 right lobectomies, one after 34 left hepatectomies and none after left lobectomies (17). Patients who developed intra-abdominal abscesses underwent significantly longer operations (mean (SEM) 400 (48) compared with 275 (21) min) (p less than 0.05) and had significantly more bleeding during the operation (7,600 (1,750) compared with 3,200 (430), p less than 0.01) than those who did not. The amounts recovered from the abdominal drains, both before and after the diagnosis, were comparatively greater in patients with abdominal abscesses. Antibiotic prophylaxis was given to 10 of 11 patients who did and 89 of 127 patients who did not, form abscesses. We conclude that the risk of intra-abdominal abscess formation after major liver resection is increased: when a large amount of liver tissue is removed (right hepatectomy or lobectomy); when there is a lot of intraoperative bleeding; and when the operation takes a long time. Antibiotic prophylaxis did not affect the risk of abscess formation this series.