Occlusion of the cystic duct with cyanoacrylate glue at laparoscopic subtotal fenestrating cholecystectomy for a difficult gallbladder.

BACKGROUND: Subtotal cholecystectomy is occasionally the management of choice in the patient with a hostile Calot's triangle but when it is not considered safe to close the cystic duct this often leads to a biliary fistula. In order to reduce this morbidity a novel strategy to seal the cystic duct with cyanoacrylate glue was introduced. The outcome of the two strategies have been compared. METHODS: Patients who had a laparoscopic subtotal cholecystectomy where the cystic duct was left open, the Unsecured group, were compared with those where the duct orifice was occluded with cyanoacrylate glue, the Glued group. The outcome of the two strategies have been compared by duration of biliary drainage, whether a leak was shown on ERCP, time to removal of the drain, length of hospital stay, the re-operation and readmission rates. RESULTS: In 78 cases of laparoscopic subtotal cholecystectomy it was considered unsafe to close the cystic duct. 36 patients were managed without closure of the cystic duct, the Unsecured group and bile drainage continued for more than 3 days in 9 cases (25%) compared with 3 of 42 cases (7%) treated with glue, the Glued group (NS). Postoperative ERCP demonstrated a leak more frequently in the Unsecured group (p < 0.02). The length of stay was reduced in the Glued group. (0.9 compared with 3.0 days, p < 0.01). CONCLUSION: The results suggest that glue may be a safe option to occlude the cystic duct orifice and reduce hospital stay when this cannot safely be closed at subtotal cholecystectomy.

Primary chemo-radiotherapy in the treatment of locally advanced and inflammatory breast cancer.

BACKGROUND: The best management of large, diffuse or inflammatory breast cancers is uncertain and the place of radiotherapy and/or surgery is not clearly defined. METHODS: A cohort of 123 patients with non-metastatic locally advanced or inflammatory breast cancer 3 cm or more in diameter or T4, was treated between 1989 and 2006. All patients received primary chemotherapy followed by radiotherapy, 40 Gy in 15 fractions with 10 Gy boost. Patients with ER positive tumours received Tamoxifen. Assessment was carried out 8 weeks post-treatment and surgery was reserved for residual or recurrent disease. RESULTS: For each stage there were T2/3: 63, T4b: 31 and T4d: 29 patients. 80 had complete clinical response (65%) but 18 patients were never free of inoperable local disease. 25 patients had residual operable disease at assessment and 12 patients who initially had a complete response developed operable local recurrence (LR). 37 Patients (30%) had surgery at a mean of 15 months post diagnosis. At 5 years, overall survival (OS) of the two surgical groups was not significantly different from those 68 patients who had complete remission without surgery, p=0.218, HR 1.46 (0.80-2.55). Surgery as an independent variable to predict survival was not significant on a Cox proportional hazards model (p=0.97). LR in the surgical groups was 13.5% vs 17.5% in the non-surgical patients. The median OS was 64.5 months and disease-free survival (DFS) was 52.5 months. 5-Year OS was 54% and DFS survival 43%. CONCLUSION: In patients with a complete or partial response to chemo-radiotherapy for locally advanced or inflammatory breast cancer, reserving surgery for those with residual or recurrent local disease did not appear to compromise survival. This finding would support examination of this treatment strategy by a randomised controlled trial.

Impact of a raised body mass index on breast cancer survival in relation to age and disease extent at diagnosis.

The prognostic value of Body Mass Index (BMI) on breast cancer outcome is controversial and previous studies from this unit have not shown any significant relation to survival. The aim of this study was to re-examine any impact of a raised BMI on recurrence and survival related to age and disease stage at the time of diagnosis. Breast cancer patients (2,298) were reviewed and divided in groups by BMI. Recurrence Free Survival (RFS), Breast Cancer Specific Survival (BCSS), and Overall Survival (OS) were compared by Kaplan-Meier life table analysis. Known prognostic factors including BMI were tested for independent prognostic significance in a Cox's regression model. Obese patients (417) had on average larger tumors (median 2.3 versus 2.1 cm, p < 0.01). A trend to an increased positive node status (37% versus 33%) was not significant, p = 0.18. Seven-year RFS was 82% versus 77% in the obese, p < 0.01, BCSS was 87% versus 85%, p = 0.046 and OS 81% versus 77%, p = 0.02. BMI was independently associated with RFS in multivariate analysis (HR: 1.43, p < 0.01). In subgroup analysis, survival differences were most prominent in patients with node positive disease and in patients <60-years old. Breast cancer outcome was worse in patients with a raised BMI and this risk was greater in younger patients and in those with node positive disease. The difference may be related to diagnosis at a more advanced stage in the obese but there was also an independent effect of BMI on survival.

A 10-year follow-up of a longitudinal study of gallstone prevalence at necropsy in South East England.

The purpose of this study was to examine a previous increase in male gallstone disease and to consider the burden of gallstones in a necropsy study with matched controls over a decade. Gallstone prevalence in 5,050 males fell from 20.2% to 19.1% (P=0.022) and in 4,125 females fell from 30.4% to 29.0% (P=0.03). Female gallstone subjects had a higher BMI than controls 24.5 vs. 23.3 (P<0.01), but males did not. Gallstones were twice as common in diabetics, but not with coronary heart disease (CHD). A third of elderly patients of both sexes had gallstones, but cholecystectomy was more common in females, 17:10%. Gallstone-related mortality was 0.7%. The prevalence of gallstones fell slightly. The association between gallstones and diabetes was confirmed, but not for CHD, and for BMI this was confined to females. Gallstones are very common in the elderly, but most are unoperated and seldom cause death.

Is hormone replacement therapy-related breast cancer more favorable? A case-control study.

Hormone replacement therapy (HRT)-related breast cancer may carry a better prognosis since there is no increase in breast cancer deaths. We looked at the prognostic risk factors and outcome inpatients who had ever taken HRT compared to those who had not, in a case control study. Subgroups of recent-users and those using HRT for >5 years were also compared to controls. Tumor size, grade, vascular invasion, lymph node, and estrogen receptor status as well as median Nottingham Prognostic Indicator (NPI) were compared between cases and controls. Absolute survival between ever-users and never-users was compared by life table analysis. There was no difference between all the cases and their controls for the five prognostic factors. NPI in each group was also similar. Absolute survival between ever-users and never-users was not significantly different either (p = 0.678). There was no evidence that HRT-related breast cancer has a more favorable outcome.

Pre-operative risk scores for the prediction of outcome in elderly people who require emergency surgery.

BACKGROUND: The decision on whether to operate on a sick elderly person with an intra-abdominal emergency is one of the most difficult in general surgery. A predictive risk-score would be of great value in this situation. METHODS: A Medline search was performed to identify those predictive risk-scores relevant to sick elderly patients in whom emergency surgery might be life-saving. RESULTS: Many of the risk scores for surgical patients include the operative findings or require tests which are not available in the acute situation. Most of the relevant studies include younger patients and elective surgery. The Glasgow Aneurysm Score and Hardman Index are specific to ruptured aortic aneurysm while the Boey Score and the Hacetteppe Score are specific to perforated peptic ulcer. The Reiss Index and Fitness Score can be used pre-operatively if the elements of the score can be completed in time. The ASA score, which includes a significant element of subjective clinical judgement, can be augmented with factors such as age and urgency of surgery but no test has a negative predictive value sufficient to recommend against surgical intervention without clinical input. CONCLUSION: Risk scores may be helpful in sick elderly patients needing emergency abdominal surgery but an experienced clinical opinion is still essential.

Co-expression of neuregulins 1, 2, 3 and 4 in human breast cancer.

We have produced antibodies to the NRG2-alpha, NRG2-beta, NRG3 and NRG4 proteins and used these, and previously described antibodies to NRG1-alpha and NRG1-beta, to detect expression of each ligand by immunocytochemical staining in a series of 45 breast cancers. Each protein was expressed in a proportion of cases. Statistical analysis suggested that expression of one factor was associated with a high probability that other members of the family were co-expressed. NRG2-alpha expression was associated with node positivity (p-value = 0.005). The mRNAs for NRG1, 2, 3 and 4 were found in established breast cancer cell lines and NRG1, 2 and 3 mRNAs were detected in primary breast cancers. Expression of NRG4 mRNA was shown by in situ hybridization in sections from primary breast cancers. This data demonstrates that each member of the NRG family of ligands is expressed in breast cancer and suggests that they may be involved in regulating cell behaviour.