Effect of jaundice and its resolution on wound re-epithelization, skin collagen synthesis, and serum collagen propeptide levels in patients with neoplastic pancreaticobiliary obstruction.

BACKGROUND: Wound and anastomotic healing is considered to be delayed in patients with obstructive jaundice. The study was designed to find out whether the healing of experimental suction blister wounds, skin collagen synthesis, and serum procollagen levels are affected by obstructive jaundice, and if biliary drainage may cause any alterations in these processes. PATIENTS AND METHODS: Suction blisters were induced on 24 patients with obstructive jaundice caused by neoplastic pancreaticobiliary obstruction and 17 control patients with the corresponding condition without jaundice, to compare healing parameters and collagen synthesis between the groups. A second set of suction blisters were induced on 13 formerly jaundiced patients after the resolution of jaundice and on 14 control patients, to find out whether drainage or time modifies healing or collagen synthesis. By using this model, it is possible to evaluate the re-epithelization and inflammation on wound healing and to assess the baseline skin collagen synthesis. The healing of suction blisters was followed up by measuring water evaporation and blood flow in the wound. Blister fluids and serum samples were collected to study collagen propeptides. RESULTS: Healing of the blister wound was unaffected by obstructive jaundice. Drainage had no effect on healing. The baseline synthesis of type I and type III collagen in the skin was decreased in jaundiced patients. Biliary drainage improved the synthesis. Serum type III procollagen propeptide levels were elevated in jaundiced patients, but began to normalize after drainage. CONCLUSION: Healing of an experimental blister wound is not disturbed by obstructive jaundice. The decreased baseline skin collagen synthesis is partly restored by the resolution of jaundice. The results indicate that cell protein synthesis is disturbed earlier than cell dynamics in obstructive jaundice. The elevated serum PIIINP levels, which are most likely to be related to early fibrosis in liver, decreased after drainage.

Five-year outcome of laparoscopic and Lichtenstein hernioplasties.

BACKGROUND: Laparoscopic hernia repair has been proved superior to open repairs in terms of short-term results, but long-term results of laparoscopic and open mesh repairs have been lacking until recently. METHODS: A total of 123 patients were randomly allocated to two treatment groups comparing laparoscopic and Lichtenstein hernioplasties in three separate trials. The first and second trials compared small and large mesh used in transabdominal preperitoneal repairs, and the third study compared totally extraperitoneal hernioplasty with the Lichtenstein operation. A 5-year follow-up visit was scheduled to assess recurrencies, symptoms, and patient satisfaction. RESULTS: For the follow up evaluation, 121 (98.4%) of the patients were reached. There were five hernia recurrences in the laparoscopic group (small mesh) and two in the Lichtenstein group (difference, 5%; 95% confidence interval, -4-13%; p = 0.3). One patient who underwent the transabdominal preperitoneal polypropylene procedure underwent reoperation 3 years later because of dense small bowel adhesions at the inguinal surgical site. Chronic groin pain was more common after open operation (0 vs 4) patients (difference 7%; confidence interval, -0.4-16%; p = 0.04). Ten patients (16%) in the laparoscopic group and 12 (20%) in the open group reported discomfort or pain at the surgical site. CONCLUSIONS: Both laparoscopic and Lichtenstein hernioplasties have a low risk for hernia recurrence if proper mesh size is used. The patients who undergo hernioplasty with open mesh hernioplasty seem to experience chronic symptoms and pain more often than those managed with the laparoscopic procedure.

The quality of life of gastroesophageal reflux disease patients waiting for an antireflux operation.

BACKGROUND: The purpose of this trial was to measure the health-related quality of life (HRQL) of gastroesophageal reflux disease (GERD) patients waiting for an antireflux operation. METHODS: A total of 120 patients waiting for a laparoscopic fundoplication were sent questionnaires measuring their symptoms and quality of life. RESULTS: Ninety-five of the patients still needing an operation returned the questionaires and were included in the analysis. Thirty-one of 84 patients (37%) felt that the symptoms had worsened, and 51/90 (57%) were unsatisfied. Thirty percent suffered from throat or airway infections, 25% from swallowing difficulties, 48% from retrosternal pain, and 18% had asthma. The mean GERD HRQL score (0-45) was 21.7 (95% confidence interval, 19.7-23.7). Short Form-36 scores of this population were significantly worse when compared to patients with inguinal hernia or moderate asthma. CONCLUSIONS: Patients waiting for a fundoplication seem to have a significantly decreased health-related quality of life due to poor symptom control regardless of continuous medical treatment.

Accuracy of hand-held Doppler in planning the operation for primary varicose veins.

OBJECTIVE: To evaluate whether hand-held Doppler (HHD) examination is an adequate screening test in planning surgical treatment for primary varicose vein. DESIGN: Prospective study. MATERIALS: One hundred and eleven consecutive patients (142 legs) with primary, uncomplicated varicose veins. METHODS: Legs were examined clinically, with HHD and duplex ultrasonography on the same day at the outpatient clinic. The plan for the subsequent treatment was recorded separately after each examination. RESULTS: At the sapheno-femoral junction and at the sapheno-popliteal junction, the sensitivity was 56 and 23%, the specificity 97 and 96%, the positive predictive values was 98 and 43%, the negative predictive value was 44 and 91%, and the Kappa coefficient was 38 and 24%, respectively. Clinical examination failed to correctly plan the treatment in 21 (26%) of 80 proposed operations. In 13 limbs (9.1%) the HHD-based treatment plan was modified on the basis of duplex ultrasound findings. In seven cases, patients would have undergone only stab avulsion procedure, whereas stripping of a saphenous vein was indicated on the basis of duplex ultrasound findings. In two other cases, HHD findings would have led to resect the wrong saphenous vein. In six cases, the treatment was wrongly planned because of assessment problems during HHD examination at the popliteal fossa. CONCLUSIONS: The accuracy of HHD in the preoperative evaluation of primary, uncomplicated varicose veins is unsatisfactory. These results suggest that duplex ultrasonography should be considered as the preoperative diagnostic method of choice.

Transmembrane carbonic anhydrase, MN/CA IX, is a potential biomarker for biliary tumours.

BACKGROUND/AIMS: Carbonic anhydrase isoenzyme IX (MN/CA IX) is a transmembrane protein with a suggested function in maintaining the acid-base balance and intercellular communication. Previous studies have demonstrated that MN/CA IX is expressed in the basolateral plasma membrane of normal biliary epithelial cells, but not in hepatocytes. This study was designed to examine the expression of MN/CA IX in hepatobiliary neoplasms and to elucidate its value as a marker for biliary differentiation. METHODS: Fifty-seven hepatobiliary lesions were immunostained for MN/CA IX using biotin-streptavidin complex method. Twenty samples containing normal biliary epithelium and five containing normal liver tissue were used as controls. RESULTS: In the biliary epithelial tumours, immunostaining for MN/CA IX was mainly localized at the basolateral surface of the epithelial cells, like in normal mucosa. All non-invasive dysplastic lesions and 57% of invasive lesions of gall-bladder expressed MN/CA IX. In liver, 78% of cholangiocellular malignant lesions showed a positive reaction for MN/CA IX, whereas only 33% of hepatocellular carcinomas showed a weak immunoreaction. CONCLUSIONS: Our results suggest that abnormal expression of MN/CA IX may be linked to malignant transformation of hepatobiliary cells. In addition, it seems to be a promising marker for biliary differentiation in hepatobiliary neoplasms.

Maximal local and minimal systemic cytokine response to colorectal surgery: the influence of perioperative filgrastim.

Thirty consecutive patients scheduled for elective colorectal surgery were prospectively randomized to receive either filgrastim [the recombinant human form of granulocyte colony-stimulating factor (r-metHu-G-CSF)] or placebo blindly. The levels of interleukin (IL-)1beta, tumour necrosis factor-alpha (TNF-alpha), IL-6, IL-8, transforming growth factor-beta (TGF-beta), and IL-10 were determined 5 and 24 h postoperatively from peripheral blood, peritoneal fluid, and wound fluid. The concentrations of all the measured cytokines were enormously higher locally at the operative site than in the systemic circulation. The only difference between the two medication groups was the lower concentration of IL-8 in peripheral blood in the filgrastim-treated patients. The present study shows abundant release of pro- and anti-inflammatory cytokines into the wound and the peritoneal cavity after abdominal surgery. The systemic response to surgery seems to be a secondary and minor reflection of local events. Filgrastim did not have any effect on the studied local cytokine levels at the operative site.

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.

Neutrophil adhesion molecules in colorectal surgery: effect of filgrastim given perioperatively.

OBJECTIVE: To assess whether the postoperative expression of neutrophil adhesion molecules CD11b/CD18 (Mac-1) and CD62L (L-selectin) would differ in peripheral blood, peritoneal fluid and wound fluid in patients operated on for colorectal conditions, and to analyse the effect of perioperative filgrastim on their expression. DESIGN: Prospective randomised double-blind placebo-controlled clinical study. SETTING: University hospital, Finland. SUBJECTS: Thirty consecutive patients undergoing elective colorectal operations (15 in each group). INTERVENTIONS: The patients were prospectively randomised to receive either filgrastim or placebo. Expression of neutrophil adhesion molecules was measured 48 hours postoperatively in peripheral blood, peritoneal fluid, and wound fluid by flow cytometry. RESULTS: Postoperative neutrophil CD11b/CD18 expression was higher in both wound fluid and peritoneal fluid than in peripheral blood in the placebo group. Simultaneously, the expression of neutrophil CD62L was higher in peripheral blood than in peritoneal fluid or wound fluid in both groups. Filgrastim caused increased postoperative expression of neutrophil CD11b/CD18 in peripheral blood but not in peritoneal fluid or wound fluid. CONCLUSIONS: Postoperative expression of neutrophil adhesion molecules differs at the local operation site from that in peripheral blood. Filgrastim increases only blood neutrophil CD11b/CD18 expression.

The feasibility of telemedicine for orthopaedic outpatient clinics--a randomized controlled trial.

We investigated the use of videoconferencing in the examination of orthopaedic outpatients. A consecutive sample of orthopaedic outpatients was randomized to examination either via videoconferencing (n = 76) while attending a primary-care unit or at a conventional hospital outpatient clinic 160 km away (n = 69). Videoconferencing was found to be feasible and the equipment functioned well technically. There were somewhat more problems in examining the telemedicine patients than the clinic patients. The two patient groups were equally satisfied with the specialist service. The telemedicine patients were more willing to have their next visit by videoconferencing than the conventional patients. Videoconferencing between primary and secondary care can be used in the examination of orthopaedic patients whenever no demanding imaging technology is needed.

Comparison of laparoscopic and open Nissen fundoplication 2 years after operation. A prospective randomized trial.

BACKGROUND: Laparoscopic operation has replaced the conventional open procedure in the treatment of gastroesophageal reflux disease (GERD) in spite of the fact that long-term results based on controlled clinical trials have been lacking. The objective of this study was to compare outcome, quality of life, and patient satisfaction after laparoscopic and open Nissen fundoplication in a community hospital setting with a 2-year follow-up. METHODS: Forty-two patients with GERD were randomized to either laparoscopic (LNF) or open (ONF) Nissen fundoplication. Outcome evaluation included reflux symptoms, gastrointestinal quality of life (GIQLI), and upper GI endoscopy. RESULTS: Esophagitis was cured among all patients in the LNF group and in 90% of the ONF group. There were two patients (10%) in both groups who had medicine-dependent recurrent reflux together with significant worsening in the GIQLI scores. One patient in the LNF group has been reoperated due to a suture granuloma in the left epigastric port. Two patients in the LNF group needed esophageal dilatation due to persistent dysphagia. GIQLI scores (scale, 0-144) were equally normalized in both groups. Overall, 90% in the LNF and 100% in the ONF group were either satisfied or very satisfied with the operation. There was only one patient (LNF) who would not choose to have the operation again. CONCLUSIONS: Laparoscopic and open Nissen fundoplication seem to be equally effective methods for improving reflux symptoms and quality of life, resulting in a high rate of satisfaction among patients with an intermediate follow-up period of 2 years.

Short-term symptomatic outcome and quality of life after laparoscopic versus open Nissen fundoplication: a prospective randomized trial.

BACKGROUND: Laparoscopic operation has replaced conventional operation in the treatment of reflux disease. This change has been mostly based on excellent results from highly experienced antireflux surgeons rather than on randomized clinical trials. AIMS: The objective of this study was to compare the short-term symptomatic outcome and patient quality of life costs after laparoscopic (LNF) or open Nissen fundoplication (ONF) in a community hospital setting with less experienced surgeons. METHODS: Forty-two patients with documented gastroesophageal reflux disease (GERD) were randomized to either LNF or ONF. Symptomatic outcome using a custom questionnaire and the Gastrointestinal Quality of Life Index (GIQLI) were measured pre- and postoperatively at one and three months. RESULTS: Esophagitis was cured among all patients in LNF group compared to 90% in the ONF group. The symptoms observed preoperatively were significantly improved in both groups, except for dysphagia and flatulence. Dysphagia was more common after LNF. The GIQLI (scale 0-144) was equally normalized in both groups. The mean GIQLI-change among all patients was 37.9 points. Patient satisfaction did not differ between the groups. CONCLUSIONS: LNF and ONF are effective methods in the operative treatment of GERD in short-term and result in a significant improvement in patients gastrointestinal symptoms and quality of life.

Use of recombinant human granulocyte-colony stimulating factor in colorectal surgery.

The purpose of the current study was to assess the effects and safety of administering perioperative recombinant human granulocyte colony-stimulating factor (r-metHuG-CSF, Filgrastim; Roche, Switzerland) to patients undergoing elective colorectal surgery. Thirty consecutive patients were prospectively randomized to receive either r-metHuG-CSF or placebo. Treatment with r-metHuG-CSF induced transient leukocytosis with shift to the left. The phagocytic or killing capacities of neutrophils were not altered in the patients treated with r-metHuG-CSF, but there was a decline in neutrophil chemotaxis. There were no serious adverse events associated with r-metHuG-CSF treatment. Thus, perioperative r-metHuG-CSF is safe for patients undergoing colorectal surgery. The presence of an increased number of functioning neutrophils may offer advantages in combating imminent infection.

Comparison of costs between laparoscopic and open Nissen fundoplication: a prospective randomized study with a 3-month followup.

BACKGROUND: Laparoscopic antireflux surgery has replaced conventional operation despite the fact that currently no randomized trials have been published regarding its cost effectiveness. The objective of the present study was to compare costs and some short-term outcomes of laparoscopic and open Nissen fundoplication. STUDY DESIGN: Forty-two patients with documented gastroesophageal reflux disease were randomized between October 1995 and October 1996 to either laparoscopic (LNF) or open (ONF) Nissen fundoplication. Some short-term outcomes, Gastrointestinal Quality of Life Index (GIQLI) hospital costs, and costs to society were assessed. Followup was 3 months. RESULTS: Medians of operation times in the LNF and ONF groups were 98 min and 74 min, respectively. Hospital stay was 2.5 days shorter after laparoscopic operation (LNF 3 days versus ONF 5.5 days). Both operations were equally safe and effective, but the LNF group experienced significantly less pain and fatigue during the first 3 postoperative weeks. Improvement in the GIQLI and overall patient satisfaction were comparable between the methods. Convalescence was faster in the LNF group: return to normal life being 14 versus 31 days and return to work being 21 versus 44 days in the LNF and ONF groups, respectively. Hospital costs were similar, $2,981 and $3,140 in the LNF and ONF groups, respectively, but total costs were lower ($7,506 versus $13,118) in the LNF group as a result of an earlier return to work. CONCLUSIONS: LNF is superior in cost effectiveness, assuming that the longterm results between the methods are comparable.

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.

A prospective randomized outcome and cost comparison of totally extraperitoneal endoscopic hernioplasty versus Lichtenstein hernia operation among employed patients.

Laparoscopic hernia operations have been criticized in regard to their high hospital costs. This study was designed to compare the costs and some outcome features of totally extraperitoneal endoscopic hernia operation (TEP) and Lichtenstein mesh repair (OPN) among 45 randomized employed patients. The medians of operative time in the TEP and OPN groups were 67.5 and 53 min, respectively. Return to normal life was 14 days in the TEP group and 20 days in the OPN group. The hospital costs per patient were $1,239 (all costs are in US dollars) in the TEP group and $782 in the OPN group. The median total costs were $3,912 and $4,661 in the TEP and OPN groups, respectively. The Lichtenstein operation is cheaper for the hospital. The total costs for working patients are lower with the endoscopic technique because fewer working days are lost.

A cost and outcome comparison between laparoscopic and Lichtenstein hernia operations in a day-case unit. A randomized prospective study.

BACKGROUND: Laparoscopic hernia repair has often been criticized for its high costs. METHODS: To compare the costs of laparoscopic and open hernia repair, 40 patients were randomized for either transabdominal laparoscopic or Lichtenstein mesh repair (under local anesthesia) in a day-case surgery unit. RESULTS: Median operative times for the laparoscopic and open groups were 62 and 65 min, respectively. Postoperative pain was comparable for the two groups. The period before return to normal life was 14 days in the laparoscopic group and 21 days in the open group. The hospital costs were 2051 FIM ($1 US = 4.6 FIM) higher in the laparoscopic group, but the total costs for employed patients (including expenses due to lost work days) were lower. CONCLUSION: Although the Lichtenstein operation is cheaper for the hospital, the total costs for working patients are lower with the laparoscopic technique, when the cost of lost work days is factored into overall expense.

Cost-effective appendectomy. Open or laparoscopic? A prospective randomized study.

BACKGROUND: The aim of this study was to compare the outcome and cost-effectiveness of laparoscopic (LA) and open appendectomy (OA). METHODS: Forty consecutive patients were randomized to either the LA (n = 19) or OA (n = 21) group. RESULTS: The medians of operative times in the LA and OA groups were 31.5 and 41 min, respectively. The total operation room times were 91 and 82 min, respectively. There was no significant difference in postoperative pain or fatigue, but return to normal life was faster in the LA group (14 versus 26. 5 days). The median hospital costs per patient were 8,538 and 6,788 FIM ($1 US = 4.6 FIM) in the LA and OA groups, respectively; but the total costs among working patients were lower in the LA group (20, 963 versus 27,778 FIM) due to faster return to work. CONCLUSIONS: Laparoscopic appendectomy is as safe as open appendectomy. The hospital costs are higher, but LA offers significant cost savings to the payer for working patients.

Immunohistochemical study of colorectal tumors for expression of a novel transmembrane carbonic anhydrase, MN/CA IX, with potential value as a marker of cell proliferation.

Carbonic anhydrase isoenzyme IX, MN/CA IX, is a recently discovered member of the carbonic anhydrase (CA) gene family with a suggested function in acid-base balance, intercellular communication, and cell proliferation. Increased expression of MN/CA IX has been observed with certain epithelial tumors. We investigated the expression of MN/CA IX in 69 colorectal neoplasms, consisting of 1 juvenile polyp, 8 hyperplastic polyps, 39 adenomatous lesions, 21 carcinomas, and 7 metastases. Tissue sections were immunostained with a monoclonal antibody specific to MN/CA IX. The proliferative activity of the tumor cells was evaluated by Ki-67 antigen immunoreactivity. The hyperplastic polyps showed a weak or moderate reaction for MN/CA IX only in the cryptal epithelium, as did the normal intestinal mucosa. The adenomas showed immunoreactivity mainly in the superficial part of the mucosa, whereas the distribution in the carcinomas and metastases was more diffuse. Comparative immunostaining of serial sections for Ki-67, a well established marker of cell proliferation, confirmed that MN/CA IX is expressed in areas with high proliferative capacity. Our results show abnormal MN/CA IX expression in colorectal neoplasms, suggesting its involvement in their pathogenesis. The co-occurrence of MN/CA IX and Ki-67 in the same tumor cells indicates its potential for use as a marker of increased proliferation in the colorectal mucosa.

Chronic inflammation and elastin degradation in abdominal aortic aneurysm disease: an immunohistochemical and electron microscopic study.

OBJECTIVES: To investigate (i) elastin degradation and the possible association between proteolysis and inflammation in abdominal aortic aneurysm disease (AAA), and (ii) the presence of cytomegalovirus (CMV) infection in the walls of AAA. MATERIALS: Specimens from 12 infrarenal AAAs, eight aortas with occlusive disease (AOD) and two normal aortas were studied by conventional light microscopy, immunohistochemistry using a monoclonal anti-elastin antibody BA-4 and anti-CMV antibody and transmission electron microscopy (TEM). MAIN RESULTS: In AAA the decrease in elastin immunoreactivity and the presence of elastin degradation was associated with increased mononuclear inflammatory cell infiltrates (p = 0.004 and p = 0.00002, respectively). The CMV immunostainings of the normal aortic wall and all the AAA and AOD samples were negative, nor could any CMV particles be demonstrated by TEM. CONCLUSIONS: The chronic inflammation and degradation of elastin in AAA suggests a possible immune-mediated mechanism. The inflammation may be induced by the chemotactic properties of elastin-derived peptides.

Risk features for surgical-site infections in coronary artery bypass surgery.

OBJECTIVE: To identify preoperative and perioperative features that may lead to a risk of surgical-site infection (SSI) after coronary artery bypass surgery. DESIGN: 884 patients who underwent coronary artery bypass grafting in 1992 and 1993 were studied. The associations between 23 preoperative and perioperative features and the presence of SSI at the donor site or in the chest area were evaluated by univariate analysis followed by multivariate logistic regression analysis. SETTING: A university hospital. RESULTS: 172 patients (19.5%) either had an SSI recorded before discharge or had received antibiotics prescribed for a suspected SSI during the 1-month surveillance period after discharge. Multivariate logistic regression analysis showed an extreme body mass index (BMI; P=.015), female gender (P=.023), and chronic obstructive pulmonary disease (COPD; P=.030) to be independent risk features for SSI. The donor site was infected in 136 patients (15.4%), an event for which female gender (P=.003) was the only independent risk feature. Forty-seven patients (5.3%) had an SSI of the chest area, with diabetes (P=.003) and extreme BMI (P=.010) as independent risk features. CONCLUSION: Extreme BMI, female gender, and COPD are highly significant independent predictors of the development of SSI. Female gender is a risk feature specifically for SSI at the donor site, whereas diabetes and extreme BMI predict it in the chest area.