What is a nurse? Is there an international consensus?

BACKGROUND: Historical experience and health service modernization partly account for the variation seen in definitions of what a 'nurse' is from country to country. It is unclear if international disparities in nursing provision, apparent in health data for developed countries, demonstrate real differences in staffing patterns or simply reflect the wide variations in understanding and use of terms for different categories of nurse. AIM: This paper is an opinion piece of international interest discussing the need for standardization in definitions of different categories of nurse internationally. DISCUSSION: The International Council for Nurses (ICN), the World Health Organization and the Organisation for Economic Cooperation and Development (OECD) all have different ways of defining a nurse. The wide variation in terms is particularly apparent from OECD countries however, where nursing density data present wide disparities, not readily accounted for by gross national product. Skill mix and clinical role developments may account for these better. CONCLUSION: Until proper consensus is reached on what a nurse is and does, any skill mix or clinical role developments will only have limited international relevance, especially in OECD countries. If nursing qualifications are to be valid even across the European Union, then recommended standards such as those of the ICN, must be specified in terms of what different categories of nurses actually can do, and their responsibilities and roles within that scope of practice. Standardization of definitions of categories of nurse internationally should reduce confusion and promote better understanding of patterns of nurse staffing and the effect these may have on patient outcomes.

Hepatic resection for benign non-cystic liver lesions.

BACKGROUND: Hepatic resection is indicated for a variety of benign conditions because of persistent symptoms, uncertainty regarding the diagnosis or the risk of malignant transformation. The aim of this study was to assess the indications for and outcome of hepatic resection for benign non-cystic liver lesions in a specialist hepatobiliary unit. PATIENTS AND METHODS: All patients who had undergone hepatic resection for benign non-cystic hepatic lesions between 1989 and 2001 were identified from a prospective database for analysis. RESULTS: A total of 49 patients (40 women, 9 men) with a mean age of 43 years (range 21-75 years) underwent resection of non-cystic benign lesions. Indications for operation included suspected liver cell adenoma (n=11), suspicion of malignancy (11), persistent symptoms attributable to the lesion (20) or chronic sepsis (7). The final diagnosis was focal nodular hyperplasia (n=12), haemangioma (12), adenoma (8), sclerosing cholangitis (5), inflammatory pseudotumour (4), intrahepatic cholelithiasis (3), chronic hepatic abscess (3), benign biliary fibrosis (I) and leiomyoma (I). Major anatomical hepatic resections were performed in 44 patients, and 5 patients underwent a segmentectomy or minor atypical resection. Median operating time was 215 min (range 45-450 min) and median blood loss was 875 ml (range 200-4000 ml). Ten patients (20%) required a median blood transfusion of 2 units (range 2-8 units). The median postoperative stay was 10 days (range 4-33 days). There were no deaths, but complications occurred in 15 patients (27%). CONCLUSIONS: Hepatic resection can be safely recommended for selected patients with a variety of benign non-cystic hepatic lesions. A small group of patients undergo resection as a result of inability to rule out a malignant process, but the large majority will be operated on because of either their malignant potential or related symptoms.

Postchemoembolisation syndrome--tumour necrosis or hepatocyte injury?

Transarterial chemoembolisation of liver tumours is typically followed by elevated body temperature and liver transaminase enzymes. This has often been considered to indicate successful embolisation. The present study questions whether this syndrome reflects damage to tumour cells or to the normal hepatic tissue. The responses to 256 embolisations undertaken in 145 patients subdivided into those with hepatocyte-derived (primary hepatocellular carcinoma) and nonhepatocyte-derived tumours (secondary metastases) were analysed to assess the relative effects of tumour necrosis and damage to normal hepatocytes in each group. Cytolysis, measured by elevated alanine aminotransferase, was detected in 85% of patients, and there was no difference in the abnormalities in liver function tests measured between the two groups. Furthermore, cytolysis was associated with a higher rate of postprocedure symptoms and side effects, and elevated temperature was associated with a worse survival on univariate analysis. Multivariate analysis demonstrated that there was no benefit in terms of survival from having elevated temperature or cytolysis following embolisation. Cytolysis after chemoembolisation is probably due to damage to normal hepatocytes. Temperature changes may reflect tumour necrosis or necrosis of the healthy tissue. There is no evidence that either a postchemoembolisation fever or cytolysis is associated with an enhanced tumour response or improved long-term survival in patients with primary or secondary liver cancer.

Incidence of benign pathology in patients undergoing hepatic resection for suspected malignancy.

BACKGROUND: Confirming the presence of hepatic or proximal bile duct malignancy pre-operatively remains difficult and some patients may undergo surgical resection for suspected malignant lesions which subsequently turn out to be benign. The aim of this study was to establish whether improvements in pre-operative staging might better identify this patient population. METHODS: Analysis of a prospectively collected database, which has been maintained in our unit since 1988. RESULTS: Of 250 consecutive patients undergoing hepatic resection for presumed malignancy, 18 (7.2%) were shown to have benign pathology. These "false positive" rates were 4 out of 160 (2.5%) resections for colorectal metastases, 4 out of 49 (8.2%) resections for other solid hepatobiliary tumours and 10 out of 41 (24.4%) resections for hilar cholangiocarcinoma. Four of the 18 patients (22%) developed post-operative complications but there was no postoperative mortality. CONCLUSION: Although hepatic resection remains a potentially curative procedure for patients with tumours involving the liver parenchyma or proximal bile ducts, pre-operative confirmation of malignancy remains difficult. Despite appropriate investigation a subset of patients with benign disease will still be subjected to major hepatic resection which should be undertaken in a specialist unit.

Virtual hepatic resection using three-dimensional reconstruction of helical computed tomography angioportograms.

OBJECTIVE: To establish the accuracy of virtual hepatic resection using three-dimensional (3D) models constructed from computed tomography angioportography (CTAP) images in determining the liver volume (LV) resected during resectional liver surgery. SUMMARY BACKGROUND DATA: The ability to measure LV before surgery could be useful in determining the extent and nature of hepatic resection. Accurate assessment of LV and an estimate of liver function may also allow prediction of postoperative liver failure in patients undergoing resection, assist in volume-enhancing embolization procedures, help with the planning of staged hepatic resection for bilobar disease, and aid in selection of living-related liver donors. METHODS: A retrospective study was conducted involving 27 patients scheduled for liver resection. Using mapping technology, 3D models were constructed from helical CTAP images. From these 3D models, tumor volume, total LV, and functional LV were calculated and were compared with body weight. The 3D liver models were subjected to a virtual hepatectomy along established anatomical planes, and the resected LV was calculated. The resected volume predicted by radiologists (unaware of the actual weight) was compared with the specimen weight measured after actual surgical resection. RESULTS: A significant correlation was found between body weight and functional LV but not total LV. The computer prediction of resected LV after virtual hepatectomy of 3D models compared well with resected liver weight. CONCLUSION: Virtual hepatectomy of 3D CTAP reconstructed images provides an accurate prediction of liver mass removed during subsequent hepatic resection. The authors intend to combine this technology with an assessment of liver function to attempt to predict patients at risk for liver failure after hepatic resection.

Distribution of colorectal liver metastases in patients referred for hepatic resection.

BACKGROUND: There is a perception that streamline flow of blood in the portal vein may influence the anatomic distribution of liver metastases, depending on the site of the primary tumor. It has previously been reported that cancers arising in the right colon are distributed to the right lobe of the liver 10 times more commonly than to the left lobe, whereas liver metastases from tumors arising from the left colon and rectum are believed to be distributed homogenously. METHODS: Data were collected prospectively on the anatomic site of hepatic metastases in 207 patients with colorectal metastases referred for consideration for surgery. Anatomic site was established by a combination of computed tomography scanning and either laparoscopic or intraoperative ultrasonography. The site of the primary tumor was known in all cases. RESULTS: A total of 708 metastases were identified, of which 67% were in the right hemiliver and 33% were in the left. The ratio of involvement of the right and left hemilivers by metastases arising from right colon tumors was 2. 02:1 and for left colon tumors 2.1:1. When patients with unilobar disease only were considered, the ratio of involvement of the right and left hemilivers increased to 2.9:1, but again no difference was evident that depended on the site of the primary tumor. CONCLUSIONS: This study could not find any evidence to support a differential pattern of metastasis within the liver dependent on the location of the primary colorectal carcinoma.

Does the subspecialty of the surgeon performing primary colonic resection influence the outcome of patients with hepatic metastases referred for resection?

OBJECTIVE: To compare resection rates and outcome of patients subsequently referred with hepatic metastases whose initial colon cancers were resected by surgeons with different specialty interests. SUMMARY BACKGROUND DATA: Variation in practice among noncolorectal specialist surgeons has led to recommendations that colorectal cancers should be treated by surgeons trained in colorectal surgery or surgical oncology. METHODS: The resectability of metastases, the frequency and pattern of recurrence after resection, and the length of survival were compared in patients referred to a single center for resection of colorectal hepatic metastases. The patients were divided into those whose colorectal resection had been performed by general surgeons (GS) with other subspecialty interests (n = 108) or by colorectal specialists (CS; n = 122). RESULTS No differences were observed with respect to age, sex, tumor stage, site of primary tumor, or frequency of synchronous metastases. Comparing the GS group with the CS group, resectable disease was identified in 26% versus 66%, with tumor recurrence after a median follow-up of 19 months in 75% versus 44%, respectively. Recurrences involving bowel or lymph nodes accounted for 55% versus 24% of all recurrences, with respective median survivals of 14 months versus 26 months. CONCLUSION: Fewer patients referred by general surgeons had resectable liver disease. After surgery, recurrent tumor was more likely to develop in the GS group; their overall outcome was worse than that of the CS group. This observation is partly explained by a lower local recurrence rate in the CS group.

Tailoring the management of nonparasitic liver cysts.

OBJECTIVE: To determine the optimal management of symptomatic non-parasitic liver cysts. SUMMARY BACKGROUND DATA: Management options for symptomatic nonparasitic liver cysts lack substantiation through comparative studies with respect to safety and long-term effectiveness. METHODS: A retrospective review of the surgical management of patients with hepatic cysts between October 1988 and August 1997 was undertaken to determine morbidity rates and to assess long-term recurrence. RESULTS: Thirty-eight patients (35 women, 3 men) underwent 48 operations for symptomatic hepatic cysts of mean diameter 12 cm, with a mean follow-up of 41 months. Twenty-three patients had simple cysts, and 15 patients had polycystic liver disease (PCLD). The symptomatic recurrence rates after laparoscopic or open deroofing for simple cysts were 8% and 29%, and for PCLD 71% and 20%, respectively. There were no symptomatic recurrences after 14 hepatic resections. There were no perisurgical deaths; however, morbidity rates were significant after laparoscopic deroofing, open deroofing, and hepatic resection (25%, 36%, and 50%, respectively). CONCLUSIONS: Selection of patients with truly symptomatic hepatic cysts is crucial before considering interventional techniques. For simple cysts, radical laparoscopic deroofing is usually curative; open deroofing should be reserved for cysts inaccessible by laparoscopy. The latter technique is well tolerated; however, long-term symptom control is unpredictable in patients with PCLD. Hepatic resection for PCLD provides satisfactory long-term symptom control but has an appreciable morbidity rate. Although laparoscopic and open deroofing procedures are less reliable in the long term for solitary cysts, they might be useful steps before embarking on this major procedure.