Alan Patrick Ainsworth

Leukocyte-depletion of blood components does not significantly reduce the risk of infectious complications : Results of a double-blinded, randomized study

Abstract. Allogeneic blood transfusions are claimed to be an independent risk factor for postoperative infections in open colorectal surgery due to immunomodulation. Leukocyte-depletion of erythrocyte suspensions has been shown in some open randomized studies to reduce the rate of postoperative infection to levels observed in nontransfused patients. Using a double-blinded, randomized design, we studied the postoperative infection rate in patients undergoing open colorectal surgery transfused with either leukocyte-depleted erythrocyte suspensions (LD-SAGM) or non-leukocyte-depleted erythrocyte suspensions (SAGM). Unselected patients (n 279) were allocated to receive LD-SAGM (n 139) or SAGM (n 140) if transfusion was indicated. Forty-five percent were transfused, yielding 48 patients in the LD-SAGM group and 64 in the SAGM group. Thirteen patients were excluded because they received one type of transfusion in spite of randomization to the other type. No significant differences in the rates of postoperative infections (P=0.5250) or postoperative complications (P=0.1779) were seen between the two transfused groups. Infection rates were 45% and 38% in the transfused groups and 21% and 23% in the nontransfused groups. No significant difference between the transfused groups was seen on any single infectious event, mortality rate, or duration of hospitalization. Leukocyte-depletion of erythrocyte suspensions transfused to patients undergoing open colorectal surgery does not reduce postoperative infection rates.

Cost-effectiveness of endoscopic ultrasonography, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography in patients suspected of pancreaticobiliary disease.

Background: It is not known whether initial endoscopic ultrasonography (EUS) or magnetic resonance cholangiopancreatography (MRCP) is more cost effective than endoscopic retrograde cholangiopancreatography (ERCP). Methods: A cost‐effectiveness analysis of EUS, MRCP and ERCP was performed on 163 patients. The effectiveness of an investigation was defined as the percentage of patients with no need for further evaluation after the investigation in question had been performed. Costs were assumed from the budget‐holders point of view. Results: MRCP, EUS and ERCP had a total accuracy of 0.91, 0.93 and 0.92, respectively. Eighty‐four (52%) patients needed endoscopic therapy in combination with ERCP, giving an effectiveness of MRCP, EUS, and ERCP of 0.44, 0.45 and 0.92, respectively. The cost‐effectiveness of MRCP, EUS, and ERCP was 6622, 7353 and 4246 Danish Kroner (DKK) per fully investigated and treated patient (1 DKK = 0.14 EUR). Conclusion: Within a patient population with a probability of therapeutic ERCP in 50% of the patients, ERCP was the most cost‐effective strategy.

Indications for and clinical impact of repeat endoscopic ultrasound

Abstract Objective. The value of repeating endoscopic ultrasound (EUS) is seldom described. This study evaluates a patient population in which EUS was repeated. Material and methods. This was a retrospective study of patients who between January 2002 and December 2006 had an EUS scan performed; this EUS scan (re-EUS) was the second or more EUS scan performed. Results. Over the study period, the department performed 3024 EUS procedures, of which 561 investigations were defined as re-EUS. According to defined exclusion criteria, 244 procedures were not analyzed further. The study group thus consisted of 317 procedures (242 patients). In 163 cases (126 patients), re-EUS was planned by the endosonographer for control of an undetermined lesion. The first re-EUS scan performed changed the further management in 91 of 126 patients (72%). Sensitivity and specificity of re-EUS regarding pancreatic cancer were 0.65 and 1.00, respectively. Re-EUS was performed in 82 cases (77 patients) where no re-investigation had been planned at the initial EUS scan but worsening of symptoms or new findings of other imaging procedures had led to an additional EUS scan. Thirteen of these patients (17%) proved to have pancreatic cancer. In 62 cases (57 patients) re-EUS and EUS-guided fine-needle aspiration (FNA) had been planed in order to confirm the suspicion of malignant disease. Following re-EUS and EUS-FNA, 40 of these patients could be referred for either oncology or surgery. In the remaining 10 cases, re-EUS was performed for miscellaneous indications. Conclusion. Re-EUS has a substantial clinical impact on the further management of the patient.

Combined preoperative endoscopic and laparoscopic ultrasonography for prediction of R0 resection in upper gastrointestinal tract cancer

This study evaluated the ability of combined endoscopic and laparoscopic ultrasonography to predict R0 resection and avoid unnecessary surgery in patients with upper gastrointestinal tract cancer (UGIC).

Cost-effectiveness of different diagnostic strategies in patients with nonresectable upper gastrointestinal tract malignancies

AbstractBackground and methods: Using a simple model, this retrospective study evaluated the cost-effectiveness of different diagnostic strategies used for pretherapeutic detection of patients with disseminated or locally nonresectable upper gastrointestinal tract malignancies (UGIM). Of 162 consecutive UGIM patients referred for treatment, 73 (45%) had disseminated or locally nonresectable disease, and these patients were eligible for evaluation. Results: The noninvasive diagnostic strategies (computed tomography [CT] with ultrasonography [US] and endoscopic ultrasonography [EUS]) had a low procedure cost, but a diagnostic strategy based on CT with US or CT with US and laparoscopy was not cost-effective. The inclusion of endoscopic or laparoscopic ultrasonography seemed necessary to the provision of a cost-effective strategy because both techniques had a high diagnostic accuracy combined with a low cost. A change in diagnostic strategy from CT with US to CT with US and EUS resulted in a net saving regarding the cost of each additional nonresectable patient detected, but this strategy still required up to 20% futile explorative laparotomies. Conclusions: The combination of endoscopic and laparoscopic ultrasonography was cost-effective and had no complications in this study. We use this strategy as our standard in the pretherapeutic evaluation of UGIM patients.

Laparoscopic ultrasound-guided biopsy in upper gastrointestinal tract cancer patients

BackgroundNoninvasive pretherapeutic staging may be supplemented with laparoscopy and laparoscopic ultrasonography (LUS) in order to detect minute liver metastases, carcinosis or other signs of nonresectable or disseminated disease in patients with upper gastrointestinal tract cancer (UGIC). The aim of this study was to evaluate the use, potential clinical gain, and safety profile of LUS-guided biopsy in patients with UGIC.MethodsA prospective consecutive study on LUS-guided biopsy in patients referred with UGIC between May 2007 and May 2008 was carried out. Previous noninvasive imaging methods had found no signs of disseminated disease. Laparoscopic or LUS-guided biopsies were only performed if a malignant result would change patient management.ResultsTwo hundred and nine patients entered the study and, based on predefined biopsy indications, laparoscopy and LUS-guided biopsies changed patient management in a total of 27.3% (54/198) of the patients with a final malignant diagnosis. There were no complications. Liver and pancreas were the main target areas for LUS-guided biopsies, and more than half of the biopsies (55%) were taken from the primary tumor where other modalities had failed to obtain proof of malignancy. Twenty-six percent of biopsies were taken from a suspected metastatic lesion not seen before, whereas 19% were taken from previously suspected metastases where other imaging modalities had failed to obtain proof of malignancy.ConclusionLUS-guided biopsy is a safe procedure which in combination with laparoscopic biopsies had an impact on patient management in one-quarter of UGIC patients.

Surgery for acute cholecystitis in Denmark

Objective. Despite laparoscopic cholecystectomy being the preferred treatment for elective cholecystectomy, surgery for acute cholecystitis is often performed using the open method. The aim of the study was to assess the incidence of cholecystectomy for acute cholecystitis and to determine the proportion of laparoscopically completed procedures compared with all cholecystectomies for acute cholecystitis. Material and methods. Data from the Danish National Patient Registry were analysed. The annual numbers of all cholecystectomies and of cholecystectomies performed for acute cholecystitis from 1996 to 2004 were registered. Separate data for open and laparoscopic operations were obtained. Results. An increase in the number of cholecystectomies for acute cholecystitis from 13.6 in 1996 to 17.2/100,000 in 2004 was observed (p<0.05). In 1996, 41% of cholecystectomies performed for acute cholecystitis were completed laparoscopically as compared with 64% in 2004 (p<0.05). For laparoscopic cholecystectomies performed for reasons other than acute cholecystitis, the corresponding rates were 78% and 87%, respectively (p<0.05). Conclusions. The total number of patients having cholecystectomy for acute cholecystitis has increased as has the rate of laparoscopically completed procedures. It is not known whether it is possible to obtain a further reduction in the number of open cholecystectomies.

Combined endoscopic and laparoscopic ultrasound as preoperative assessment of patients with pancreatic cancer

BACKGROUND An accurate pre-therapeutic assessment of the resectability in pancreatic cancer patients is essential to reduce the number of futile surgical explorations. The aim of this study was to assess the combination of endoscopic ultrasound (EUS) and laparoscopic ultrasound (LUS) regarding the detection of patients with non-resectable tumours. PATIENTS AND METHODS From 2002 to 2004, 179 consecutive patients with pancreatic cancer referred for surgical treatment were eligible. Thirty-one (17%) patients were excluded due to co-morbidity and poor performance status. Two patients (1%) were excluded due to metastasis seen on CT scans prior to referral. Thus, 146 patients entered the study. Patients were first examined with EUS followed by LUS, if EUS found no signs of non-resectability. Only patients with tumours found to be resectable or possibly resectable at EUS and LUS were offered surgical treatment. Resectability criteria were defined prior to the study. RESULTS In all, 108 (74%) patients had non-resectable tumours by the pre-defined criteria. EUS identified 68 (63%) patients and LUS identified an additional 26 (24%) patients. Thus, a total of 94 (87%) patients were non-resectable at either EUS or LUS. Fifty-two (36%) patients underwent surgery. Six patients had surgical exploration and three patients had palliative surgery. Forty-three patients (29%) were resected with curative intention, of whom 38 (88%) had an R0 resection and 5 (12%) had a palliative resection. DISCUSSION The combination of EUS and LUS is accurate in identifying the non-resectable patients and has a high predictive value for complete resection.

Endoscopic ultrasound-guided fine-needle marking of lymph nodes

BACKGROUND AND STUDY AIMS: No previous studies have evaluated the ability of endoscopic ultrasonography to describe the anatomic location of lymph nodes on the basis of a node-to-node comparison. The aim of this study was to assess the feasibility and safety of a new endoscopic ultrasound (EUS)-guided fine-needle technique for marking lymph nodes. PATIENTS AND METHODS: Twenty-five patients with suspected or confirmed malignancies of the upper gastrointestinal tract were prospectively included. EUS-guided fine-needle marking (EUS-FNM) was performed with a silver pin with a diameter that allowed it to fit into a 19-gauge needle. The position of the pin was verified by EUS. End points were the ability to identify and isolate the marked lymph node during surgery and a comparison between the location of the pin as suggested by EUS and the actual location found in the resected specimen. RESULTS: Twenty-three lymph nodes were marked. Nineteen intended surgical isolations were performed. The lymph nodes were isolated in the resection specimens in 18 patients (95 %). In 2 out of 20 cases the pin was not localized by laparoscopic ultrasonography. In 89 % of the cases the marked lymph node was in the same location as described by EUS. One pin (5 %) was not retrieved. In three cases, a small hematoma was observed. There was no sign of long-term complications. CONCLUSION: EUS-FNM with a silver pin in lymph nodes is feasible and safe. EUS-FNM seems to be a suitable tool for evaluating lymph nodes on the basis of a node-to-node comparison.

Potential impact of adding endoscopic ultrasound to standard imaging procedures in the preoperative assessment of resectability in patients with liver tumors.

Abstract Objective. The value of endoscopic ultrasonography (EUS) in patients with liver diseases is limitedly described. The aim of this study was to evaluate the potential impact of adding EUS to standard imaging procedures in the evaluation of resectability in patients with liver tumors. Material and methods. Patients who, based on the findings of CT and/or MRI, had been referred for curative resection of liver tumours were studied. Each patient underwent EUS before the final assessment of resectability, which was done by laparoscopic ultrasound or laparotomy. Results. Sixty-four patients were included. Intended curative resection was performed in 19 (30%) patients. Thirty-five (55%) patients were considered to have non-curative malignant disease. In 10 (15%) patients, the tumor was judged to be benign and surgery was not performed. There were no complications related to EUS. The sensitivity, specificity, positive predictive value, and negative predictive value of EUS regarding prediction of non-resectability were 0.24, 0.94, 0.80 and 0.56 (tumor in right lobe), 0.50, 1.0, 1.0 and 0.75 (tumor in left lobe), and 0.60, 0.67, 0.86 and 0.33 (tumors in both lobes), respectively. Sixteen patients (25%) would have had changed their further management, if decision regarding non-resectability had been taken after EUS. Discussion. Addition of EUS to a standard imaging set-up based on CT and/or MRI would have changed the management in 25% of the patients otherwise scheduled for resection of suspected liver tumors.