Christopher D. Sutton

Pancreas Resection and Islet Autotransplantation for End-Stage Chronic Pancreatitis

ObjectiveTo assess the safety and efficacy of islet autotransplantation (IAT) combined with total pancreatectomy (TP) to prevent diabetes. Summary Background DataThere have been recent concerns regarding the safety of TP and IAT. This is thought to be related to the infusion of large volumes of unpurified pancreatic digest into the portal vein. Minimizing the volume of islet tissue by purifying the pancreatic digest has not been previously evaluated in terms of the postoperative rate of death and complications, pain relief, and insulin independence. MethodDuring a 54-month period, 24 patients underwent pancreas resection with IAT. Islets were isolated using collagenase and a semiautomated method of pancreas digestion. Where possible, islets were purified on a density gradient and COBE processor. Islets were embolized into the portal vein, within the spleen and portal vein, or within the spleen alone. The total median volume of digest was 9.9 mL. ResultsThe median number of islets transplanted was 140,419 international islet equivalents per kilogram. The median increase in portal pressure was 8 mmHg. Early complications included duodenal ischemia, a wedge splenic infarct, partial portal vein thrombosis, and splenic vein thrombosis. Intraabdominal adhesions were the main source of long-term problems. Eight patients developed transient insulin independence. Three patients were insulin-independent as of this writing. Patients had significantly decreased insulin requirements and glycosylated hemoglobin levels compared with patients undergoing TP alone. Of the patients alive and well as of this writing, four had failed to gain relief of their abdominal pain and were still opiate-dependent. ConclusionCombined TP and IAT can be a safe surgical procedure. Unfortunately, almost all patients were still insulin-dependent, but they had decreased daily insulin requirements and glycosylated hemoglobin levels compared with patients undergoing TP alone. A prospective randomized study is therefore needed to assess the long-term benefit of TP and IAT on diabetic complications.

Ten-year experience of endoscopic transanal resection.

ObjectiveTo audit the results of endoscopic transanal resection of tumor (ETAR) performed by a single surgeon at a specialized colorectal unit during a 10- year period. Summary Background DataA minimally invasive surgical technique, ETAR has enabled much progress to be made in the development of local treatment strategies for rectal neoplasia. It can be used in both the curative and palliative management of rectal lesions and is a treatment option for patients who would be unable to tolerate major surgery. MethodsThe surgical outcome of 104 patients (43 women, 61 men) undergoing ETAR under the care of a single surgeon between 1989 and 1999 was reviewed. Patients were identified from the consultant’s personal records and cross-referenced with operating room logs. Data were collected retrospectively and no patients were lost to follow-up. ResultsOne hundred four patients underwent 163 procedures during the study period. Follow-up ranged from 6 months to 10 years. Seventy-five patients with a pre-ETAR diagnosis of benign rectal adenoma underwent resection. In 60 patients, the diagnosis was confirmed to be benign; 30 of these were treated with a single resection and 28 with multiple resections. There were two technical failures, both a result of high mobility of the lesion. In no patients did carcinoma subsequently develop. In the remaining 15 patients the final histology demonstrated a malignancy; 9 patients underwent an open surgical rectal resection and 5 had complete endoscopic resection of their lesion. No carcinomas that were fully resected endoscopically have recurred (follow-up 13 months to 8years). The final patient had an extensive rectal cancer and was palliated for 2 months by ETAR. Twelve patients (8 men, 4 women) underwent ETAR for anastomotic strictures; successful treatment was achieved in 11. The one failure was in a Park’s pouch that was subsequently refashioned. Seventeen patients underwent 30 ETARs for palliation of nonresectable rectal adenocarcinoma. Successful palliation of symptoms was achieved in 13 patients and the remainder underwent colostomy formation. One patient died of a myocardial infarction. There were two further complications (blood transfusion for postoperative bleeding, postoperative cerebrovascular accident). ConclusionsEndoscopic transanal resection of tumor is safe and effective and offers successful palliation or definitive treatment of rectal lesions with low rates of death and complications when performed by a dedicated surgeon.

A computer image analysis system for microvessel density measurement in solid tumours.

Microvessel density (MVD) is a widely used surrogate measure of angiogenesis in pathological specimens and tumour models. Measurement of MVD can be achieved by several methods. Automation of counting methods aims to increase the speed, reliability and reproducibility of these techniques. The image analysis system described here enables MVD measurement to be carried out with minimal expense in any reasonably equipped pathology department or laboratory. It is demonstrated that the system translates easily between tumour types which are suitably stained with minimal calibration. The aim of this paper is to offer this technique to a wider field of researchers in angiogenesis.

The inguinal release procedure for groin pain: initial experience in 73 sportsmen/women

Objective: To assess the impact of the laparoscopic inguinal release procedure with mesh reinforcement on athletes with groin pain. Design: Prospective cohort study. Setting: Private sector. Patients: Professional and amateur sportsmen/women undergoing the inguinal release for groin pain. Main outcome measurements: Change in patient’s symptoms, functional limitation and time to resuming sporting activity following surgery. Results: 73 sportsmen/women underwent laparoscopic inguinal release in the study period, 37 (51%) of whom were professionals. 95% were male with a median age of 30 years. Following operation, patients returned to light training at a median of 1 week, full training at 3 weeks (professionals—2 weeks) and playing competitively at 4 weeks (professionals—3 weeks). 74% considered themselves match-fit by 4 weeks (84% of professionals). Following surgery, there was a highly significant improvement in frequency of pain, severity of pain and functional limitation in both the whole cohort and professional group. 88% reported a return to full fitness at follow-up, with 73% reporting complete absence of symptoms. 97% of the cohort thought the operation had improved their symptoms. Conclusions: This study shows that the laparoscopic inguinal release procedure may be effective in the treatment of a subgroup of athletes with groin pain.

Expression of Thrombospondin-1 in Resected Colorectal Liver Metastases Predicts Poor Prognosis

Purpose: The aim of this study was to examine the expression and prognostic relevance of thrombospondin-1 (TSP-1) in tumor biopsies taken from a consecutive series of liver resections done at the University Hospitals of Leicester and the Royal Liverpool Hospital. Experimental Design: Patients having undergone a liver resection for colorectal liver metastases at our institutions between 1993 and 1999 inclusive were eligible. Inclusion criteria were curative intent, sufficient tumor biopsy, and patient follow-up data. One hundred eighty-two patients were considered in this study. Standard immunohistochemical techniques were used to study the expression of TSP-1 in 5-μm tumor sections from paraffin-embedded tissue blocks. TSP-1 was correlated with survival using the Kaplan-Meier method and log-rank test for univariate analysis and the Cox proportional hazard model for multivariate analysis. Results: One hundred eighty-two patients (male, n = 122 and female, n = 60) ages between 25 and 81 years (mean, 61 years) were included. TSP-1 was expressed around blood vessels (n = 45, 25%) or in the stroma (n = 59, 33%). No expression was detected in the remaining tumors. TSP-1 significantly correlated with poor survival on univariate (P = 0.01 for perivascular expression and P = 0.03 for stromal expression) and multivariate analysis (P = 0.01 for perivascular expression). Conclusion: TSP-1 is a negatively prognostic factor for survival in resected colorectal liver metastases.

Reduced Thrombospondin-1 at Presentation Predicts Disease Progression in Superficial Bladder Cancer

OBJECTIVES Superficial bladder cancer (SBC) presents a difficult clinical dilemma at diagnosis as only a small subgroup of patients will subsequently develop invasive disease. Study of cancer biology has found that angiogenesis is central to growth and spread. This study examines the relationship between the angiogenic inhibitory factor Thrombospondin-1 (TSP-1) at initial presentation and subsequent progression of SBC. METHODS Using immunohistochemistry, 220 cases of SBC were examined for pattern and extent of expression of TSP-1 at initial presentation. RESULTS TSP-1 was detected in perivascular tissue, at the epithelial-stromal junction, in the stroma and in tumour cells and reduced perivascular TSP-1 staining at presentation was an independent predictive factor for the subsequent development of muscle invasive or metastatic disease. CONCLUSION This adds further weight to the theory that TSP-1 plays a major part in the biology of bladder cancer possibly through the control of angiogenesis.

Laparoscopic inguinal ligament tenotomy and mesh reinforcement of the anterior abdominal wall: a new approach for the management of chronic groin pain.

Background Chronic groin pain has an incidence of up to 6.2% and is common in people undertaking regular sports activity. A variety of surgical options exist for unresolving pain, which consist, for the most part, of a repair of the posterior abdominal wall, with or without mesh placement. We describe a new technique, which combines laparoscopic inguinal ligament tenotomy in conjunction with a mesh repair. Methods A retrospective analysis of the notes of 48 patients was undertaken in conjunction with a mailed questionnaire. Success of surgery was judged on return to preinjury sporting activity, severity of pain scores, frequency of pain scores, and functional limitation scores. Results There were no major complications associated with the procedure. Severity of pain, frequency of pain, and functional limitation scores were all significantly improved after surgery (P=0.0012, <0.0001, and <0.0001, respectively). Ninety-two percent of patients polled returned to normal sports activity after their surgery (n=24). The median return to strenuous sports activity was 28 days (range of 14 to 40 d). Conclusions The success rates of laparoscopic tenotomy and mesh repair are comparable with the published literature and a lower median time interval before returning to preinjury sporting activity.

The effects of supervised exercise training 12–24 months after bariatric surgery on physical function and body composition: a randomised controlled trial

Background:Bariatric surgery is effective for the treatment of stage II and III obesity and its related diseases, although increasing evidence is showing weight regain ~12–24 months postsurgery. Weight regain increases the risk of physical function decline, which negatively affects an individuals ability to undertake activities of daily living. The study assessed the effects of a 12-week supervised exercise intervention on physical function and body composition in patients between 12 and 24 months post bariatric surgery.Methods:Twenty-four inactive adult bariatric surgery patients whose body mass index remained ⩾30 kg m2 12 to 24 months post surgery were randomised to an exercise intervention (n=12) or control group (n=12). Supervised exercise consisted of three 60-min gym sessions per week of moderate intensity aerobic and resistance training for 12 weeks. Control participants received usual care. The incremental shuttle walk test (ISWT) was used to assess functional walking performance after the 12-week exercise intervention, and at 24 weeks follow-up. Measures of anthropometric, physical activity, cardiovascular and psychological outcomes were also examined. Using an intention-to-treat protocol, independent t-tests were used to compare outcome measures between groups.Results:Significant improvements in the exercise group were observed for the ISWT, body composition, physical function, cardiovascular and self-efficacy measures from baseline to 12 weeks. A large baseline to 12-week change was observed for the ISWT (exercise: 325.00±117.28 m; control: 355.00±80.62 m, P<0.001). The exercise group at 24 weeks recorded an overall mean improvement of 143.3±86.6 m and the control group recorded a reduction of −32.50±75.93 m. Findings show a 5.6 kg difference between groups in body mass change from baseline to 24 weeks favouring the exercise group.Conclusions:A 12-week supervised exercise intervention led to significant improvements in body mass and functional walking ability post intervention, with further improvements at the 24-week follow-up.

Predictive factors for unanticipated admission following day case surgery.

In general, a surgical day case is a patient admitted for investigation or operation on a planned non-resident basis who requires facilities for recovery [1]. For these patients the proposed limit of their hospital stay is 23 hours or less [1,2]. In reality, many day surgery units (DSUs) do not operate over a 23-hour period, hence, patients requiring a hospital stay longer than planned will need transfer to a main surgical ward. The Department of Health in the UK has set a target of 75% of elective surgery to be performed as day cases, and it has been recommended that the unplanned admission rate should be less than 3% for these cases [1]. Identifying the predisposing factors contributing to unplanned admissions is vital in order to reduce costs and pressure on acute hospital beds.

Incidental adult nesidioblastosis after distal pancreatectomy for endocrine microadenoma.

Persistent hyperinsulinaemic hypoglycaemia (nesidioblastosis) presenting with hypoglycaemia is extremely rare in adults. The features are suggestive of an insulinoma with a vague presentation and delayed diagnosis. We describe a report of adult nesidioblastosis in association with a pancreatic endocrine microadenoma.