G. S. M. Robertson

Long-term results of unilateral neck exploration for preoperatively localized nonfamilial parathyroid adenomas

BACKGROUND Unilateral neck exploration for sporadic parathyroid adenomas remains a contentious policy. The morbidity is lower than for bilateral surgery, but the long-term outcome may be inferior. METHODS The results of a policy of unilateral neck exploration for primary hyperparathyroidism based on preoperative localization are reviewed. RESULTS Over a 10-year period, 89 patients were operated on, 57 undergoing unilateral neck exploration. Unilateral neck exploration significantly reduced operative time (P < 0.0001) and postoperative hypocalcaemia (P = 0.021). Over a mean biochemical follow-up of 38 months, recurrent hypercalcaemia occurred in 6% of patients, including 3.5% of those undergoing unilateral neck exploration, an additional 10% of patients were normocalcaemic with an inappropriately elevated parathormone level. CONCLUSIONS A policy of unilateral neck exploration can achieve comparable long-term results to more extensive bilateral surgery.

The optimization of large-scale density gradient isolation of human islets.

The use of the COBE 2991 cell processor (COBE Laboratories, Colorado) for large-scale islet purification using discontinuous density gradients has been widely adopted. It minimizes many of the problems such as wall effects, normally encountered during centrifugation, and avoids the vortexing at interfaces that occurs during acceleration and deceleration by allowing the gradient to be formed and the islet-containing interface to be collected while continuing to spin. We have produced cross-sectional profiles of the 2991 bag during spinning which allow the area of interfaces in such step gradients to be calculated. This allows the volumes of the gradient media layers loaded on the machine to be adjusted in order to mazimize the area of the gradient interfaces. However, even using the maximal areas possible (144.5 cm2), clogging of tissue at such interfaces limits the volume of digest which can be separated on one gradient to 15 ml. We have shown that a linear continuous density gradient can be produced within the 2991 bag, that allows as much as 40 ml of digest to be successfully purified. Such a system combines the intrinsic advantages of the 2991 with those of continuous density gradients and provides the optimal method for density-dependent islet purification.

Microwave ablation for unresectable hepatic tumours: clinical results using a novel microwave probe and generator.

BACKGROUND Microwave ablation is an in situ method of tumour destruction used to treat patients with unresectable liver tumours. A new microwave generator and probe, designed to deliver high energy into solid tumours quickly has been developed at our institution. We report the results of its use in patients with unresectable liver tumours treated by a single surgeon in a single institution. METHODS Thirty-one patients with 89 unresectable liver tumours were recruited into the study and underwent microwave ablation in a single procedure. RESULTS There were no post-operative complications. At a median of 24 months post ablation, 15 patients were alive with 7 patients disease free. At a median of 26 months, 8 patients were alive with tumour recurrence but only 1 with local recurrence. The remaining 7 patients with recurrence were found to have new disease at locations remote from the ablation site. Fourteen patients died of disease progression at a median survival of 15 months, with only 1 patient with local and remote tumour recurrence. Of the total numbers of tumours treated (n=89), a local tumour recurrence rate of 2% was observed. Overall median survival was 29 months with 3 year survival of 40%. DISCUSSION Microwave tissue ablation using this novel generator and probe has a low local recurrence and complication rate. Overall survival is comparable to alternative ablation modalities and its ability to treat, even large tumours, with a single insertion of the probe makes it an extremely attractive treatment option.

An Algorithm for the Management of Bile Leak Following Laparoscopic Cholecystectomy

INTRODUCTION The management of bile leaks following laparoscopic cholecystectomy has evolved with increased experience of ERCP and laparoscopy. The purpose of this study was to determine the impact of a minimally invasive management protocol. PATIENTS AND METHODS Twenty-four patients with a bile leak following laparoscopic cholecystectomy were recorded consecutively between 1993 and 2003. Between 1993-1998, 10 patients were managed on a case-by-case basis. Between 1998-2003, 14 patients were managed according to a minimally invasive protocol utilising ERC/biliary stenting and re-laparoscopy if indicated. RESULTS Bile leaks presented as bile in a drain left in situ post laparoscopic cholecystectomy (8/10 versus 10/14) or biliary peritonitis (2/10 versus 4/14). Prior to 1998, neither ERC nor laparoscopy were utilised routinely. During this period, 4/10 patients recovered with conservative management and 6/10 (60%) underwent laparotomy. There was one postoperative death and median hospital stay post laparoscopic cholecystectomy was 10 days (range, 5-30 days). In the protocol era, ERC +/- stenting was performed in 11/14 (P = 0.01 versus pre-protocol) with the main indication being a persistent bile leak. Re-laparoscopy was necessary in 5/14 (P = 0.05 versus preprotocol). No laparotomies were performed (P < 0.01 versus pre-protocol) and there were no postoperative deaths. Median hospital stay was 11 days (range, 5-55 days). CONCLUSIONS The introduction of a minimally invasive protocol utilising ERC and re-laparoscopy offers an effective modern algorithm for the management of bile leaks after laparoscopic cholecystectomy.

HUMAN ISLET ISOLATION - A PROSPECTIVE RANDOMIZED COMPARISON OF PANCREATIC VASCULAR PERFUSION WITH HYPEROSMOLAR CITRATE OR UNIVERSITY-OF-WISCONSIN SOLUTION

University of Wisconsin solution has become the most commonly used vascular perfusate during multiorgan donation world-wide. In the UK however, hyperosmolar citrate remains in common use. The purpose of this prospective randomized study was to compare the effect of systemic perfusion with UW or HOC on subsequent islet yield and purification for pancreata with short cold ischemic times. Seven pancreata were randomized to each group, with the donor age, pancreas weight, and period of cold ischemia being similar in both. Perfusion with UW was shown to inhibit collagenase digestion, and a higher concentration of this enzyme was needed to achieve comparable numbers of islets with good separation of exocrine and islet tissue after a similar period of digestion. There were no differences in the number, size, purity, or viability of islets between the two groups. In conclusion, UW solution offers no benefits over HOC for pancreata with short cold ischemic times, and because of its expense and need to use greater amounts of collagenase enzyme, we continue to use HOC.

STORAGE OF PORCINE PANCREATIC DIGEST PRIOR TO ISLET PURIFICATION - THE BENEFITS OF UW SOLUTION AND THE ROLES OF ITS INDIVIDUAL COMPONENTS

The aim of this study was to establish the beneficial effect of storage of pancreatic digest in University of Wisconsin solution on porcine islet purification, the mechanism of this effect, and the components of UW responsible. Ten porcine pancreata were collagenase-digested, and samples of digest were washed and stored for 1 hr in either UW or minimum essential medium at 4°C, prior to separation on continuous linear density gradients of bovine serum albumin. Samples of digest from a further ten pancreata were similarly treated, comparing storage in MEM, UW, and five solutions varying in lactobionate:chloride ratio and raffinose content. The purity of the islet preparations and the densities of islets and exocrine tissue were determined from insulin and amylase assay of aliquots aspirated from these gradients. Washing and storage of digest in UW markedly improved islet purity, compared with MEM, due to an increase in the density of exocrine tissue. Exocrine tissue density following storage was dependent upon the control of acinar cell volume, rather than exocrine enzyme discharge, and was determined primarily by the chloride:lactobionate ratio of the storage solution. Raffinose was of little additional benefit, while the beneficial effect of UW was greater than that due to its lactobionate and raffinose content alone. In conclusion, inadequate purification of islets results from exocrine tissue swelling. This swelling is reduced by storage of the pancreatic digest in UW solution, due primarily to the replacement of chloride by lactobionate in UW.

Storage of pancreatic digest before islet purification : the influence of colloids and the sodium to potassium ratio in University of Wisconsin-based preservation solutions

The density-dependent purification of islets from several species of mammalian pancreata is improved by prior storage of the dispersed, collagenase-digested pancreas in suitable storage solutions, such as University of Wisconsin (UW) solution. The optimal composition of such solutions, however, is not fully established, although previous investigations have suggested separately that cellular impermeants and colloids are important components. To investigate this issue further, dispersed tissues from 7 porcine and 7 human pancreata were stored in UW or in solutions containing the impermeants lacto-bionate and raffinose, with either no added colloid or in the presence of the colloids hydroxyethyl starch, dextran 40, dextran 250, or Ficoll 400; hydroxyethyl starch-containing solutions in which the principal cation was sodium, rather than potassium, were also studied. Subsequent purification of islets on continuous linear density gradients of BSA was then assessed by insulin/amylase assay of gradient fractions. Islet purity was slightly reduced using solutions containing impermeants but lacking a colloid, compared with using UW. In the combined presence of impermeants and a colloid, however, islet purity was similar to that obtained with UW, and for porcine pancreata, solutions containing Ficoll 400 or dextran 40 were slightly superior to UW. Purity was not, however, influenced by the sodium to potassium ratio of storage media. In conclusion, impermeants and colloids are both essential components of solutions used to preserve pancreatic tissue before islet purification, findings which may be relevant when designing media for use during other phases of islet isolation, e.g., during collagenase digestion/density gradient purification.

Electrolytic Treatment of Colorectal Liver Tumour Deposits in a Rat Model: A Technique with Potential for Patients with Unresectable Liver Tumours

Background/Aims: Patients with unresectable malignant liver tumours have a poor prognosis. A technique is needed which improves long-term survival. Previous studies in the rat have shown that electrolysis is a safe, predictable and reproducible method for creating areas of necrosis in the normal rat liver. This study examined the effects of electrolysis on colorectal liver ‘metastases’ in the rat. Methods: Tumours of colorectal origin were implanted into the livers of Wistar-WAG rats. Two weeks after implantation the tumours were treated with electrolysis. A direct current generator, connected to 2 platinum intrahepatic electrodes was used to examine the effects of various electrode configurations on the extent of tumour necrosis. Results: Significant (p<0.001) tumour ablation was achieved with all electrode configurations. Tumour necrosis was more complete (p<0.05) with the electrodes positioned on either side of the tumour than with both electrodes placed in the centre of the tumour. Liver enzymes (AST and ALT) were significantly (p<0.001) elevated after treatment, but returned towards normal by 2 days. Conclusions: This study has shown that colorectal liver ‘metastasis’ can be ablated by electrolysis in a rat model. Two separate mechanisms of tumour ablation were observed: With the electrodes directly in or adjacent to the tumour, necrosis resulted from the action of cytotoxic electrode products, whereas by positioning the electrodes proximal to the tumour, necrosis was induced by a ‘secondary’ ischaemic effect. The findings confirm the view that electrolysis has great potential for treating patients with unresectable malignant liver tumours.

The use of continuous density gradients for the assessment of islet and exocrine tissue densities and islet purification

The purification of large numbers of human pancreatic islets remains one of the limiting factors in islet transplantation. This paper describes and validates a method for accurately and reproducibly determining the density of islets and exocrine tissue in pancreatic digest on the basis of their isopycnic distribution on linear continuous density gradients. The use of this data to analyse and compare the purity of a standard 60% islet yield is described. The results obtained using such gradients will enable factors responsible for the variation in yield between pancreases to be determined and optimized, improving the results and reliability of islet purification.

Electrolytic ablation as an adjunct to liver resection: Safety and efficacy in patients.

Background:  Electrolytic ablation is a relatively new method for the local destruction of colorectal liver metastases. Experimental work in animal models has shown this method to be safe and efficacious. However, before proceeding to clinical trials it was necessary to confirm these findings in a pilot study of five patients.