John McCall

Prospective randomized comparison of open versus laparoscopic appendectomy in men.

Abstract. A prospective, randomized trial was performed to compare open appendectomy with laparoscopic appendectomy in men with a clinical diagnosis of acute appendicitis. Sixty-four patients with a median age of 25 years (range 18–84 years) were randomized to open appendectomy (n = 31) or laparoscopic (n = 33) appendectomy. Of the 64 men, 56 (87.5%) had appendicitis (27 open, 29 laparoscopic procedures). The mean operating times were 50.6 ± 3.7 minutes (± SEM) for open and 58.9 ± 4.0 minutes for laparoscopic appendectomy (p = 0.13). Five (15%) patients randomized to laparoscopic appendectomy had an open operation. The mean postoperative hospital stay was significantly longer for open appendectomy (3.8 ± 0.4 days) than for laparoscopic appendectomy (2.9 ± 0.3 days) (t = 2.05,df = 62,p = 0.045). The complication rate after open appendectomy (25.8%) was not significantly different from that after laparoscopic appendectomy (12.1%). There was a single postoperative death due to a pulmonary embolus in the laparoscopic group and a single death due to cardiac and renal failure in the open group. The mean time to return to normal activities was significantly longer following open appendectomy (19.7 ± 2.4 days) than after laparoscopic appendectomy (10.4 ± 0.9 days), (t = 3.75,df = 49,p = 0.001). In conclusion, laparoscopic appendectomy in men has significant advantages in terms of a more rapid recovery compared to open appendectomy. There were no significant disadvantages to laparoscopic appendectomy compared to open appendectomy.

Nocturnal nutritional supplementation improves total body protein status of patients with liver cirrhosis: A randomized 12‐month trial

Patients with liver cirrhosis exhibit early onset of gluconeogenesis after short‐term fasting. This accelerated metabolic reaction to starvation may underlie their increased protein requirements and muscle depletion. A randomized controlled trial was conducted to test the hypothesis that provision of a late‐evening nutritional supplement over a 12‐month period would improve body protein stores in patients with cirrhosis. A total of 103 patients (68 male, 35 female; median age 51, range 28–74; Child‐Pugh grading: 52A, 31B, 20C) were randomized to receive either daytime (between 0900 and 1900 hours) or nighttime (between 2100 and 0700 hours) supplementary nutrition (710 kcal/day). Primary etiology of liver disease was chronic viral hepatitis (67), alcohol (15), cholestatic (6), and other (15). Total body protein (TBP) was measured by neutron activation analysis at baseline, 3, 6, and 12 months. Total daily energy and protein intakes were assessed at baseline and at 3 months by comprehensive dietary recall. As a percentage of values predicted when well, TBP at baseline was similar for the daytime (85 ± 2[standard error of the mean]%) and nighttime (84 ± 2%) groups. For the nighttime group, significant increases in TBP were measured at 3 (0.38 ± 0.10 kg, P = 0.0004), 6 (0.48 ± 0.13 kg, P = 0.0007), and 12 months (0.53 ± 0.17 kg, P = 0.003) compared to baseline. For the daytime group, no significant changes in TBP were seen. Daily energy and protein intakes at 3 months were higher than at baseline in both groups (P < 0.0001), and these changes did not differ between the groups. Conclusion: Provision of a nighttime feed to patients with cirrhosis results in body protein accretion equivalent to about 2 kg of lean tissue sustained over 12 months. This improved nutritional status may have important implications for the clinical course of these patients. (HEPATOLOGY 2008.)

Multiple Gene Expression Classifiers from Different Array Platforms Predict Poor Prognosis of Colorectal Cancer

Purpose: This study aimed to develop gene classifiers to predict colorectal cancer recurrence. We investigated whether gene classifiers derived from two tumor series using different array platforms could be independently validated by application to the alternate series of patients. Experimental Design: Colorectal tumors from New Zealand (n = 149) and Germany (n = 55) patients had a minimum follow-up of 5 years. RNA was profiled using oligonucleotide printed microarrays (New Zealand samples) and Affymetrix arrays (German samples). Classifiers based on clinical data, gene expression data, and a combination of the two were produced and used to predict recurrence. The use of gene expression information was found to improve the predictive ability in both data sets. The New Zealand and German gene classifiers were cross-validated on the German and New Zealand data sets, respectively, to validate their predictive power. Survival analyses were done to evaluate the ability of the classifiers to predict patient survival. Results: The prediction rates for the New Zealand and German gene-based classifiers were 77% and 84%, respectively. Despite significant differences in study design and technologies used, both classifiers retained prognostic power when applied to the alternate series of patients. Survival analyses showed that both classifiers gave a better stratification of patients than the traditional clinical staging. One classifier contained genes associated with cancer progression, whereas the other had a large immune response gene cluster concordant with the role of a host immune response in modulating colorectal cancer outcome. Conclusions: The successful reciprocal validation of gene-based classifiers on different patient cohorts and technology platforms supports the power of microarray technology for individualized outcome prediction of colorectal cancer patients. Furthermore, many of the genes identified have known biological functions congruent with the predicted outcomes.

Inflammatory pseudotumor of the liver: demographics, diagnosis, and the case for nonoperative management

BACKGROUND Inflammatory pseudotumor of the liver (IPL) is an unusual tumor-like condition that is becoming recognized as an important differential diagnosis in the patient presenting with liver masses. This report describes six cases of IPL. STUDY DESIGN Clinical, diagnostic, pathologic, and followup data were collected prospectively on six patients presenting to a specialist hepatobiliary unit. RESULTS Six patients with IPL presented over a 2-year period. Median age was 35 years (range 2 to 79 years) and five patients were men. Three patients were Polynesian (Tongan and Samoan) and one was New Zealand Maori. Five patients presented with nonspecific symptoms (fever, arthralgia, myalgia) and IPL was an incidental finding in one patient. At presentation, four patients had elevated white cell counts, and five patients had abnormal liver function tests with elevations in alkaline phosphotase and gamma-glutamyl transferase the most commonly seen. Carcinogenic embryonic antigen and alpha fetoprotein were normal in all patients, although one was a known hepatitis B carrier. In all cases of IPL, diagnosis was made on core biopsy of the liver lesions and all patients were managed nonoperatively with complete resolution of the tumors. Two patients had marked reduction in systemic symptoms (fever and pain) from a short course of oral steroids. CONCLUSIONS IPL appears to be a relatively common problem in Maori and Polynesians. Recognition and differentiation of this condition from malignant liver lesions are important to avoid unnecessary surgery.

Systematic review of tumour number and outcome after radical treatment of colorectal liver metastases

Resection of colorectal liver metastases (CLMs) is potentially curative but the effect of tumour number on prognosis is uncertain. This study compared the prognosis after resection and/or ablation of between one and three, or four or more CLMs.

Sequential Changes in the Metabolic Response to Orthotopic Liver Transplantation During the First Year After Surgery

ObjectiveTo quantify the sequential changes in the metabolic response occurring in patients with end-stage liver disease after orthotopic liver transplantation (OLT). Summary Background DataDetailed quantification of the changes in energy expenditure, body composition, and physiologic function that occur in patients after OLT has not been performed. Understanding these changes is essential for the optimal management of these patients. MethodsFourteen patients who underwent OLT for end-stage liver disease had measurements of resting energy expenditure, body composition, and physiologic function immediately before surgery and 5, 10, 15, 30, 90, 180, and 360 days later. ResultsResting energy expenditure was significantly elevated after surgery (24% above predicted), peaking around day 10 after OLT, when it averaged 42% above predicted. A significant degree of hypermetabolism was still present at 6 months, but at 12 months measured resting energy expenditure was close to predicted values. Before surgery, measured total body protein was 82% of estimated preillness total body protein. During the first 10 days after OLT, a further 1.0 kg (10%) of total body protein was lost, mostly from skeletal muscle. Only 54% of this loss was restored by 12 months. Significant overhydration of the fat-free body was seen before OLT, and it was still present 12 months later. Although significant losses of body fat and bone mineral occurred during the early postoperative period, only body fat stores were restored at 12 months. Both subjective fatigue score and voluntary hand grip strength improved rapidly after OLT to exceed preoperative levels at 3 months. At 12 months grip strength was close to values predicted for these patients when well. Respiratory muscle strength improved less markedly and was significantly lower than predicted normal levels at 12 months. ConclusionsBefore surgery, these patients were significantly protein-depleted, overhydrated, and hypermetabolic. After surgery, the period of hypermetabolism was prolonged, restoration of body protein stores was gradual and incomplete, and respiratory muscle strength failed to reach expected normal values. Our measurements indicate that OLT does not normalize body composition and function and imply that a continuing metabolic stress persists for at least 12 months after surgery.

Randomized controlled trial of preoperative oral carbohydrate treatment in major abdominal surgery

Major surgery is associated with postoperative insulin resistance which is attenuated by preoperative carbohydrate (CHO) treatment. The effect of this treatment on clinical outcome after major abdominal surgery has not been assessed in a double‐blind randomized trial.

Prognostic significance of occult metastases in colon cancer.

AbstractPURPOSE: The purpose of this study was to determine the prognostic significance of occult lymph node metastases in colon cancer detected by cytokeratin 20 reverse transcription polymerase chain reaction. METHODS: Two hundred patients undergoing elective colonic resections were enrolled in the study. Lymph nodes from resected specimens were dissected fresh and assessed by both reverse transcription polymerase chain reaction and histopathology. Follow-up was undertaken for up to five years, and the major end point of death was recorded. Univariate survival analysis was performed by the log-rank method and the change-in-estimate method was used to construct multivariate analysis models for the effect of cytokeratin 20 reverse transcription polymerase chain reaction lymph node status on overall survival. RESULTS: A total of 2,317 lymph nodes from 200 patients were assessed by both histopathology and cytokeratin 20 reverse transcription polymerase chain reaction. Forty-eight of 141 (34 percent) histologically lymph node–negative patients had evidence of occult metastases by cytokeratin 20 reverse transcription polymerase chain reaction. An interim analysis was performed at a median of 42 (range, 23–75) months. Cytokeratin 20 reverse transcription polymerase chain reaction lymph node status was a highly significant predictor of overall survival (P < 0.0001) on univariate analysis. In addition, the number of reverse transcription polymerase chain reaction–positive lymph nodes was a significant predictor of survival in the histologically lymph node–negative group (P < 0.0001) on univariate analysis. On multivariate analysis cytokeratin 20 reverse transcription polymerase chain reaction lymph node status had independent prognostic significance for overall survival (P = 0.021; hazard ratio = 2.7) and the number of cytokeratin 20 reverse transcription polymerase chain reaction–positive lymph nodes was a significant predictor of overall survival in the histologically lymph node–negative group (P = 0.005; hazard ratio = 1.1–11.1). CONCLUSION: Cytokeratin 20 reverse transcription polymerase chain reaction has potential as a clinically useful marker for staging colorectal cancer. Further follow-up is required, but if the current trends continue, a study of the effect of adjuvant therapy in patients with occult metastases detected by cytokeratin 20 reverse transcription polymerase chain reaction is indicated.

Differential Diagnosis of Stenosing Lesions at the Hepatic Hilus

ABSTRACTA significant number of stenosing lesions at the hepatic hilus represent benign disease rather than hilar cholangiocarcinoma. It is unclear, however, which perioperative investigations are useful for defining benign lesions in this location. A series of 49 consecutive patients who presented with obstructive jaundice due to a stenosing lesion at the hepatic hilus were investigated by documenting elevated plasma bilirubin levels, the presence of weight loss, and elevated carcinoembryonic antigen (CEA) and Ca 19-9 concentrations. Radiologic investigations included direct cholangiography, transabdominal ultrasonography, computed tomographic (CT) scans and magnetic resonance imaging (MRI). A tissue diagnosis was obtained in all patients, and the preoperative investigations were reviewed to assess their accuracy for predicting malignancy. The final tissue diagnosis was a benign lesion in 12 patients (benign idiopathic strictures 10, choledocholithiasis 2). Among the 37 patients who presented with a malignant lesion, 2 had metastatic colorectal cancer, 7 had gallbladder cancer, and 28 had hilar cholangiocarcinoma. Of the 12 patients with benign lesions, 4 (33%) had elevated tumor markers (CEA and CA 19-9), 12 (100%) had cholangiograms suspicious for malignancy, and 9 (75%) had CT and MRI features consistent with a malignant diagnosis. Thus among patients presenting with hilar strictures approximately one-fifth are due to nonmalignant causes, but the preoperative diagnosis is difficult and resection remains the most reliable way to rule out malignancy in this site.

Is routine placement of surgical drains necessary after elective hepatectomy? Results from a single institution.

Routine drainage is no longer used after many major abdominal procedures. However, the role of routine surgical drainage after hepatic resection is unclear. Of the two randomized trials published, one concluded drainage is unnecessary after hepatectomy, and another concluded it could be used after major resections only. Between January 1999 and December 2003, 211 elective hepatic resections were performed by two surgeons at Auckland Hospital. Drains were used routinely by one surgeon (n = 126), while another routinely did not drain (n =85). Patients undergoing a biliary reconstruction were not included in this analysis. Patient and clinical data were recorded prospectively, and no outcome analyses were performed until 2004. The demographic features were similar between the drained and nondrained groups. There were no differences in length of hospital stay (no drain, 7 +- 0.8 days; drain, 7 +- 0.9 days: P = not signi.cant [NS]), in mortality (no drain, 1.2%; drain, 1.6%: P =NS), biliary flstula (no drain, zero cases; drain, two cases: P = NS), or overall complication rate (no drain, 50.5%; drain, 54.7%: P =NS). Both groups had similar rates of postoperative collection (no drain, four patients [5%]; drain, five patients [4%]: P =NS), and there was no difference in the use of percutaneous drainage of collections between the groups (no drain, four patients [5%]; drain, two patients [2%]: P =NS). Multivariate analysis showed that intraoperative blood loss of 2000 ml or greater (relative risk [RR], 1.57; 95% confidence interval [CI], 1.39-1.75; P < 0.01), number of segments resected (RR, 1.4; 95% CI, 1.21-1.89; P < 0.01), and presence of steatosis/.brosis or cirrhosis (RR, 1.6; 95% CI, 1.01-2.1; P <0.05) to be predictive of postoperative complications. The presence of a surgical drain was not predictive of complications. Routine surgical drainage after elective hepatectomy is not necessary.