227 Multiple Outbreak Of SARS-COVID-19 In Surgical Wards at The Tertiary Hospital

Background

Since the second surge of SARS-COVID-19 on 18th of September, additional several measures were introduced, and pathways created in order to execute safe surgical practices and protect both patients and staff from SARS-COVID-19. Despite these measures, there have been reported cases of outbreaks in various parts of UK amongst patients and clinical staff.

Method

Three outbreaks in the past 6 weeks (10, September 2020 to 21, October 2020) were reported in our surgical wards and we compiled the timing, initial source, number of affected individuals and immediate management steps taken.

Results

Following the first outbreak on wards, 28-day surveillance helped us understand responsible variants. Several staff members were found walking out of hospital, in groups once they had removed their PPEs. Communal lunching with inadequate social distancing, attending work with symptoms (albeit atypical for COVID), sharing cars to/from work or not wearing PPE correctly were highlighted in the subsequent investigations. The reduction in number of affected individuals during the last two incidents reflected a degree of efficacy of the implemented preventative measures, which were reviewed again following the subsequent incidents.

Conclusions

In the present climate, a robust and prompt response to outbreaks is required. Continual iteration with regards to the need for PPE, adequate social distancing and avoiding over-crowding in communal areas is paramount to reduce the probability of ward outbreaks and inter-professional transmission. Asymptomatic staff testing, particularly in high-risk areas could also be considered but would require adequate laboratory capacity and rapid turnaround of test results.

228 Outcomes of Gallstone Complications During the COVID Pandemic

Background

The Intercollegiate General Surgery Guidance on COVID-19 recommended either non-surgical management or cholecystostomy drains for the management of acute biliary disease replacing gold standard practice of early laparoscopic cholecystectomy within 1 week of index admission with drainage reserved for high-risk patients where surgery is not appropriate.

Method

This is the retrospective study presenting the impact of gallstone disease in our unit during five months of the COVID- 19 pandemic (March 2020-August 2020) compared with the equivalent period in 2019.

Results

Patients presenting to the HPB unit with a coded diagnosis of gallstones were included and during the study period 1447 patients presented compared with 1413 in 2019. In 2020 compared with 2019 there was a significant decrease in patients presenting with cholecystitis (240 vs 313; p = 0.031) but no significant difference in patients presenting due to gallbladder perforation (44 vs 51). Interestingly the numbers of cholecystostomies were comparable, with 11 in 2020 and 15 in 2019 representing significantly less than the 7.2% figure published by Peckham-Cooper et al.

Conclusions

In our study there was a decrease in patients with cholecystitis and perforation and there was an increase in patients with gallstone pancreatitis, increase waiting lists with increase in the incidence of serious complications. In our trust we currently have 656 patients awaiting cholecystectomy compared to 280 in august 2019. With the recent elevation of the alert level to 4 and increased government restrictions, a consistent National approach is required to mitigate these risks.

88 Prevalence Of SARS-COVID-19 Serum Igg Antibodies Amongst Staff on An Acute Surgical Unit

Background

The United Kingdom now has one of the highest death rates from COVID 19, with over 40,000 deaths (1). It has been posited that the identification of care workers with immunity or increased resistance could be important in developing future strategies.

Method

This was a retrospectively conducted survey of general surgical staff at a tertiary surgical unit.

Results

We surveyed 215 staff that had undergone antibody testing. Of the 175/215 who reported contact with COVID-19 positive patients, 6/215 had a positive PCR result and 15/215 reported a positive antibody test. Only 3/6 that had a positive PCR test demonstrated antibodies.

Conclusions

Our “immunity” rate of 7% is extremely low and is concerning especially in respect of the anticipated “herd immunity” which would mitigate many of the issues presently being confronted and it is likely to be many months at least before this makes realistic contribution. Continued testing for the presence of COVID-19 antibodies will contribute to crucial seroprevalence data that can be used by public health bodies whose advice will necessarily evolve as increasing data sets become available.

Medical therapy for polycystic liver disease

Introduction Somatostatin analogues and rapamycin inhibitors are two classes of drugs available for the management of polycystic liver disease but their overall impact is not clearly established. This article systematically reviews the literature on the medical management of polycystic liver disease. The outcomes assessed include reduction in liver volume and the impact on quality of life. Methods The English language literature published between 1966 and August 2014 was reviewed from a MEDLINE(®), PubMed, Embase™ and Cochrane Library search. Search terms included 'polycystic', 'liver', 'sirolimus', 'everolimus', 'PCLD', 'somatostatin', 'octreotide', 'lanreotide' and 'rapamycin'. Both randomised trials and controlled studies were included. References of the articles retrieved were also searched to identify any further eligible publications. The studies included were appraised using the Jadad score. Results Seven studies were included in the final review. Five studies, of which three were randomised trials, investigated the role of somatostatin analogues and the results showed a mean reduction in liver volume ranging from 2.9% at six months to 4.95 ±6.77% at one year. Only one randomised study examined the influence of rapamycin inhibitors. This trial compared dual therapy with everolimus and octreotide versus octreotide monotherapy. Liver volume reduced by 3.5% and 3.8% in the control and intervention groups respectively but no statistical difference was found between the two groups (p=0.73). Two randomised trials investigating somatostatin analogues assessed quality of life using SF-36(®). Only one subdomain score improved in one of the trials while two subdomain scores improved in the other with somatostatin analogue therapy. Conclusions Somatostatin analogues significantly reduce liver volumes after six months of therapy but have only a modest improvement on quality of life. Rapamycin inhibitors do not confer any additional advantage.

A qualitative study of the impact of the UK 'bedroom tax'

Background

The implementation of the ‘Removal of the Spare Room Subsidy’ in April 2013, commonly known as the ‘bedroom tax’, affects an estimated 660 000 working age social housing tenants in the UK, reducing weekly incomes by £12–£22. This study aimed to examine the impact of this tax on health and wellbeing in a North East England community in which 68.5% of residents live in social housing.

Methods

Qualitative study using interviews and a focus group with 38 social housing tenants and 12 service providers.

Results

Income reduction affected purchasing power for essentials, particularly food and utilities. Participants recounted negative impacts on mental health, family relationships and community networks. The hardship and debt that people experienced adversely affected their social relationships and ability to carry out normal social roles. Residents and service providers highlighted negative impacts on the neighbourhood, as well as added pressure on already strained local services.

Conclusions

The bedroom tax has increased poverty and had broad-ranging adverse effects on health, wellbeing and social relationships within this community. These findings strengthen the arguments for revoking this tax.

The differential effects of statins on the risk of developing pancreatic cancer: a case-control study in two centres in the United Kingdom

INTRODUCTION

There are plausible biological mechanisms for how statins may prevent pancreatic cancer, although the evidence from epidemiological studies in the general population is conflicting. This study aims to clarify whether statins exert their effects in specific sub-groups, namely, gender, smoking status and diabetes.

METHODS

A matched case-control study was conducted in patients diagnosed with pancreatic cancer, and a group of dermatology patients of similar ages and gender, diagnosed with basal cell carcinoma. Participants' medical records were reviewed for information on statin use prior to diagnosis. Odds ratios and 95 % CIs for the development of pancreatic cancer were estimated using conditional logistic regression. Subgroup analysis was performed in men, women, smokers and those with type 2 diabetes.

RESULTS

Two hundred fifty-two cases (median age 71 years, range 48-73 years, 51 % women) and 504 controls were identified, of which 23 % of cases were regular statin users versus 21 % of controls. In the general study population there was no association between pancreatic cancer and regular statin use (OR 0.82, 95 % CI 0.53-1.23, p = 0.33). However, in male smokers, regular statin use was associated with significantly reduced odds of pancreatic cancer compared to male smokers not prescribed a statin (OR 0.11, 95 % CI 0.01-0.96, p = 0.05). In patients with type 2 diabetes statins use was not associated with reduced odds (OR 0.92, 95 % CI 0.35-2.45, p = 0.80), with no gender effects.

CONCLUSIONS

In male smokers, statins may reduce the odds of pancreatic cancer. Statin use should be measured in aetiological studies of pancreatic cancer but analysed in specific sub-groups. Future work should investigate statins as chemopreventative agents in this high risk sub-group.

Preliminary assessment of Treponema pallidum-specific IgM antibody detection and a new rapid point-of-care assay for the diagnosis of syphilis in human immunodeficiency virus-1-infected patients

The aims of the study were to assess whether Treponema pallidum-specific IgM may provide a useful marker of infectious syphilis in human immunodeficiency virus (HIV)-infected patients, and to compare the performance of a prototype IgM-rapid point-of-care test (PoCT) with a standard IgM-enzyme immunoassay (EIA). Twenty samples from HIV-infected patients with untreated syphilis (n = 4 primary syphilis, n = 11 secondary and n = 5 early latent) and 51 follow-up samples at three, six or 12 months after treatment were tested for the presence of IgM with the Mercia-EIA (Microgen Bioproducts Ltd, Camberley, UK) and a prototype PoCT (Select Vaccines Ltd, Melbourne, Australia). Although sample numbers were small, IgM detection by EIA appears to be a reliable marker for untreated syphilis in HIV-infected patients with primary (4/4 IgM-positive) or secondary syphilis (10/11 IgM-positive, 1/11 equivocal). After treatment, IgM was no longer detected after three months in the majority of patients (87%) and was either negative or equivocal in all patients after six and 12 months. The overall sensitivity of the IgM-PoCT was 82% and varied with clinical stage, being highest in secondary (10/10 EIA positives) but lower in primary (2/4 EIA positives) and early latent syphilis (2/3 EIA positives). Overall specificity was 95%. Rapid detection of IgM would enable clinicians to distinguish between past-treated and infectious syphilis and allow for diagnosis and treatment in a single visit.

Comparison of University of Wisconsin and ET-Kyoto preservation solutions for the cryopreservation of primary human hepatocytes

Primary human hepatocytes are clinically used for transplantation or in bioartificial liver devices for the treatment of patients with liver failure. We aimed to assess whether an organ preservation solution containing trehalose, namely ET-Kyoto solution (ETK), could improve human liver cell viability when used for cryopreservation in comparison to the University of Wisconsin solution (UW). Our study showed beneficial effects of ETK when used in combination with other cryoprotectants on the viability of thawed hepatocytes. Indeed, no significant difference was seen between the viability of freshly isolated cells and cryopreserved cells when cryopreserved with ETK combined with other cryoprotectants. In contrast, a significant decrease of viability was observed in cells cryopreserved with UW or ETK combined with dimethysulfoxide (DMSO) only, or with UW combined with other cryoprotectants, compared to freshly isolated cells. No significant difference was observed between the four different groups of cryopreserved hepatocytes with regards to cell recovery rate or cell attachment after thawing. However, a significant decrease in cell metabolic activity was found in cells cryopreserved with UW 10% DMSO compared to the other groups. In conclusion, our study confirms the beneficial effect of ETK for the cryopreservation of human hepatocytes in combination with other cryoprotective agents.

Women presenting with lower abdominal pain: A missed opportunity for chlamydia screening?

INTRODUCTION

Many young women presenting with lower abdominal pain are referred to general surgeons with possible appendicitis. For some of these patients there will be a gynaecological cause for their pain. There has been a steady increase in the incidence of Chlamydia infections and pelvic inflammatory disease (PID) among the general population. Therefore, are general surgeons considering this as a diagnosis for lower abdominal pain in women?

METHODS

One hundred and ninety three women who had been admitted with lower abdominal pain to a single hospital between 1999 and 2001 were identified using computerised records and the notes were examined. One hundred and eighty six women were included in the audit. Investigations and treatments instigated for these patients were then carefully recorded.

RESULTS

Seventy-four patients underwent appendicectomy, of which 59 were histologically confirmed. Eighty-nine patients (47.8%) of admissions had no final diagnosis and were not screened for Chlamydia trachomatis. Sexual history was recorded in only 51% of admissions. Vaginal swabs were sent in only 7.3% of admissions.

CONCLUSION

Current guidelines for Chlamydia trachomatis screening produced by the Chief Medical Officer (CMO) include screening in women presenting with lower abdominal pain as well as those with post-coital or intermenstrual bleeding. Most women who present with classical symptoms of PID will present to gynaecological specialities for further management. However, a significant number of women presenting atypically will be referred to surgeons to exclude gastrointestinal causes for their lower abdominal pain. These women could and probably should be screened for Chlamydia trachomatis.

Molecular biomarkers of colorectal carcinogenesis and their role in surveillance and early intervention

Modern medicine is increasingly focused towards population surveillance for disease, coupled with the implementation of preventative measures applied to 'at-risk' patients. Surveillance in colorectal cancer is limited by the cost and risk of endoscopy. Trials of putative chemopreventive agents in colorectal cancer are hampered by difficulties in following up large cohorts of patients over long periods of time to ascertain the clinical effect. Research into possible pathways of colorectal carcinogenesis has revealed a range of biological intermediates which could be used in surveillance, the identification of high risk populations and early diagnosis of cancer. The aim of this paper was to review the possible role of biomarkers in surveillance and the timing of intervention. A literature review using both Medline and Web of Science was performed from 1995 onwards using keywords: biomarkers, colorectal cancer, carcinogenesis, chemoprevention, surveillance and screening. Research has identified many potential biomarkers, such as cyclooxygenase-2 (COX-2), oxidative DNA adducts and glutathione S-transferase (GST) polymorphisms, which could be applied in a clinical setting to screen for and detect colorectal cancer. Molecular biomarkers, such as COX-2, oxidative DNA adducts and GST polymorphisms offer new prospects in the detection of early colorectal cancer, surveillance of high-risk populations and prediction of the clinical effectiveness of chemopreventive drugs. Their role could be extended into surgical surveillance for potentially operable disease and post-operative follow-up for disease recurrence. Research should be directed at assessing complementary biomarkers to increase clinical effectiveness in determining management options for patients.

Beneficial effect of alanine on metabolic recovery of fasted livers submitted to cold ischemia

The aim of this study was to investigate the possible beneficial effect on perfused mouse liver of alanine as an exogenous substrate for gluconeogenesis. Livers from fed and fasted animals were perfused with oxygenated Krebs' Henseleit buffer for 30 min, then stored at 4 degrees C in University of Wisconsin solution for 48 h. Then reperfusion at 37 degrees C was performed according to two protocols. In the first one, reperfusion with alanine-free Krebs' Henseleit buffer was used for 1 h. 8 mM (3-(13)C) alanine was then added and perfusion was prolonged for a second hour. In the second one, the first hour of perfusion was omitted and the organs were reperfused directly for an hour in the presence of 8 mM (3-(13)C)alanine. 31P NMR was used to measure the NTP recovery of the livers. At the end of the reperfusions, 13C and 1H NMR spectra of perfusates and of glutamine extracted from these perfusates by HPLC were recorded. These data were analysed according to a model of liver metabolism assuming that the only substrate of the liver was (3-(13)C)alanine and endogenous substrates were metabolizable only through pyruvate. It was found that in the absence of initial alanine at reperfusion, livers from fasted mice recovered less NTP than those of fed ones (40 +/- 4% vs 60 +/- 5%, p <0.01), but not if this substrate is present at the beginning of reperfusion (61 +/- 5% vs 60 +/- 5%). This was confirmed by the amount of labelled metabolites produced. However, the dilution of 13C labelled metabolites by unlabelled ones did not indicate a larger concentration of endogenous substrates in livers from fed mice. The conclusion reached was that the lower pyruvate dehydrogenase activity of livers from fasted mice relatively to that from fed mice could be compensated for by the greater pyruvate concentration provided by alanine for the initial production of NTP after cold ischemia and warm reperfusion.

Local anaesthesia for major general surgical procedures. A review of 116 cases over 12 years

Between 1980 and 1992, 116 patients had either a simple mastectomy (32) or intra-abdominal procedures (84) under local anaesthesia (0.5-1% lignocaine with 1:200 000 adrenaline). A wide variety of general surgical procedures were feasible using only supplementary intravenous sedation (54%). Complications were uncommon and related to surgical procedure (three incorrect diagnoses, three procedures impossible) rather than the anaesthetic technique. There were no anaesthetic toxicity or postoperative problems. Local anaesthesia is extremely safe and facilitates larger surgical procedures than is generally appreciated.

The effects of donor and recipient endotoxemia on TNF alpha production and mortality in the rat model of syngenic orthotopic liver transplantation

The effects of administration of endotoxin to donors or recipients on the mortality rate, evolution of endotoxin levels, and tumor necrosis factor alpha (TNF-alpha) release were investigated in a syngenic orthotopic liver transplantation model in Lewis rats with portal reperfusion only. No significant recipient endotoxemia, TNF-alpha release, or mortality occurred in control recipients following transplantation from normal donors. The doses of endotoxin needed to kill 50% and 100% of animals after hepatic artery ligation were, respectively, 4 mg/kg and 10 mg/kg. Transplantation of animals' livers with no preservation phase from donors who were administered a lethal dose of endotoxin for this combination (10 mg/kg) produced significant recipient endotoxemia at 10 min (6.9 +/- 2.5 x 10(3) endotoxin unit/ml (EU/ml), P < 0.01), 45 min (8.8 +/- 1.1 x 10(3) EU/ml, P < 0.001) and 8 hr (18.5 +/- 3.5 x 10(3) EU/ml, P < 0.001) after graft reperfusion. Significant levels of TNF-alpha were also detected in these animals at 45 min (280 +/- 70 pg/ml, P < 0.007) and 8 hr (80 +/- 40 pg/ml, P < 0.05) when compared with the controls. Mortalities in recipients of OLT from donor animals that had received endotoxin (2 mg/kg or 4 mg/kg) immediately prior to the harvesting procedure was 0% and 20%, respectively, compared with no death in the control group. When recipient animals were administered endotoxin immediately after graft reperfusion the resistance to endotoxin administration was significantly reduced compared with animals that had not received OLT (LD50 < 2 mg/kg versus 4 mg/kg; LD100 4 mg/kg versus 10 mg/kg, respectively). These results show that endotoxin and its effects can be transferred from the liver graft donor to the recipient and that OLT per se reduces the recipient resistance to endotoxin with subsequent increase in mortality.

Primary anastomosis with transverse colostomy as an alternative to Hartmann's procedure

Hartmann's procedure remains the favoured option in patients with acute left colonic and sigmoid disease, despite the well documented morbidity and mortality associated with reversal. In 40 patients with left colonic pathology, primary anastomosis was performed; 32 had a covering transverse colostomy. There were six hospital deaths, five in the transverse colostomy group. Closure was not attempted in seven of the 27 patients surviving with a colostomy (three refused, four had disseminated malignancy). In the 20 undergoing closure, there was no morbidity or mortality. With advances in intensive care, antibiotic therapy and anaesthesia, it is reasonable to consider alternatives to Hartmann's procedure, particularly when subsequent reconstruction is envisaged.

A magnetic resonance study of the effect of nutritional status on cold-preserved murine liver

BACKGROUND/AIMS

Clinical and experimental studies suggest a link between nutritional status and the recovery of hepatic function after hypoxic and hypothermic insults. This study aimed at determining the metabolic pathways involved in such recovery as a function of nutrition.

METHODS

Livers from fed and fasted mice were perfused with oxygenated Krebs'-Henseleit buffer (RBKB). After depletion of glycogen, 31P and 13C nuclear magnetic resonance spectra were acquired. Livers were flushed with University of Wisconsin solution and stored at 4 degrees C for 0, 24, or 48 hours. At reperfusion with RBKB, recovery of nucleoside triphosphates (NTP) was followed up. After 45 minutes, [3-13C]alanine was added and substrate consumption and metabolic products assessed.

RESULTS

Livers from fed animals recovered more NTP at reperfusion both after 24 hours (85% +/- 11% vs. 67% +/- 7%; P < 0.01) and 48 hours (61% +/- 10% vs. 36% +/- 10%; P < 0.01, respectively) of cold storage. Gluconeogenesis as reflected by [3-13C]alanine consumption was also higher from fed animals. Hepatic glycogen before preservation was low in both groups. Livers from fasted animals contained increased triglyceride levels, but these did not contribute to NTP production at reperfusion.

CONCLUSIONS

Livers from fed mice show an improved recovery after cold ischemia. Glycogen levels are low in these organs, and NTP synthesis must be from substrates other than fatty acids.

FK 506 renal toxicity and lack of detectable cytochrome P-450 3A in the liver graft of a patient undergoing liver transplantation

Many commonly used drugs are substrates for hepatic cytochrome P-450 3A in human beings, and its role in the metabolism of potentially toxic immunosuppressants has been highlighted (cyclosporine, FK 506). One hundred fifty human liver grafts were biopsied before and after liver transplantation, and levels of cytochromes P-450 3A, 1A2, 2D6 and 2C were estimated by means of the Western-blot technique and correlated with histological appearance, glycogen content and clinical course. In 15 of the grafts, cyclosporine oxidase was also measured, and in 12 of 15 recipients, urinary 6 beta-hydroxycortisol excretion was assayed. A wide range of cytochrome P-450 3A values were observed (25 to 366 arbitrary units/mg; mean, 105 +/- 63 arbitrary units/mg). In one graft (no. 730) no cytochrome P-450 3A was detectable on immunoblotting, despite increasing homogenate concentrations. In this sample, cytochromes P-450 1A2, 2D6, and 2C were present in normal ranges. Levels of cyclosporine oxidase and 6 beta-hydroxycortisol in the urine specimens of the recipient were found to be low. The recipient of graft 730 experienced reversible complications of FK 506 therapy despite adherence to the administration protocol and drug plasma level in the normal range. The subsequent appearance of the cytochrome P-450 3A was associated with the consequent tolerance of oral FK 506. The absence of detectable amounts of P-450 3A in one biopsy from a donated human liver graft dramatically emphasizes the extreme range of this enzyme levels and has important clinical implications.

Transjugular intrahepatic portosystemic shunt worsens the hyperdynamic circulatory state of the cirrhotic patient: preliminary report of a prospective study

The aim of this prospective nonrandomized study was to assess the immediate and short-term sequelae of transjugular intrahepatic portosystemic shunting on the circulatory hyperdynamic state of the cirrhotic patient. Twelve transjugular portosystemic shunting procedures were performed in 12 cirrhotic patients for sclerotherapy failure (10 cases) and/or intractable ascites (4 cases). Self-expandable stents 10 mm in diameter were used in all cases. Portal pressure measurement and right-heart catheterization were performed before and 30 min and 1 mo after the procedure. The portoatrial pressure gradient decreased from 15 +/- 3 to 7 +/- 3 mm Hg 30 min after surgery (p < 0.0001) to 8 +/- 3 mm Hg 1 mo after surgery (p < 0.001, in comparison with basal values). The cardiac index increased from 4.5 +/- 1.3 to 5.7 +/- 1.5 L/min.m2 30 min after surgery (p < 0.001) to 7.4 +/- 1.4 L/min.m2 1 mo after surgery (p < 0.001). Systemic vascular resistance decreased from 808 +/- 323 to 646 +/- 209 dyne.sec.cm-5 30 min after surgery (p < 0.01) to 467 +/- 101 dyne.sec.cm-5 1 mo after surgery (p < 0.05). This study demonstrates that transjugular portosystemic shunting rapidly and significantly worsens the hyperdynamic circulatory state of the cirrhotic patient. Although apparently noninvasive, this procedure should be considered with caution in cirrhotic patients with limited cardiac reserve.

Relationship between graft cytochrome P-450 3A content and early morbidity after liver transplantation

Cytochrome P-450 3A metabolizes CsA into several metabolites with very limited pharmacological activity and toxicity. In 40 liver donors, the relative concentrations of P-450 3A was assessed by immunoblot analysis using a specific monoclonal antibody exhibited a 10-fold variation (mean = 92 +/- 50 arbitrary units [AU]/mg) in levels. Problems consequent upon CsA usage (nephrotoxicity, neurotoxicity, and hypertension) occurred in 8 of 34 transplant recipients in the immediate postoperative period, and in these 8 patients the problems were always associated with low graft P-4503A levels (mean = 52 +/- 19 A.U./mg, P = 0.0003, cf. patients with no toxicity). Four of these patients had CsA levels that were also high, but 4 had CsA levels in the therapeutic range. Episodes of early graft rejection were related to higher P-450 3A levels (mean = 110 +/- 24 A.U./mg). Cytochrome P-450 3A levels were also found to be inversely related to CsA whole blood levels (assessed with a specific antibody 12 hr after the intravenous infusion of CsA at 1 mg/kg in the recipients (P < 0.02). Cytochrome P-450 3A can provide information that should allow individualized immunosuppression with CsA maintaining therapeutic levels but avoiding toxicity in susceptible individuals.

Liver resection versus transplantation for hepatocellular carcinoma in cirrhotic patients

OBJECTIVE

Currently, there is considerable controversy about the place of transplantation in the treatment of hepatocellular carcinoma (HCC). This study compared resection to transplantation in cirrhotic patients with HCC in order to determine reasonable indications of each treatment.

SUMMARY BACKGROUND DATA

The usual procedure is to resect when feasible and to transplant in other cases.

METHODS

Three-year survival with and without recurrence was analyzed in 60 patients who underwent resection and 60 who underwent transplantation. Several prognostic factors, such as size, number of nodules, portal thrombus, and histologic form, were studied.

RESULTS

In terms of overall survival rates, resection and transplantation yield the same results (50% vs. 47%, respectively, at 3 years). For transplantation, however, the rate for survival without recurrence is better than that for resection (46% vs. 27%, respectively; p < 0.05). In the case of small uninodular or binodular tumors (< 3 cm), transplantation has much better results than resection (survival without recurrence, 83% vs. 18%, respectively; p < 0.001). However, it seems that a group of patients with high risk of recurrence after transplantation can be determined (diffuse form, more than two nodules > 3 cm, or presence of portal thrombus).

CONCLUSIONS

The best indication for transplantation seems to be patients with small and uninodular or binodular tumors; until now, these patients were considered to be the best candidates for resection. Patients undergoing transplantation for unresectable, large, multinodular or diffuse tumors seem to represent bad indications for transplantation. These results could help define reasonable indications for transplantation in an era with a shortage of liver grafts.

Incidence of adverse reactions to cyclosporine after liver transplantation is predicted by the first blood level

Despite the availability of whole-blood cyclosporine assays, the different responses of individual patients to its administration after transplantation continue to pose clinical problems, particularly with respect to toxicity. Fifty-seven recipients of first orthotopic liver transplants were studied between January 1992 and July 1992. Initial immunosuppression was carried out with azathioprine, methylprednisolone and cyclosporine, at a dose of 1 mg/kg/day adjusted to achieve blood levels between 400 and 600 ng/ml. Cyclosporine levels were measured 12 hr after the start of intravenous administration and correlated with the occurrence of toxic complications. Twelve patients experienced toxic complications in the first 7 days after orthotopic liver transplantation. These were neurological in six patients (of whom four also had kidney failure) and renal complications in the other six patients. All complications were reversed by reducing or stopping administration of cyclosporine. We noted excellent correlation between the occurrence of complications and cyclosporine whole-blood levels (p < 0.0001) despite the fact that levels did not exceed the therapeutic range. However, no correlation was observed between toxicity and cumulative dosage. In this study we were able to demonstrate that a standardized dose of cyclosporine does not prevent the occurrence of toxic side effects even when cyclosporine whole-blood levels are subsequently maintained in the therapeutic range. This highlights the importance of the first dose of cyclosporine and consequent early postoperative blood levels and indicates that these problems are unlikely to be overcome until a method of predicting individual requirements can be established in clinical practice.

Recent developments in liver transplantation

The many developments that have occurred and continue to occur have also meant that the quality of life experienced by recipients of a successful graft is excellent, with more than 85% of patients returning to normal life and work (even having children). While long-term survival still occurs more frequently in favorable groups such as children with metabolic abnormalities or biliary atresia, results are still extremely good for adults, with 3-year survival figures after transplantation for cirrhosis in the order of 75%. These figures also continue to improve, and with the skill and enthusiasm that workers in this field display they seem destined to continue unabated.

Prospective study in adults of splenic preservation after traumatic rupture

Seventy-five adults with splenic injury were evaluated prospectively over 45 months to examine the possibility of splenic preservation. Haemodynamically unstable patients underwent surgery with the intent of splenic preservation. Stable patients received non-operative treatment regardless of the grade of splenic injury determined by ultrasonography and computed tomography. Thirty-seven patients required splenectomy and in 38 the organ was preserved (20 operative preservation, 18 non-operative treatment). Of 22 patients initially receiving non-operative treatment, there were four secondary haemorrhages after 7, 7, 10 and 13 days making surgery necessary. Three of these patients underwent splenectomy and in one the spleen was preserved by partial resection. After splenectomy four patients required reoperation because of rebleeding or for evacuation of a haematoma. Patients who had undergone splenectomy had a significantly increased infection rate (P < 0.005) compared with those in whom the spleen was preserved, even when patients were matched with respect to multiple trauma using the Injury Severity Score (P < 0.01).

A randomized comparison of infrared photocoagulation with bipolar diathermy for the outpatient treatment of hemorrhoids

One hundred two patients with symptomatic hemorrhoids were randomized to receive treatment with either infrared photocoagulation (IRPC) or a bipolar diathermy probe (BD). There was no significant difference in complications, number of treatments required (IRPC 1.7 [0.9], BD 1.6 [0.8]). Third-degree hemorrhoids required more treatments than smaller piles. BD has some practical advantages over IRPC but results are similar.

Successful combined medical and surgical treatment of a lower extremity sclerodermal ulcer

Combined medical and surgical treatment of a chronic lower extremity ulcer in a patient with systemic scleroderma is described. Recent pharmacological advances including calcium channel blockers, meticulous surgical care, and skin grafting offer promise for more consistent wound closure in sclerodermal skin ulcerations.

Preoperative percutaneous localisation of parathyroid tumours: a preliminary report

Uncomplicated bilateral percutaneous subclavian venous sampling for parathormone estimation was performed preoperatively in 10 patients with primary hyperparathyroidism. In 7 cases there was correlation of the higher parathormone level with the side of the parathyroid tumour subsequently found at operation. In conjunction with the "Tibblin strategy of unilateral parathyroidectomy" (1) a dual approach is suggested that may provide a simple, accurate method of treating patients with hyperparathyroidism.

The effect of pre-operative glucose loading on postoperative nitrogen metabolism

The nitrogen sparing effect of glucose loading at either 1 mg kg-1 min-1 or 5 mg kg-1 min-1 from the evening before surgery was compared with similar glucose infusions commenced after elective surgery. Thirty-two patients undergoing abdominal surgery of moderate severity were studied. Glucose at 5 mg kg-1 min-1 reduced urea excretion compared with glucose at 1 mg kg-1 min-1. The timing of the carbohydrate infusion was not critical in altering the overall extent of the protein sparing at either rate. High dose glucose infusions markedly reduced overall urea and 3-methylhistidine excretion. This implies a reduction in protein breakdown. A pre-operative high dose infusion of glucose may in particular improve protein synthesis for the first 24 h after surgery.

Effect of estrogen on thyrotropin-releasing hormone-induced release of prolactin in intact, ovariectomized, and stalk-sectioned female rhesus monkeys

The effects of estrogen treatment on basal and TRH-induced serum PRL concentrations were studied in three groups of four female rhesus monkeys; intact monkeys, ovariectomized animals, and monkeys in which the pituitary gland had been isolated from direct hypothalamic influences by pituitary stalk section. The TRH tests (50 microgram, iv) were performed before and 7 and 21 days after the sc implantation of one or two 3-cm long silastic capsules containing 17 beta-estradiol. Treatment with estradiol significantly increased the PRL response to TRH in the three groups of animals. The highest PRL response to TRH was observed after stalk section. The estrogen treatment also increased basal PRL concentrations in stalk-sectioned monkeys but no statistically significant increase was observed in intact or ovariectomized animals. These results indicate that physiological amounts of estradiol increase the magnitude of TRH-induced PRL release in rhesus monkeys, and that this estrogen effect is probably enacted directly at the level of the anterior pituitary gland.