1
|
Wittkopf PG, Lloyd DM, Johnson MI. The effect of visual feedback of body parts on pain perception: A systematic review of clinical and experimental studies. Eur J Pain 2017; 22:647-662. [PMID: 29271535 DOI: 10.1002/ejp.1162] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2017] [Indexed: 12/15/2022]
Abstract
The aim of this systematic review was to evaluate the effect of visual feedback techniques on pain perception by analysing the effect of normal-sized, magnified or minified visual feedback of body parts on clinical and experimentally-induced pain. Databases searched: Medline, Embase, PsychInfo, PEDro, CINAHL, CENTRAL and OpenSIGLE. Studies investigating pain patients and pain-free participants exposed to experimentally-induced pain were analysed separately. Risk of bias was assessed and data were meta-analysed. Thirty four studies were included. A meta-analysis of clinical data favoured mirror visual feedback (six trials; mean difference = -13.06 mm; 95% CI = -23.97, -2.16). Subgroup analysis favoured mirror visual feedback when used as a course of treatment (three trials; mean difference = -12.76 mm; 95% CI = -24.11, -1.40) and when used for complex regional pain syndrome for complex regional pain syndrome (three trials; standard mean difference = -1.44; 95% CI = -1.88, -0.99). There is insufficient evidence to determine differences between normal-sized view and a size-distorted view of the limb. Mirror visual feedback was not superior to object view or direct view of the hand for reducing experimental pain in pain-free participants. There were inconsistencies in study findings comparing normal-sized reflection of a body part and a reflection of an object, or a magnified or minified reflection. There is tentative evidence that mirror visual feedback can alleviate pain when delivered as a course of treatment, and for patients with complex regional pain syndrome. It was not possible to determine whether normal-sized, magnified or minified visual feedback of body parts affects pain perception because of contradictory findings in primary studies. SIGNIFICANCE It was not possible to determine whether normal-sized, magnified or minified visual feedback of body parts affected pain perception in clinical or experimental settings because of contradictory findings in primary studies. This emphasizes the need for higher quality studies.
Collapse
Affiliation(s)
- P G Wittkopf
- Centre for Pain Research, School of Clinical and Applied Sciences, Leeds Beckett University, Leeds, UK
| | - D M Lloyd
- School of Psychology, University of Leeds, Leeds, UK
| | - M I Johnson
- Centre for Pain Research, School of Clinical and Applied Sciences, Leeds Beckett University, Leeds, UK
| |
Collapse
|
2
|
Boam T, Sellars P, Isherwood J, Hollobone C, Pollard C, Lloyd DM, Dennison AR, Garcea G. Adherence to vaccination guidelines post splenectomy: A five year follow up study. J Infect Public Health 2017; 10:803-808. [PMID: 28189514 DOI: 10.1016/j.jiph.2017.01.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 11/21/2016] [Accepted: 01/07/2017] [Indexed: 11/16/2022] Open
Abstract
Following a splenectomy patients are at increased risk of significant infections. In its most severe form, overwhelming post-splenectomy infection (OPSI) has a mortality rate of up to 80%. In this study we aim to establish the adherence to vaccination and antibiotic national guidelines in splenectomised patients. A retrospective study of 100 patients who underwent splenectomy (21 emergency, 79 elective), in two teaching hospitals was undertaken over a five-year period. Patients were followed up for five years. Hospital and GP records were reviewed for adherence to pre, intra and postoperative vaccination, thromboprophylaxis and antibiotic guidance. Eighty-six eligible patients (91.5%) received their Haemophilus influenzae B, meningococcal C and pneumococcus vaccinations peri-operatively. Eighty-one (86%) received post-operative antibiotics. Ninety-nine percent of patients received thromboprophylaxis treatment. Eighty-nine (95%) were treated with long-term antibiotic prophylaxis. Only 20 patients (23%) had an emergency supply of antibiotics. Ninety-five percent of patients were administered an annual influenza vaccination and 84% of eligible patients received a five-year pneumococcal booster vaccination. Improvement in the management of this patient cohort can be achieved by a multidisciplinary approach involving adherence to national guidelines, standardised trust protocols, patient information leaflets and advice detailing risk of infection, standardised GP letters and a splenectomy register to monitor and manage this vulnerable group of patients.
Collapse
Affiliation(s)
- Tristan Boam
- Nottingham University Hospitals, Nottingham, UK.
| | | | - John Isherwood
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, University of Leicester, Leicester, UK(1)
| | - Chloe Hollobone
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, University of Leicester, Leicester, UK(1)
| | - Cristina Pollard
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, University of Leicester, Leicester, UK(1)
| | - David M Lloyd
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, University of Leicester, Leicester, UK(1)
| | - Ashley R Dennison
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, University of Leicester, Leicester, UK(1)
| | - Giuseppe Garcea
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, University of Leicester, Leicester, UK(1)
| |
Collapse
|
3
|
Lončarević I, Pajin B, Petrović J, Zarić D, Sakač M, Torbica A, Lloyd DM, Omorjan R. The impact of sunflower and rapeseed lecithin on the rheological properties of spreadable cocoa cream. J FOOD ENG 2016. [DOI: 10.1016/j.jfoodeng.2015.10.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
4
|
|
5
|
Gravante G, Ong SL, Metcalfe MS, Sorge R, Sconocchia G, Orlando G, Lloyd DM, Dennison AR. Cytokine response to ischemia/reperfusion injury in an ex vivo perfused porcine liver model. Transplant Proc 2015; 41:1107-12. [PMID: 19460492 DOI: 10.1016/j.transproceed.2009.02.054] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND We evaluated the degree of inflammatory response after ischemia/reperfusion injury by an extracorporeal normothermic autologous hemoperfusion of porcine livers. MATERIALS AND METHODS Livers explanted from 7 pigs were perfused extracorporeally at 39 degrees C with autologous blood. Serum samples were obtained hourly until 6 hours from the beginning of reperfusion and assayed for 9 different cytokines. RESULTS Significant elevations in interleukin 6 (IL-6) and IL-8 were noted following reperfusion (P < .001), with both demonstrating an increase which followed a sigmoid curve; other cytokines that were assessed showed no significant change. CONCLUSIONS The ex vivo model excludes the liver from the influence of external systemic factors such as hormones, the autonomic nervous system, and other regulatory molecules produced elsewhere in the body, allowing the response to the ischemia/reperfusion injury to be studied in isolation and in considerable detail. Although this study examined a relatively short period, the increases in only IL-6 and IL-8 suggested that these are important molecules in the early phase after reperfusion.
Collapse
Affiliation(s)
- G Gravante
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, United Kingdom.
| | | | | | | | | | | | | | | |
Collapse
|
6
|
James MI, Iwuji C, Irving G, Karmokar A, Higgins JA, Griffin-Teal N, Thomas A, Greaves P, Cai H, Patel SR, Morgan B, Dennison A, Metcalfe M, Garcea G, Lloyd DM, Berry DP, Steward WP, Howells LM, Brown K. Curcumin inhibits cancer stem cell phenotypes in ex vivo models of colorectal liver metastases, and is clinically safe and tolerable in combination with FOLFOX chemotherapy. Cancer Lett 2015; 364:135-41. [PMID: 25979230 PMCID: PMC4510144 DOI: 10.1016/j.canlet.2015.05.005] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 04/16/2015] [Accepted: 05/04/2015] [Indexed: 12/11/2022]
Abstract
In vitro and pre-clinical studies have suggested that addition of the diet-derived agent curcumin may provide a suitable adjunct to enhance efficacy of chemotherapy in models of colorectal cancer. However, the majority of evidence for this currently derives from established cell lines. Here, we utilised patient-derived colorectal liver metastases (CRLM) to assess whether curcumin may provide added benefit over 5-fluorouracil (5-FU) and oxaliplatin (FOLFOX) in cancer stem cell (CSC) models. Combination of curcumin with FOLFOX chemotherapy was then assessed clinically in a phase I dose escalation study. Curcumin alone and in combination significantly reduced spheroid number in CRLM CSC models, and decreased the number of cells with high aldehyde dehydrogenase activity (ALDH(high)/CD133(-)). Addition of curcumin to oxaliplatin/5-FU enhanced anti-proliferative and pro-apoptotic effects in a proportion of patient-derived explants, whilst reducing expression of stem cell-associated markers ALDH and CD133. The phase I dose escalation study revealed curcumin to be a safe and tolerable adjunct to FOLFOX chemotherapy in patients with CRLM (n = 12) at doses up to 2 grams daily. Curcumin may provide added benefit in subsets of patients when administered with FOLFOX, and is a well-tolerated chemotherapy adjunct.
Collapse
Affiliation(s)
- Mark I James
- Department of Cancer Studies, University of Leicester, Leicester Royal Infirmary, Leicester, LE2 7LX, UK
| | - Chinenye Iwuji
- Department of Cancer Studies, University of Leicester, Leicester Royal Infirmary, Leicester, LE2 7LX, UK
| | - Glen Irving
- Department of Cancer Studies, University of Leicester, Leicester Royal Infirmary, Leicester, LE2 7LX, UK
| | - Ankur Karmokar
- Department of Cancer Studies, University of Leicester, Leicester Royal Infirmary, Leicester, LE2 7LX, UK
| | - Jennifer A Higgins
- Department of Cancer Studies, University of Leicester, Leicester Royal Infirmary, Leicester, LE2 7LX, UK
| | - Nicola Griffin-Teal
- Department of Cancer Studies, University of Leicester, Leicester Royal Infirmary, Leicester, LE2 7LX, UK
| | - Anne Thomas
- Department of Cancer Studies, University of Leicester, Leicester Royal Infirmary, Leicester, LE2 7LX, UK
| | - Peter Greaves
- Department of Cancer Studies, University of Leicester, Leicester Royal Infirmary, Leicester, LE2 7LX, UK
| | - Hong Cai
- Department of Cancer Studies, University of Leicester, Leicester Royal Infirmary, Leicester, LE2 7LX, UK
| | - Samita R Patel
- Department of Cancer Studies, University of Leicester, Leicester Royal Infirmary, Leicester, LE2 7LX, UK
| | - Bruno Morgan
- Department of Cancer Studies, University of Leicester, Leicester Royal Infirmary, Leicester, LE2 7LX, UK
| | - Ashley Dennison
- Department of Hepatobiliary Surgery, Leicester General Hospital, Gwendolen Road, Leicester, UK
| | - Matthew Metcalfe
- Department of Hepatobiliary Surgery, Leicester General Hospital, Gwendolen Road, Leicester, UK
| | - Giuseppe Garcea
- Department of Hepatobiliary Surgery, Leicester General Hospital, Gwendolen Road, Leicester, UK
| | - David M Lloyd
- Department of Hepatobiliary Surgery, Leicester General Hospital, Gwendolen Road, Leicester, UK
| | - David P Berry
- Department of Hepatobiliary Surgery, University Hospitals of Wales, Cardiff, UK
| | - William P Steward
- Department of Cancer Studies, University of Leicester, Leicester Royal Infirmary, Leicester, LE2 7LX, UK
| | - Lynne M Howells
- Department of Cancer Studies, University of Leicester, Leicester Royal Infirmary, Leicester, LE2 7LX, UK.
| | - Karen Brown
- Department of Cancer Studies, University of Leicester, Leicester Royal Infirmary, Leicester, LE2 7LX, UK
| |
Collapse
|
7
|
James MI, Howells LM, Karmokar A, Higgins JA, Greaves P, Cai H, Dennison A, Metcalfe M, Garcea G, Lloyd DM, Berry DP, Steward WP, Brown K. Characterization and propagation of tumor initiating cells derived from colorectal liver metastases: trials, tribulations and a cautionary note. PLoS One 2015; 10:e0117776. [PMID: 25658706 PMCID: PMC4319830 DOI: 10.1371/journal.pone.0117776] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 12/30/2014] [Indexed: 12/27/2022] Open
Abstract
Tumor initiating cells (TIC) are increasingly being put forward as a potential target for intervention within colorectal cancer. Whilst characterisation and outgrowth of these cells has been extensively undertaken in primary colorectal cancers, few data are available describing characteristics within the metastatic setting. Tissue was obtained from patients undergoing surgical resection for colorectal liver metastases, and processed into single cell suspension for assessment. Tumor initiating cells from liver metastases were characterised using combinations of EPCAM, Aldehyde dehydrogenase activity, CD133 and CD26. CD133 expression was significantly lower in patients who had received chemotherapy, but this was accounted for by a decrease observed in the male patient cohort only. ALDHhigh populations were rare (0.4 and 0.3% for EPCAM+/ALDHhigh/CD133- and EPCAM+/ALDHhigh/CD133+ populations respectively) and below the limits of detection in 28% of samples. Spheroid outgrowth of metastatic tumor cells across all samples could not be readily achieved using standard spheroid-formation techniques, thus requiring further method validation to reliably propagate cells from the majority of tissues. Spheroid formation was not enhanced using additional growth factors or fibroblast co-culture, but once cells were passaged through NOD-SCID mice, spheroid formation was observed in 82% samples, accompanied by a significant increase in CD26. Order of spheroid forming ability was ALDHhigh>CD133>CD26. Samples sorted by these markers each had the ability to reform ALDHhigh, CD133 and CD26 positive populations to a similar extent, suggestive of a high degree of plasticity for each population. Ex vivo TIC models are increasingly being utilised to assess efficacy of therapeutic interventions. It is therefore essential that such investigations use well-characterised models that are able to sustain TIC populations across a large patient cohort in order that the inherent heterogeneity observed in cancer populations is maintained.
Collapse
MESH Headings
- AC133 Antigen
- Aged
- Aged, 80 and over
- Aldehyde Dehydrogenase/metabolism
- Animals
- Antigens, CD/metabolism
- Antigens, Neoplasm/metabolism
- Biomarkers, Tumor/metabolism
- Cell Adhesion Molecules/metabolism
- Cell Line
- Cell Proliferation
- Coculture Techniques
- Colorectal Neoplasms/drug therapy
- Colorectal Neoplasms/metabolism
- Colorectal Neoplasms/pathology
- Dipeptidyl Peptidase 4/metabolism
- Epithelial Cell Adhesion Molecule
- Female
- Fibroblasts/cytology
- Fibroblasts/metabolism
- Flow Cytometry
- Glycoproteins/metabolism
- Humans
- Liver Neoplasms/drug therapy
- Liver Neoplasms/metabolism
- Liver Neoplasms/secondary
- Male
- Mice, Inbred NOD
- Mice, SCID
- Middle Aged
- Neoplastic Stem Cells/metabolism
- Peptides/metabolism
- Spheroids, Cellular/metabolism
- Spheroids, Cellular/pathology
- Transplantation, Heterologous
- Tumor Cells, Cultured
Collapse
Affiliation(s)
| | | | | | | | | | - Hong Cai
- University of Leicester, Leicester, United Kingdom
| | - Ashley Dennison
- University Hospitals of Leicester, Leicester, United Kingdom
| | | | - Giuseppe Garcea
- University Hospitals of Leicester, Leicester, United Kingdom
| | - David M. Lloyd
- University Hospitals of Leicester, Leicester, United Kingdom
| | | | | | - Karen Brown
- University of Leicester, Leicester, United Kingdom
| |
Collapse
|
8
|
Spyropoulos F, Lloyd DM, Hancocks RD, Pawlik AK. Advances in membrane emulsification. Part B: recent developments in modelling and scale-up approaches. J Sci Food Agric 2014; 94:628-638. [PMID: 24122852 DOI: 10.1002/jsfa.6443] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 08/05/2013] [Accepted: 10/10/2013] [Indexed: 06/02/2023]
Abstract
Membrane emulsification is a promising process for formulating emulsions and particulates. It offers many advantages over conventional 'high-shear' processes with narrower size distribution products, higher batch repeatability and lower energy consumption commonly demonstrated at a small scale. Since the process was first introduced around 25 years ago, understanding of the underlying mechanisms involved during microstructure formation has advanced significantly leading to the development of modelling approaches that predict processing output; e.g. emulsion droplet size and throughput. The accuracy and ease of application of these models is important to allow for the development of design equations which can potentially facilitate scale-up of the process and meet the manufacturer's specific requirements. Part B of this review considers the advantages and disadvantages of a variety of models developed to predict droplet size, flow behaviour and other phenomena (namely droplet-droplet interactions), with presentation of the appropriate formulae where necessary. Furthermore, the advancement of the process towards an industrial scale is also highlighted with additional recommendations by the authors for future work.
Collapse
Affiliation(s)
- Fotis Spyropoulos
- School of Chemical Engineering, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | | | | | | |
Collapse
|
9
|
Spyropoulos F, Lloyd DM, Hancocks RD, Pawlik AK. Advances in membrane emulsification. Part A: recent developments in processing aspects and microstructural design approaches. J Sci Food Agric 2014; 94:613-627. [PMID: 24122870 DOI: 10.1002/jsfa.6444] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 08/05/2013] [Accepted: 10/10/2013] [Indexed: 06/02/2023]
Abstract
Modern emulsion processing technology is strongly influenced by the market demands for products that are microstructure-driven and possess precisely controlled properties. Novel cost-effective processing techniques, such as membrane emulsification, have been explored and customised in the search for better control over the microstructure, and subsequently the quality of the final product. Part A of this review reports on the state of the art in membrane emulsification techniques, focusing on novel membrane materials and proof of concept experimental set-ups. Engineering advantages and limitations of a range of membrane techniques are critically discussed and linked to a variety of simple and complex structures (e.g. foams, particulates, liposomes etc.) produced specifically using those techniques.
Collapse
Affiliation(s)
- Fotis Spyropoulos
- School of Chemical Engineering, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | | | | | | |
Collapse
|
10
|
Abstract
Right upper quadrant pain is a common presenting complaint to the general and hepatobiliary surgical team. Differential diagnoses include gallstones, cholecystitis, liver and pancreatic pathology. A 64-year-old man presented to our general surgical unit with right upper quadrant pain and deranged liver function tests. He underwent ultrasonography several times as well as magnetic resonance cholangiopancreatography (MRCP) in pursuit of hepatobiliary pathology. However, it was the identification of an empyema on MRCP that led to computed tomography of the thorax and the eventual discovery of the cause of the pain: a paraspinal abscess causing T10/T11 discitis. Right upper quadrant pain and deranged liver function tests justify hepatobiliary investigation. Nevertheless, after several negative tests, the differential diagnoses should be broadened and referred pain considered.
Collapse
Affiliation(s)
- G Cheyne
- University Hospitals of Leicester NHS Trust, UK
| | | | | |
Collapse
|
11
|
Chung WY, Eltweri AM, Isherwood J, Haqq J, Ong SL, Gravante G, Lloyd DM, Metcalfe MS, Dennison AR. Steps for the autologous ex vivo perfused porcine liver-kidney experiment. J Vis Exp 2013:e50567. [PMID: 24378595 DOI: 10.3791/50567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
The use of ex vivo perfused models can mimic the physiological conditions of the liver for short periods, but to maintain normal homeostasis for an extended perfusion period is challenging. We have added the kidney to our previous ex vivo perfused liver experiment model to reproduce a more accurate physiological state for prolonged experiments without using live animals. Five intact livers and kidneys were retrieved post-mortem from sacrificed pigs on different days and perfused for a minimum of 6 hr. Hourly arterial blood gases were obtained to analyze pH, lactate, glucose and renal parameters. The primary endpoint was to investigate the effect of adding one kidney to the model on the acid base balance, glucose, and electrolyte levels. The result of this liver-kidney experiment was compared to the results of five previous liver only perfusion models. In summary, with the addition of one kidney to the ex vivo liver circuit, hyperglycemia and metabolic acidosis were improved. In addition this model reproduces the physiological and metabolic responses of the liver sufficiently accurately to obviate the need for the use of live animals. The ex vivo liver-kidney perfusion model can be used as an alternative method in organ specific studies. It provides a disconnection from numerous systemic influences and allows specific and accurate adjustments of arterial and venous pressures and flow.
Collapse
Affiliation(s)
- Wen Yuan Chung
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals of Leicester
| | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Abstract
Ganglia arising from the hip are rare. Its diagnosis is difficult owing to the anatomic location. A high index of suspicion and high-resolution imaging is essential to make the diagnosis. Treatment depends on the size, location, and symptoms. This report is of 2 patients with ganglia arising from the transverse acetabular ligament.
Collapse
Affiliation(s)
- Rajesh Botchu
- Department of Musculoskeletal Radiology, University Hospitals of Leicester, Leicester, United Kingdom
| | | | | | | |
Collapse
|
13
|
Sheen AJ, Stephenson BM, Lloyd DM, Robinson P, Fevre D, Paajanen H, de Beaux A, Kingsnorth A, Gilmore OJ, Bennett D, Maclennan I, O'Dwyer P, Sanders D, Kurzer M. ‘Treatment of the Sportsman's groin’: British Hernia Society's 2014 position statement based on the Manchester Consensus Conference. Br J Sports Med 2013; 48:1079-87. [DOI: 10.1136/bjsports-2013-092872] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
14
|
Gravante G, Ong SL, Metcalfe MS, Sorge R, Fox AJ, Lloyd DM, Maddern GJ, Dennison AR. Changes in acid-base balance during electrolytic ablation in an ex vivo perfused liver model. Am J Surg 2012; 204:666-70. [PMID: 20451173 DOI: 10.1016/j.amjsurg.2009.12.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2009] [Revised: 12/22/2010] [Accepted: 12/22/2009] [Indexed: 01/31/2023]
Abstract
BACKGROUND Electrolytic ablation (EA) destroys tissues through extreme pH changes in the local microenvironment. An ex vivo perfused liver model was used to assess the systemic effects of EA on the acid-base balance without the influence of compensatory organs (lungs and kidneys). METHODS Eleven pigs were perfused extracorporeally at 39°C with autologous blood; 4 also underwent EA after 1 hour of reperfusion. Arterial blood samples were obtained hourly. RESULTS pH and CO(2) levels did not change throughout the experiments. A significant increase of HCO(3)-, anion gap, base excess, and lactate was present after the third hour. No differences were observed between EA experiments and controls. CONCLUSIONS EA does not alter the acid-base balance even when the confounding influence of compensatory organs is removed. Such findings should be considered when planning ablations in patients with renal failure or respiratory diseases in which EA could avoid undesirable metabolic changes.
Collapse
Affiliation(s)
- Gianpiero Gravante
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester LE5 4PW, UK.
| | | | | | | | | | | | | | | |
Collapse
|
15
|
Alzaraa A, Gravante G, Chung WY, Al-Leswas D, Bruno M, Dennison AR, Lloyd DM. Targeted microbubbles in the experimental and clinical setting. Am J Surg 2012; 204:355-66. [PMID: 22920405 DOI: 10.1016/j.amjsurg.2011.10.024] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 10/12/2011] [Accepted: 10/12/2011] [Indexed: 01/17/2023]
Abstract
BACKGROUND Microbubbles have improved ultrasonography imaging techniques over the past 2 decades. Their safety, versatility, and easiness of use have rendered them equal or even superior in some instances to other imaging modalities such as computed tomography and magnetic resonance imaging. Herein, we conducted a literature review to present their types, general behavior in tissues, and current and potential use in clinical practice. METHODS A literature search was conducted for all preclinical and clinical studies involving microbubbles and ultrasonography. RESULTS Different types of microbubbles are available. These generally improve the enhancement of tissues during ultrasonography imaging. They also can be attached to ligands for the target of several conditions such as inflammation, angiogenesis, thrombosis, apoptosis, and might have the potential of carrying toxic drugs to diseased sites, thereby limiting the systemic adverse effects. CONCLUSIONS The use of microbubbles is evolving rapidly and can have a significant impact on the management of various conditions. The potential for their use as targeting agents and gene and drug delivery vehicles looks promising.
Collapse
Affiliation(s)
- Ahmed Alzaraa
- Department of Hepatobiliary and Pancreatic Surgery, NHS Trust, Leicester General Hospital, Gwendolen Rd., Leicester, LE5 4PW, UK.
| | | | | | | | | | | | | |
Collapse
|
16
|
Gravante G, Ong SL, West K, McGregor A, Maddern GJ, Metcalfe MS, Lloyd DM, Dennison AR. Patterns of histological changes following hepatic electrolytic ablation in an ex-vivo perfused model. Pathol Oncol Res 2012; 18:1085-9. [PMID: 22706978 DOI: 10.1007/s12253-012-9549-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2012] [Accepted: 05/30/2012] [Indexed: 10/28/2022]
Abstract
Electrolytic ablation (EA) destroys the liver by releasing toxic radicles and producing modifications in the local pH without increasing the tissue temperature. We assessed the histological changes produced by EA using an ex-vivo perfused model. Five porcine livers were harvested, preserved in ice and reperfused for six hours in an extracorporeal circuit using autologous normothermic blood. One hour after reperfusion EA was performed and liver biopsies collected at the end of the experiments. The main necrotic zone consisted of coagulative necrosis, sinusoidal dilatation and haemorrhage with an unusual morphological pattern. The coagulative necrosis and haemorrhage affected mainly the peripheral area of the lobule with relative sparing of the area surrounding the centrilobular vein. Contrasting with this sinusoidal dilatation appeared to be more prominent in the centrilobular area. EA produces patterns of tissue destruction that have not been observed with the more commonly used thermal techniques. Further studies should obtain more information about the influence of adjacent biliary and vascular structures so that appropriate clinical trials can be designed.
Collapse
Affiliation(s)
- Gianpiero Gravante
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK.
| | | | | | | | | | | | | | | |
Collapse
|
17
|
Chung WY, Gravante G, Al-Leswas D, Alzaraa A, Sorge R, Ong SL, Pollard C, Lloyd DM, Metcalfe MS, Dennison AR. Addition of a kidney to the normothermic ex vivo perfused porcine liver model does not increase cytokine response. J Artif Organs 2012; 15:290-4. [PMID: 22476783 DOI: 10.1007/s10047-012-0641-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Accepted: 03/15/2012] [Indexed: 11/29/2022]
Abstract
The addition of a kidney to the ex vivo liver perfused model may facilitate the circuit homeostatic balance of important biochemical parameters (i.e. pH changes, urea and creatinine, or glucose levels) but might also increase the inflammatory reaction produced. In this study, we compared the production of various cytokines between liver-kidney and liver-alone circuits. Seven livers were harvested from female pigs and perfused for 6 h. In five additional experiments, a kidney was also harvested and connected in parallel. Blood samples for interleukins (IL) 1, 2, 4, 6, 8, 10, and 12, interferon (IFN)-γ and tumor necrosis factor (TNF)-α were collected before perfusion and at hours 1, 2, 4 and 6 postperfusion. In the combined liver-kidney circuit, a significant increase was present only for IL-6 and IL-8, but this did not differ significantly from those recorded in the liver-alone circuit. All other cytokines were not modified from baseline levels. The addition of a kidney to the perfusion circuit does not stimulate a greater inflammatory reaction than that of the liver alone and therefore further confirms the safety of the experimental setups in view of more delicate experiments requiring strict homeostatic conditions.
Collapse
Affiliation(s)
- Wen Yuan Chung
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, University of Leicester, Gwendolen Road, Leicester LE5 4PW, UK.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Abstract
INTRODUCTION The United Kingdom's Department of Health has identified reducing delays in patient discharge as a key aim for Health Service development. Laparoscopic cholecystectomy and laparoscopic inguinal hernia repair may be safely performed on a short stay basis, but day case rates remain low, with delays in discharge identified as a major contributing factor. Nurse-led discharge has been widely advocated to speed patient discharge across varied specialities, but objective evidence to support its use is lacking. This study aimed to assess the effectiveness of nurse-led discharge following laparoscopic surgery. METHODS A retrospective comparison of doctor-led and nurse-led discharge following laparoscopic surgery was performed by analysis of two consecutive 4-month periods, prior to and following the introduction of nurse-led discharge by a laparoscopic nurse specialist. Outcomes assessed included time to discharge, reasons for delayed discharge, hospital readmissions and primary care episodes following discharge. RESULTS A total of 128 patients were included in the study, with each discharge group containing 64 patients. Patients in the nurse-led discharge group were significantly more likely to be discharged on the day of surgery than patients in the doctor-led discharge group (17.2% vs. 4.7%; P = 0.023), with a highly significant difference in same day discharge rates noted among patients operated on during morning theatre lists (44.0% vs. 10.7%; P = 0.006). There was no significant difference between the discharge groups in readmission rates or in the number of patients seeking primary care attention following discharge. CONCLUSIONS Nurse-led discharge may speed discharge following laparoscopic surgery with no apparent detriment to patient care.
Collapse
Affiliation(s)
- Lisa Graham
- Department of Surgery, Leicester Royal Infirmary, Leicester, UK
| | | | | | | | | | | |
Collapse
|
19
|
|
20
|
Affiliation(s)
- N Bhardwaj
- Department of Surgery, Leicester General Hospital, Leicester, UK.
| | | |
Collapse
|
21
|
Affiliation(s)
- N Bhardwaj
- Department of Surgery Leicester General Hospital, Leicester, UK
| | - DM Lloyd
- Department of Surgery Leicester General Hospital, Leicester, UK
| |
Collapse
|
22
|
Lloyd DM, Lau KN, Welsh F, Lee KF, Sherlock DJ, Choti MA, Martinie JB, Iannitti DA. International multicentre prospective study on microwave ablation of liver tumours: preliminary results. HPB (Oxford) 2011; 13:579-85. [PMID: 21762302 PMCID: PMC3163281 DOI: 10.1111/j.1477-2574.2011.00338.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Microwave ablation (MWA) is increasingly utilized in the treatment of hepatic tumours. Promising single-centre reports have demonstrated its safety and efficacy, but this modality has not been studied in a prospective, multicentre study. METHODS Eighteen international centres recorded operative and perioperative data for patients undergoing MWA for tumours of any origin in a voluntary Internet-based database. All patients underwent operative MWA using a 2.45-GHz generator with a 5-mm antenna. RESULTS Of the 140 patients, 114 (81.4%) were treated with MWA alone and 26 (18.6%) were treated with MWA combined with resection. Multiple tumours were treated with MWA in 40.0% of patients. A total of 299 tumours were treated in these 140 patients. The median size of ablated lesions was 2.5 cm (range: 0.5-9.5 cm). Tumours were treated with a median of one application (range: 1-6 applications) for a median of 4 min (range: 0.5-30.0 min). A power setting of 100 W was used in 78.9% of cases. Major morbidity was 8.3% and in-hospital mortality was 1.9%. CONCLUSIONS These multi-institution data demonstrate rapid ablation time and low morbidity and mortality rates in patients undergoing operative MWA with a high rate of multiple ablations and concomitant hepatic resection. Longterm follow-up will be required to determine the efficacy of MWA relative to other forms of ablative therapy.
Collapse
Affiliation(s)
- David M Lloyd
- Department of Hepatobiliary and Pancreatic Surgery, Leicester Royal InfirmaryLeicester
| | - Kwan N Lau
- Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical CenterCharlotte, NC, and
| | - Fenella Welsh
- Department of Hepatobiliary Surgery, North Hampshire HospitalBasingstoke
| | - Kit-Fai Lee
- Department of Surgery, Prince of Wales HospitalHong Kong, China
| | - David J Sherlock
- Hepato-Pancreato-Biliary Unit, North Manchester General HospitalManchester, UK
| | | | - John B Martinie
- Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical CenterCharlotte, NC, and
| | - David A Iannitti
- Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical CenterCharlotte, NC, and
| | | |
Collapse
|
23
|
Gravante G, Ong SL, Metcalfe MS, Sorge R, Overton J, Lloyd DM, Maddern GJ, Dennison AR. Cytokine response of electrolytic ablation in an ex vivo perfused liver model. ANZ J Surg 2010; 80:537-41. [PMID: 20795969 DOI: 10.1111/j.1445-2197.2010.05380.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The inflammatory response following hepatic ablation depends on different factors including the method used, the duration and intensity of the treatment and the presence or absence of ischemia. Debate continues about the use of different modalities and whether some aspects of the response may be advantageous by releasing immunological active substances. Little data have been published concerning the cytokine response elicited by hepatic electrolytic ablation (EA). Study of an ex vivo liver model could allow for the evaluation of this response without the influence of confounding systemic factors. METHODS Livers explanted from 11 pigs were perfused extracorporeally with normothermic autologous blood. Four of them underwent EA after 1 h of reperfusion. Serum samples were obtained up to 6 h after the reperfusion and assayed for IL-1 beta, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12, IFN-gamma, TNF-alpha. RESULTS Significant changes in the control group were observed for IL-6 after the second hour and IL-8 after the first hour compared with baseline levels (P < 0.001). In the EA group, IL-6 and IL-12 were raised after the second hour and IL-8 and IL-10 after the first hour (P < 0.001). The comparison between groups showed significant differences for IL-2, IL-4 (decreased in the EA group compared with controls), IL-10 and TNF-alpha (EA group increased compared with controls; P < 0.001). CONCLUSIONS The ex vivo perfused liver model demonstrated changes in levels of IL-2, IL-4, IL-10 and TNF-alpha following hepatic EA.
Collapse
Affiliation(s)
- Gianpiero Gravante
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK.
| | | | | | | | | | | | | | | |
Collapse
|
24
|
Gravante G, Knowles T, Ong SL, Al-Taan O, Metcalfe M, Dennison AR, Lloyd DM. Bile changes after liver surgery: experimental and clinical lessons for future applications. Dig Surg 2010; 27:450-60. [PMID: 21063120 DOI: 10.1159/000320459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
INTRODUCTION The aim of this review is to summarize the available evidence for changes in bile composition following liver surgery and assess their use in predicting post-operative complications. MATERIALS AND METHODS A literature search was undertaken for all studies focusing on bile composition, bile volume and analysis. Articles were selected from MEDLINE, Embase and the Cochrane Central Register of Controlled Trials databases up to May 2009. RESULTS Low values of pre-operative bilirubin diglucuronide predict reduced post-operative liver function and the occurrence of jaundice. Low concentrations of hepatocyte growth factor and interleukin-6 in bile following surgery are associated with the subsequent development of liver failure and are probably surrogate markers for situations where the resultant hepatic regeneration is inadequate. CONCLUSIONS Analysis of the composition and quality of bile is probably underused as a tool for the pre-operative screening and early post-operative monitoring of patients at high risk of developing liver failure following major hepatobiliary procedures.
Collapse
Affiliation(s)
- Gianpiero Gravante
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals of Leicester, Leicester, UK.
| | | | | | | | | | | | | |
Collapse
|
25
|
Ahmad F, Gravante G, Bhardwaj N, Strickland A, Basit R, West K, Sorge R, Dennison AR, Lloyd DM. Changes in interleukin-1β and 6 after hepatic microwave tissue ablation compared with radiofrequency, cryotherapy and surgical resections. Am J Surg 2010; 200:500-6. [PMID: 20887844 DOI: 10.1016/j.amjsurg.2009.12.025] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2009] [Revised: 12/12/2009] [Accepted: 12/22/2009] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cytokine changes after microwave tissue ablation (MTA) were compared with hepatic resection, cryotherapy (CRYO), and radiofrequency ablation (RFA). Cytokine production was measured at various ablation volumes for each modality and correlated with the transitional inflammatory zone produced by the ablation techniques. METHODS Live rats underwent MTA, surgical resection, CRYO or RFA of 15%, 33%, or 66% of the total hepatic volume. Serum samples were collected preoperatively and at 1, 3, 6, 24, and 48 hours after surgery and analyzed for pro-inflammatory cytokines interleukin (IL)-1β and IL-6. RESULTS Significantly higher levels of both cytokines were present after CRYO and RFA compared with MTA, hepatic resection, or controls (P < .001). All animals survived except those undergoing RFA or CRYO of 66% of the hepatic volume, which died within 6 hours. Transitional zones produced after RFA were larger than those after CRYO or MTA, but no correlation was present with the amount of cytokines. CONCLUSIONS Large-volume MTA is associated with a significant decreased cytokine response and is well tolerated compared with RFA and CRYO.
Collapse
Affiliation(s)
- Fateh Ahmad
- Department of Hepatobiliary and Pancreatic Surgery, Leicester Royal Infirmary, Leicester, UK
| | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Mann CD, Metcalfe MS, Lloyd DM, Maddern GJ, Dennison AR. The safety and efficacy of ablative techniques adjacent to the hepatic vasculature and biliary system. ANZ J Surg 2010; 80:41-9. [PMID: 20575879 DOI: 10.1111/j.1445-2197.2009.05174.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Ablative techniques may provide an alternative to resection in treating awkwardly placed hepatic malignancy adjacent to major vascular and biliary structures. The heat-sink effect may reduce efficacy adjacent to major vascular structures. Vascular occlusion improves efficacy but is associated with increased vascular and biliary complications. The safety and efficacy of ablation in these situations remain to be defined. Further studies comparing both safety and efficacy are needed.
Collapse
Affiliation(s)
- Christopher D Mann
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals of Leicester, Gwendolen Road, Leicester, UK.
| | | | | | | | | |
Collapse
|
27
|
Ahmad F, Gravante G, Bhardwaj N, Strickland A, Basit R, West K, Sorge R, Dennison AR, Lloyd DM. Renal effects of microwave ablation compared with radiofrequency, cryotherapy and surgical resection at different volumes of the liver treated. Liver Int 2010; 30:1305-14. [PMID: 20536713 DOI: 10.1111/j.1478-3231.2010.02290.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Renal changes after microwave tissue ablation (MTA) were compared with those following hepatic resection, cryotherapy (CRYO), and radiofrequency ablation (RFA). Structural damage producing renal impairment has been assessed directly by examining tissue specimens and by serum analysis for two sensitive biomarkers, retinol binding protein (RBP) and the heat shock protein 70 (HSP-70) for each modality at different ablation volumes. METHODS Live rats underwent MTA, surgical resection, CRYO or RFA of 15, 33 or 66% of total hepatic volume. Urine and tissue samples were collected at the time of death. Percentage of tubules with casts and glomerular damage, tissue expression of HSP-70 and urine RBP were evaluated and compared. Behaviour of the animals was also assessed by means of five different parameters and combined to produce a response score. RESULTS All RFA and CRYO rats undergoing 66% died and these animals had >60% of damaged tubuli and 8% of altered glomeruli. No animals treated by MTA or surgical resection died. Cut-off values (those predicting fatal treatments) could be identified for levels of HSP-70 and RBP. CONCLUSIONS Large volume MTA is associated with a significant reduced renal damage and is well tolerated compared with RFA and CRYO.
Collapse
Affiliation(s)
- Fateh Ahmad
- Department of Hepatobiliary and Pancreatic Surgery, Leicester Royal Infirmary, Leicester, UK
| | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Gravante G, Ong SL, Cameron IC, Richards C, Metcalfe MS, Dennison AR, Lloyd DM. Two primary tumours metastasizing to the liver in a collision phenomenon. ANZ J Surg 2010; 80:368-9. [PMID: 20557514 DOI: 10.1111/j.1445-2197.2010.05281.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Gianpiero Gravante
- Departments of Hepatobiliary and Pancreatic Surgery, University Hospitals of Leicester, Leicester, UK
| | | | | | | | | | | | | |
Collapse
|
29
|
Abstract
INTRODUCTION Laparoscopic splenectomy has emerged as a safe and effective treatment for a variety of haematological conditions. The objective was to review the results from a large personal series from the perspective of outcomes according to operative time, conversion to open operation, complications and mortality. The application of laparoscopic splenectomy to cases of splenomegaly without hand assistance is examined. PATIENTS AND METHODS A retrospective review of 140 patients undergoing laparoscopic splenectomy at a single university hospital by one surgeon during 1994-2006. Case notes were reviewed and data collected on operative time, conversion to open procedure, morbidity and mortality. Particular reference was made towards the results of cases of splenomegaly. RESULTS In total 140 laparoscopic splenectomies were performed with a complication rate of 15% and no mortality. The median operative time was 100 min and conversion to open procedure was necessary in 2.1%. Conversion for cases of splenomegaly was only 5.7%. The median hospital stay was 3 days. CONCLUSIONS Laparoscopic splenectomy is a safe procedure with acceptable morbidity. A laparoscopic approach for splenomegaly is feasible.
Collapse
Affiliation(s)
- Clare J Pattenden
- Department of Surgery, University Hospitals of Leicester, Leicester Royal Infirmary, Leicester, UK
| | | | | | | | | |
Collapse
|
30
|
Gravante G, Ong SL, Metcalfe MS, Sorge R, Bikhchandani J, Lloyd DM, Dennison AR. Effects of Hypoxia Due to Isovolemic Hemodilution on an Ex Vivo Normothermic Perfused Liver Model. J Surg Res 2010; 160:73-80. [DOI: 10.1016/j.jss.2008.09.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2008] [Revised: 09/01/2008] [Accepted: 09/24/2008] [Indexed: 11/27/2022]
|
31
|
Gravante G, Ong SL, Metcalfe MS, Bhardwaj N, Maddern GJ, Lloyd DM, Dennison AR. Experimental application of electrolysis in the treatment of liver and pancreatic tumours: principles, preclinical and clinical observations and future perspectives. Surg Oncol 2010; 20:106-20. [PMID: 20045634 DOI: 10.1016/j.suronc.2009.12.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Revised: 11/18/2009] [Accepted: 12/07/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND Electrolytic ablation (EA) is a treatment that destroys tissues through electrochemical changes in the local microenvironment. This review examined studies using EA for the treatment of liver and pancreatic tumours, in order to define the characteristics that could endow the technique with specific advantages compared with other ablative modalities. METHODS Literature search of all studies focusing on liver and pancreas EA. RESULTS A specific advantage of EA is its safety even when conducted close to major vessels, while a disadvantage is the longer ablation times compared to more frequently employed techniques. Bimodal electric tissue ablation modality combines radiofrequency with EA and produced significant larger ablation zones compared to EA or radiofrequency alone, reducing the time required for ablation. Pancreatic EA has been investigated in experimental studies that confirmed similar advantages to those found with liver ablation, but has never been evaluated on patients. Furthermore, few clinical studies examined the results of liver EA in the short-term but there is no appropriate follow-up to confirm any survival advantage. CONCLUSIONS EA is a safe technique with the potential to treat lesions close to major vessels. Specific clinical studies are required to confirm the technique's safety and eventually demonstrate a survival advantage.
Collapse
Affiliation(s)
- G Gravante
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals of Leicester, Leicester, UK.
| | | | | | | | | | | | | |
Collapse
|
32
|
Bhardwaj N, Strickland AD, Ahmad F, El-Abassy M, Morgan B, Robertson GSM, Lloyd DM. Microwave ablation for unresectable hepatic tumours: clinical results using a novel microwave probe and generator. Eur J Surg Oncol 2009; 36:264-8. [PMID: 19880269 DOI: 10.1016/j.ejso.2009.10.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Revised: 09/29/2009] [Accepted: 10/05/2009] [Indexed: 12/16/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- N Bhardwaj
- Department of Hepatobiliary surgery, 6th floor Balmoral Building, Leicester Royal Infirmary, LE1 5WW, UK.
| | | | | | | | | | | | | |
Collapse
|
33
|
Gravante G, Ong SL, Metcalfe MS, Lloyd DM, Dennison AR. The porcine hepatic arterial supply, its variations and their influence on the extracorporeal perfusion of the liver. J Surg Res 2009; 168:56-61. [PMID: 20031170 DOI: 10.1016/j.jss.2009.09.050] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2009] [Revised: 09/08/2009] [Accepted: 09/30/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Variations in the porcine hepatic vasculature may contribute to the outcome of experiments based on liver perfusion models. We studied the hepatic artery (HA), variations of its branches, and the correlation with the resultant perfusion. MATERIALS AND METHODS Nineteen animals were used. After 6 h of perfusion, dissection of the HA and its branches was conducted up to the insertion in the liver parenchyma. Data about the macroscopic appearance of lobes and the pattern of branching were recorded. RESULTS In all cases, the HA bifurcated into two constant branches, one for the LL/LM lobes (further divided in two vessels for each lobe) and one for the RM lobe. Five main patterns were identified involving vessels for the RL and the CL lobes. Two variations produced complete and uniform perfusion of the entire liver in all cases, while in the remaining cases, only part of them were completely perfused. CONCLUSIONS Some variants of the porcine HA and its branches are associated with the risk of incomplete perfusion if the perfusion cannula placement does not take the individual hepatic arterial anatomy into account. Understanding of the hepatic arteries branching patterns is essential when ex vivo perfusion models are being established.
Collapse
Affiliation(s)
- Gianpiero Gravante
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals of Leicester, Leicester, United Kingdom.
| | | | | | | | | |
Collapse
|
34
|
Ong SL, Garcea G, Pollard CA, Furness PN, Steward WP, Rajesh A, Spencer L, Lloyd DM, Berry DP, Dennison AR. A fuller understanding of pancreatic neuroendocrine tumours combined with aggressive management improves outcome. Pancreatology 2009; 9:583-600. [PMID: 19657214 DOI: 10.1159/000212085] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Neuroendocrine tumours of the pancreas (PNETs) represent 1-2% of all pancreatic tumours. The terms 'islet cell tumours' and 'carcinoids' of the pancreas should be avoided. The aim of this review is to offer an overview of the history and diagnosis of PNETs followed by a discussion of the available treatment options. METHODS A search on PubMed using the keywords 'neuroendocrine', 'pancreas' and 'carcinoid' was performed to identify relevant literature over the last 30 years. RESULTS The introduction of a revised classification of neuroendocrine tumours by the World Health Organisation (WHO) in 2000 significantly changed our understanding of and approach to the management of these tumours. Advances in laboratory and radiological techniques have also led to an increased detection of PNETs. Surgery remains the only treatment that offers a chance of cure with increasing number of non-surgical options serving as beneficial adjuncts. The better understanding of the behaviours of PNETs together with improvements in tumour localisation has resulted in a more aggressive management strategy with a concomitant improvement in symptom palliation and a prolongation of survival. CONCLUSION Due to their complex nature and the wide range of therapeutic options, the involvement of specialists from all necessary disciplines in a multidisciplinary team setting is vital to provide optimal treatment of this disease.
Collapse
Affiliation(s)
- S L Ong
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Gravante G, Garcea G, Ong SL, Metcalfe MS, Berry DP, Lloyd DM, Dennison AR. Prediction of mortality in acute pancreatitis: a systematic review of the published evidence. Pancreatology 2009; 9:601-14. [PMID: 19657215 DOI: 10.1159/000212097] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE In this review, we focus on studies that examined such prognostic indices in relation to predicting a fatal outcome from pancreatitis. SUMMARY BACKGROUND DATA Acute pancreatitis (AP) is a common emergency, and early identification of high-risk patients can be difficult. For this reason, a plethora of different prognostic variables and scoring systems have been assessed to see if they can reliably predict the severity of pancreatitis and/or subsequent mortality. METHODS All studies that focused on AP, including retrospective series and prospective trials, were retrieved and analysed for factors that could influence mortality. Articles that analysed factors influencing the severity of the disease or the manifestation of disease-related complications were excluded. RESULTS 58 articles meeting the inclusion criteria were identified. Among the various factors investigated, APACHE II seemed to have the highest positive predictive value (69%). However, most prognostic variables and scores showed high negative predictive values but suboptimal values for positive predictive power. CONCLUSIONS Despite the proliferation of scoring systems for grading AP, none are ideal for the prediction of mortality. With the exception of the APACHE II, the other scores and indexes do not have a high degree of sensitivity, specificity and predictive values.
Collapse
Affiliation(s)
- G Gravante
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals of Leicester, Leicester, UK.
| | | | | | | | | | | | | |
Collapse
|
36
|
Bhardwaj N, Strickland AD, Ahmad F, Atanesyan L, West K, Lloyd DM. A comparative histological evaluation of the ablations produced by microwave, cryotherapy and radiofrequency in the liver. Pathology 2009; 41:168-72. [PMID: 19152189 DOI: 10.1080/00313020802579292] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
AIMS Complete tumour cell death is necessary for any ablative technique to be successful. Microwave tissue ablation (MTA), radiofrequency (RF) and cryotherapy (CT) are three methods of destroying liver tumours in situ. Unlike MTA, RF and CT rely on conduction of the thermal insult for their cytotoxicity, potentially affecting lesion uniformity. The aim of this study was to compare the uniformity of demarcation of lesions induced by MTA, RF and CT in the rat liver. METHODS Twenty-one rats were assigned to each of the three ablative modalities. RESULTS All specimens exhibited macroscopically well-demarcated lesions. Microscopically, the most clearly delineated lesions were induced by MTA with no intra-lesional viable hepatocytes or peri-vascular survival. All vessels and bile ducts had undergone complete necrosis. CT specimens showed more prominent inflammation at the lesion edge than MTA and peri-vascular hepatocyte survival within the ablated volumes. RF showed hepatocyte survival in the ablated area and conspicuous peri-vascular hepatocyte survival with evidence of a very irregular lesion edge. Cell viability was only assessed with H&E staining and not immunocytochemically. CONCLUSION Unlike RF and CT, MTA induced microscopically well-demarcated lesions, with no intralesional hepatocyte survival. Intralesional cell survival in RF and CT may be due to the relatively prolonged treatment times needed, allowing thermal energy to dissipate via blood flow. This is known as the heat sink effect and may contribute to the high local recurrence rates following treatment of larger tumours with RF and CT.
Collapse
Affiliation(s)
- N Bhardwaj
- Department of Hepatobiliary Surgery, Surgical Directorate, Leicester Royal Infirmary, Leicester, UK.
| | | | | | | | | | | |
Collapse
|
37
|
Dobson AJ, Alexander HM, Al-Roomi K, Gibberd RW, Heller RF, Leeder SR, Lloyd DM, Malcolm JA, Steele PL. Coronary events in the Hunter region of New South Wales, Australia: 1984-1986. Acta Med Scand Suppl 2009; 728:84-9. [PMID: 3202036 DOI: 10.1111/j.0954-6820.1988.tb05558.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The results of coronary event registration using the protocol of the World Health Organization MONICA Project are reported for two years for the Hunter Region, the area in and around Newcastle in New South Wales, Australia. The Newcastle MONICA Project monitors all suspected cases of heart attack by identifying patients from hospital admissions and obtaining information while they are still in hospital. For people who die out of hospital, the initial source of information is usually the death certificate. Rates for the most robust MONICA diagnostic categories, non-fatal definite myocardial infarction and all coronary deaths, differed for the two years reported here. Monthly rates suggested possible seasonal effects, and the possible influence of lower respiratory infections including an epidemic of influenza A. The results demonstrate that consistent monitoring over several years will be necessary to establish clear trends in coronary heart disease.
Collapse
Affiliation(s)
- A J Dobson
- Hunter Region Heart Disease Prevention Programme, University of Newcastle, New South Wales, Australia
| | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Abstract
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.
Collapse
Affiliation(s)
- C D Mann
- Department of Surgery, University Hospitals of Leicester, Leicester Royal Infirmary, Leicester, UK.
| | | | | | | |
Collapse
|
39
|
Gravante G, Sconocchia G, Ong SL, Dennison AR, Lloyd DM. Immunoregulatory effects of liver ablation therapies for the treatment of primary and metastatic liver malignancies. Liver Int 2009; 29:18-24. [PMID: 19018971 DOI: 10.1111/j.1478-3231.2008.01915.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Ablation of liver tissue produces in situ tumoural antigens and elicits specific immune responses. The aim of this review is to examine the available data about the local and systemic responses produced and to compare differences between the methods available. A literature search was undertaken for all papers focusing on immune responses following ablative therapy of the liver, including experimental and clinical studies. Following ablative procedures, the cellular response is elicited by the presentation of antigens by dendritic cells to specific CD4(+) T cells, which in turn stimulate natural killer or CD8(+) cytotoxic cells. The local release of intracellular debris activates Kupffer cells to produce cytokines, which, in the immediate vicinity, activate monocytes/macrophages or specific T cells that respond and produce systemic reactions such as fever, thrombocytopaenia or shock. The immune responses elicited by cryotherapy, both cellular and cytokine, seem far greater than those produced by radiofrequency or microwave ablation, probably as a consequence of the peculiar mechanism of cell death of the former (disruptive necrosis). This mechanism is considered central to the pathogenesis of cryoshock. Ablative techniques stimulate the immune system and provide an easy way to achieve in vivo vaccination against tumoural antigens. Immunomodulatory approaches have the potential to augment the initial immune stimulation and this combined approach could pave the way to a more selective and specific method of treating liver tumours.
Collapse
Affiliation(s)
- Gianpiero Gravante
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, University Hospitals of Leicester, Leicester, UK.
| | | | | | | | | |
Collapse
|
40
|
Ong SL, Garcea G, Thomasset SC, Neal CP, Lloyd DM, Berry DP, Dennison AR. Ten-year experience in the management of gallbladder cancer from a single hepatobiliary and pancreatic centre with review of the literature. HPB (Oxford) 2008; 10:446-58. [PMID: 19088932 PMCID: PMC2597309 DOI: 10.1080/13651820802392346] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2008] [Indexed: 02/06/2023]
Abstract
BACKGROUND There is no consensus regarding the optimum surgical approach to gallbladder cancer. This study reviews the management of gallbladder cancer in a single unit. METHODS Retrospective study of 73 consecutive patients diagnosed with gallbladder cancer. Twenty-three patients underwent surgery with curative intent (surgical group), 28 patients underwent exploratory surgery but had inoperable disease (surgically inoperable group) and 22 patients had inoperable disease radiologically (radiologically inoperable group). Within the surgical group, nine patients (cholecystectomy group) were diagnosed with gallbladder cancer after routine cholecystectomy. RESULTS The inoperable groups had significantly higher bilirubin and alkaline phosphatase (ALP) than the surgical group (p=0.02 and p<0.01, respectively). Age>68, white cell count (WCC)>7.6 x 109/L, platelet>345 x 109/L, bilirubin>16 mol/L, ALP >124 iu/L and sodium < or = 137 mmol/L were markers of inoperability. Age, haemoglobin and neutrophil:lymphocyte ratio (NLR) were predictors for survival following surgery (p=0.04, p=0.01 and p<0.01, respectively). The surgical and cholecystectomy groups had significantly higher median survivals than the surgically and radiologically inoperable groups (18.97 and 26.17 months versus 5.03 and 12.20 months, p=0.04). CONCLUSION Curative surgical resection of gallbladder cancer improved survival. Exploratory laparotomy which revealed inoperable disease reduced survival. Preoperative WCC, platelet, bilirubin and ALP may be used as additional discriminators during the investigation and work up prior to surgery.
Collapse
Affiliation(s)
- Seok L. Ong
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, University Hospitals of Leicester NHS TrustLeicesterUK
| | - Giuseppe Garcea
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, University Hospitals of Leicester NHS TrustLeicesterUK
| | - Sarah C. Thomasset
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, University Hospitals of Leicester NHS TrustLeicesterUK
| | - Christopher P. Neal
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, University Hospitals of Leicester NHS TrustLeicesterUK
| | - David M. Lloyd
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, University Hospitals of Leicester NHS TrustLeicesterUK
| | - David P. Berry
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, University Hospitals of Leicester NHS TrustLeicesterUK
| | - Ashley R. Dennison
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, University Hospitals of Leicester NHS TrustLeicesterUK
| |
Collapse
|
41
|
Ong SL, Sachdeva A, Garcea G, Gravante G, Metcalfe MS, Lloyd DM, Berry DP, Dennison AR. Elevation of carbohydrate antigen 19.9 in benign hepatobiliary conditions and its correlation with serum bilirubin concentration. Dig Dis Sci 2008; 53:3213-7. [PMID: 18465243 DOI: 10.1007/s10620-008-0289-8] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2008] [Accepted: 04/09/2008] [Indexed: 12/11/2022]
Abstract
BACKGROUND Carbohydrate antigen 19.9 (CA19.9), a tumor marker for malignancies of the hepatobiliary tract and pancreas, has frequently been shown to be deranged in a number of non-malignant conditions that are associated with jaundice. This study aims to demonstrate the correlation between CA19.9 and serum bilirubin concentration in patients with benign conditions and to determine the frequency of a false-positive increase in CA19.9 in patients being investigated for potential HPB malignancies. METHODS This is a retrospective review of 83 consecutive patients presenting with an abnormal CA19.9 and radiological or clinical features suggestive of HPB malignancy subsequently shown to have benign disease. All patients were thoroughly investigated and followed up until the diagnosis of malignancy could be safely excluded. RESULTS Serum bilirubin, sodium, lymphocyte count, neutrophil:lymphocyte ratio (NLR), beta-human chorionic gonadotrophin (HCG), and age were found to correlate with CA19.9 by Pearson's correlation (P = 0.001, P = 0.006, P = 0.006, P < 0.001, P = 0.012, and P = 0.049, respectively). In multivariate regression analysis, bilirubin was identified as an independent variable that may predict CA19.9 level (P = 0.028). CONCLUSION CA19.9 level is significantly influenced by serum bilirubin and elevated levels have been observed in patients with non-malignant HPB conditions. Adjusting CA19.9 according to bilirubin levels is likely to improve the specificity of this antigen in the differential diagnosis of benign and malignant HPB diseases and its reliability in the monitoring of disease response to chemotherapy.
Collapse
Affiliation(s)
- S L Ong
- Department of Hepatobiliary & Pancreatic Surgery, Leicester General Hospital, Gwendolen Road, Leicester, LE4 5PW, UK.
| | | | | | | | | | | | | | | |
Collapse
|
42
|
Abstract
Microwave (MW) ablation therapy is a local treatment by which tumours are destroyed by coagulation from the passage of MWs into cells. The aim of this review is to examine histological results obtained from preclinical and clinical studies. A literature search was undertaken for all studies focusing on MW therapy and in which lesions were excised for a complete histopathological examination after treatment. Two main zones were described after ablative therapy (central and transitional). Both corresponded to specific microscopic characteristics and evolved over time in a precise manner. No viable cells even up to 6 cm in diameter were demonstrated in 93% of lesions after treatment. Microwave therapy is a reliable technique under a variety of clinical situations. Future investigations are needed to compare MW with other ablative techniques to identify factors that influence the effectiveness of the various techniques and to determine specific indications.
Collapse
Affiliation(s)
- Gianpiero Gravante
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals of Leicester, Leicester, UK.
| | | | | | | | | | | |
Collapse
|
43
|
MacIver K, Lloyd DM, Kelly S, Roberts N, Nurmikko T. Phantom limb pain, cortical reorganization and the therapeutic effect of mental imagery. ACTA ACUST UNITED AC 2008; 131:2181-91. [PMID: 18567624 PMCID: PMC2494616 DOI: 10.1093/brain/awn124] [Citation(s) in RCA: 243] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Using functional MRI (fMRI) we investigated 13 upper limb amputees with phantom limb pain (PLP) during hand and lip movement, before and after intensive 6-week training in mental imagery. Prior to training, activation elicited during lip purse showed evidence of cortical reorganization of motor (M1) and somatosensory (S1) cortices, expanding from lip area to hand area, which correlated with pain scores. In addition, during imagined movement of the phantom hand, and executed movement of the intact hand, group maps demonstrated activation not only in bilateral M1 and S1 hand area, but also lip area, showing a two-way process of reorganization. In healthy participants, activation during lip purse and imagined and executed movement of the non-dominant hand was confined to the respective cortical representation areas only. Following training, patients reported a significant reduction in intensity and unpleasantness of constant pain and exacerbations, with a corresponding elimination of cortical reorganization. Post hoc analyses showed that intensity of constant pain, but not exacerbations, correlated with reduction in cortical reorganization. The results of this study add to our current understanding of the pathophysiology of PLP, underlining the reversibility of neuroplastic changes in this patient population while offering a novel, simple method of pain relief.
Collapse
Affiliation(s)
- K MacIver
- Pain Research Institute, Unit of Neuroscience, School of Clinical Sciences, Lower Lane, Liverpool, L9 7AL, UK.
| | | | | | | | | |
Collapse
|
44
|
Ahmad F, Saunders RN, Lloyd GM, Lloyd DM, Robertson GSM. An algorithm for the management of bile leak following laparoscopic cholecystectomy. Ann R Coll Surg Engl 2007; 89:51-6. [PMID: 17316523 PMCID: PMC1963538 DOI: 10.1308/003588407x160864] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- F Ahmad
- Department of Hepatobiliary and Laparoscopic Surgery, Leicester Royal Infirmary, Leicester, UK.
| | | | | | | | | |
Collapse
|
45
|
Abstract
OBJECTIVE This study aimed to determine whether peer-assisted learning (PAL) can enhance clinical examination skills training. METHODS Three student trainers studied small-group theory and clinical examination and provided PAL as extra tuition for 86 trainees. Trainees watched an examination video, were videotaped practising the examination and, after constructive feedback, repeated the examination. Responses to PAL were evaluated to attain an overview of trainee and trainer performance using visual analogue and Likert scale analyses. Year-group review was undertaken using questionnaires. RESULTS Trainees evaluated all aspects of PAL highly, including their post-training confidence in examination skills (mean > 7.7 on a 10-cm scale), indicating that the PAL was effective. Written comments confirmed the students perceived the sessions as well structured and of high quality. Compared with trainees in the first groups, those from later groups gave all parameters similar or higher gradings. Those for interest (P = 0.03) and appropriateness (P = 0.01) were significantly higher, suggesting that trainers may improve their technique with time. Students with previous degrees gave similar or lower gradings than standard entry students, with answers about post-training confidence and recommendation to friends being statistically lower (P < 0.006). Six months later, year-group analysis showed that 90% of trainees rated PAL highly, and 86% wished to become trainers. Of the trainers' year group, 79% perceived that PAL training could improve examination skills. CONCLUSIONS In the context of clinical skills training, PAL was highly evaluated across many parameters, including confidence after training. Student interest and enthusiasm supports suggestions that PAL could be a useful adjunct to clinical skills training.
Collapse
Affiliation(s)
- Max Field
- Medical Education Department, University of Glasgow Medical School, University of Glasgow, Glasgow, UK.
| | | | | | | |
Collapse
|
46
|
Abstract
Splenic artery aneurysms are rare and often asymptomatic; however, rupture may prove fatal. Although many can be treated with percutaneous embolization, tortuosity of the artery may render this approach impossible. Presented is a case report describing laparoscopic ligation of a splenic artery aneurysm after failed attempt at embolization.
Collapse
Affiliation(s)
- Rebecca M Sandford
- Department of Surgery, Level 2 RKCSB, Leicester Royal Infirmary, Leicester, UK.
| | | | | |
Collapse
|
47
|
Gregory SG, Barlow KF, McLay KE, Kaul R, Swarbreck D, Dunham A, Scott CE, Howe KL, Woodfine K, Spencer CCA, Jones MC, Gillson C, Searle S, Zhou Y, Kokocinski F, McDonald L, Evans R, Phillips K, Atkinson A, Cooper R, Jones C, Hall RE, Andrews TD, Lloyd C, Ainscough R, Almeida JP, Ambrose KD, Anderson F, Andrew RW, Ashwell RIS, Aubin K, Babbage AK, Bagguley CL, Bailey J, Beasley H, Bethel G, Bird CP, Bray-Allen S, Brown JY, Brown AJ, Buckley D, Burton J, Bye J, Carder C, Chapman JC, Clark SY, Clarke G, Clee C, Cobley V, Collier RE, Corby N, Coville GJ, Davies J, Deadman R, Dunn M, Earthrowl M, Ellington AG, Errington H, Frankish A, Frankland J, French L, Garner P, Garnett J, Gay L, Ghori MRJ, Gibson R, Gilby LM, Gillett W, Glithero RJ, Grafham DV, Griffiths C, Griffiths-Jones S, Grocock R, Hammond S, Harrison ESI, Hart E, Haugen E, Heath PD, Holmes S, Holt K, Howden PJ, Hunt AR, Hunt SE, Hunter G, Isherwood J, James R, Johnson C, Johnson D, Joy A, Kay M, Kershaw JK, Kibukawa M, Kimberley AM, King A, Knights AJ, Lad H, Laird G, Lawlor S, Leongamornlert DA, Lloyd DM, Loveland J, Lovell J, Lush MJ, Lyne R, Martin S, Mashreghi-Mohammadi M, Matthews L, Matthews NSW, McLaren S, Milne S, Mistry S, Moore MJF, Nickerson T, O'Dell CN, Oliver K, Palmeiri A, Palmer SA, Parker A, Patel D, Pearce AV, Peck AI, Pelan S, Phelps K, Phillimore BJ, Plumb R, Rajan J, Raymond C, Rouse G, Saenphimmachak C, Sehra HK, Sheridan E, Shownkeen R, Sims S, Skuce CD, Smith M, Steward C, Subramanian S, Sycamore N, Tracey A, Tromans A, Van Helmond Z, Wall M, Wallis JM, White S, Whitehead SL, Wilkinson JE, Willey DL, Williams H, Wilming L, Wray PW, Wu Z, Coulson A, Vaudin M, Sulston JE, Durbin R, Hubbard T, Wooster R, Dunham I, Carter NP, McVean G, Ross MT, Harrow J, Olson MV, Beck S, Rogers J, Bentley DR, Banerjee R, Bryant SP, Burford DC, Burrill WDH, Clegg SM, Dhami P, Dovey O, Faulkner LM, Gribble SM, Langford CF, Pandian RD, Porter KM, Prigmore E. The DNA sequence and biological annotation of human chromosome 1. Nature 2006; 441:315-21. [PMID: 16710414 DOI: 10.1038/nature04727] [Citation(s) in RCA: 170] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2005] [Accepted: 03/13/2006] [Indexed: 11/08/2022]
Abstract
The reference sequence for each human chromosome provides the framework for understanding genome function, variation and evolution. Here we report the finished sequence and biological annotation of human chromosome 1. Chromosome 1 is gene-dense, with 3,141 genes and 991 pseudogenes, and many coding sequences overlap. Rearrangements and mutations of chromosome 1 are prevalent in cancer and many other diseases. Patterns of sequence variation reveal signals of recent selection in specific genes that may contribute to human fitness, and also in regions where no function is evident. Fine-scale recombination occurs in hotspots of varying intensity along the sequence, and is enriched near genes. These and other studies of human biology and disease encoded within chromosome 1 are made possible with the highly accurate annotated sequence, as part of the completed set of chromosome sequences that comprise the reference human genome.
Collapse
Affiliation(s)
- S G Gregory
- The Wellcome Trust Sanger Institute, The Wellcome Trust Genome Campus, Hinxton, Cambridgeshire CB10 1SA, UK.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
48
|
Sutton CD, O'Byrne K, Goddard JC, Marshall LJ, Jones L, Garcea G, Dennison AR, Poston G, Lloyd DM, Berry DP. Expression of thrombospondin-1 in resected colorectal liver metastases predicts poor prognosis. Clin Cancer Res 2005; 11:6567-73. [PMID: 16166434 DOI: 10.1158/1078-0432.ccr-05-0439] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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-microm 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.
Collapse
|
49
|
Karkos CD, Hayes PD, Lloyd DM, Fishwick G, White SA, Quadar S, Sayers RD. Combined Laparoscopic and Percutaneous Treatment of a Type II Endoleak Following Endovascular Abdominal Aortic Aneurysm Repair. Cardiovasc Intervent Radiol 2005; 28:656-60. [PMID: 16010514 DOI: 10.1007/s00270-004-0120-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We describe a novel approach in treating a persistent type II endoleak related to the inferior mesenteric artery (IMA) and the lower lumbar arteries. The endoleak failed to thrombose following percutaneous IMA coil embolization. We proceeded to one-stage laparoscopic IMA division and intra-sac thrombin injection under direct laparoscopic vision and fluroscopy. A CT scan at 1 and 7 months post-intervention showed no evidence of endoleak and the growth of the aneurysm was arrested. This combined laparoscopic and percutaneous approach may be a useful treatment option in the management of persistent complex type II endoleak. Its durability, however has yet to be defined.
Collapse
Affiliation(s)
- Christos D Karkos
- Department of Vascular & Endovascular Surgery, Leicester Royal Infirmary, Leicester, LE1 5WW, UK.
| | | | | | | | | | | | | |
Collapse
|
50
|
Strickland AD, Clegg PJ, Cronin NJ, Elabassy M, Lloyd DM. Rapid microwave ablation of large hepatocellular carcinoma in a high-risk patient. Asian J Surg 2005; 28:151-3. [PMID: 15851373 DOI: 10.1016/s1015-9584(09)60282-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
A 74-year-old male with an inoperable, large (6 cm in diameter) primary hepatocellular carcinoma of the liver was successfully treated using a novel microwave ablating system. Using a single applicator, the tumour was treated at 150 W for 4 minutes. An ablation zone 8 cm in diameter was achieved, which gradually shrunk to form scar tissue that remained unchanged without tumour recurrence for 2 years.
Collapse
Affiliation(s)
- Andrew D Strickland
- Department of Hepatobiliary Surgery, Leicester Royal Infirmary, Leicester, United Kingdom
| | | | | | | | | |
Collapse
|