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Annals of The Royal College of Surgeons of England logoLink to Annals of The Royal College of Surgeons of England
. 2007 Mar;89(2):181–186. doi: 10.1308/003588407X155554

Publication of Abstracts from the Best Regional Presentations

Editor: Linda de Cossart
PMCID: PMC1964582
Ann R Coll Surg Engl. 2007 Mar;89(2):181. doi: 10.1308/003588407X155554

Clinical and Computerised Tomography Imaging-Based Predictors of Neoplastic Potential of Cystic Lesions of the Pancreas

D Gomez 1, SH Rahman 1, LF Wong 1, M Sheridan 1, C Verbeke 1, MJ McMahon 1, KV Menon 1, PJ Guillou 1

Introduction

Cystic lesions of the pancreas (CLP) are increasingly being recognised due to the wide-spread use of cross-sectional imaging. The vast majority although asymptomatic is associated with malignant potential and proves to be a diagnostic challenge. Therefore, the ability to predict neoplastic potential based on imaging and simple biochemistry is important.

Patients and Methods

From 1995–2005, all radiology and pathology records were reviewed for the presence of CLP. Patients with evidence of pancreatitis were excluded. CLP was divided into three groups – Gp1, solid/cystic papillary tumours, lympho-epithelial cysts and simple cysts; Gp2, serous and mucinous cystic neoplasms; and Gp3, intraductal papillary mucinous neoplasm, cystic neuroendocrine tumours, and cystadenocarcinomas.

Results

In total, 121 patients had CLP, of whom 75 patients without documented pancreatitis were included (62%) – Gp1 (n = 37), Gp2 (n = 13), Gp3 (n = 25). Cysts were located proximally (head/uncinate) in 52%, neck 13%, body 24%, and tail 11%. Abdominal pain was equally common in all groups, although jaundice was more prevalent in Gp3 (48%) > Gp2 (15%) > Gp1 (0%); P < 0.01. Cyst size on CT (χ2 = 24; P<0.001) was an independent predictor of malignant potential on univariate analysis, irrespective of cyst location. Proximal cysts were more frequently Gp3 lesions (> 50%), and Gp1 in the neck/body (>70%). In proximal lesions, jaundice (P < 0.001), cyst size (χ2 = 16; P < 0.001), and serum ALT concentration (χ2 = 10, P = 0.006) were associated with malignant potential. Similar relationships were demonstrated for cysts in the neck/body of pancreas (P = 0.02), but not for more distal lesions. The association of ALT concentration with malignancy was independent of biliary dilatation on imaging.

Conclusions

The data suggest that cyst location, size on CT, elevation in serum ALT concentration, and the presence of jaundice are independent predictors of neoplastic potential for cysts located proximal to the tail of pancreas.

Ann R Coll Surg Engl. 2007 Mar;89(2):181–182. doi: 10.1308/003588407X155554

Attitudes to Research in Surgical Training (Winner)

PA Coughlin 1, IC Chetter 1

Introduction

The role of research as part of surgical training has recently been challenged. We aimed to assess opinion of different grades of surgeon regarding the role of research during surgical training.

Materials and Methods

A single-paged questionnaire was distributed examining the necessity, duration, provision and benefits of research. Questionnaires were returned by 47 members of the Leeds Regional Surgical Club (consultants, response rate 75%), 128 specialist registrars from the Association of Surgeons In Training (ASIT) (SpRs, response rate 54%) and 36 basic surgical trainees from the East Yorkshire School of Surgery and from ASIT (BSTs, response rate 63%).

Results

Over 60% of all respondents felt a period of research to be highly desirable with a high proportion of all respondents believing that there should be flexibility in the length of time spent in research. BSTs had more fixed views on when research should be undertaken with a significantly higher proportion thinking it should be started either during foundation training or between basic and higher surgical training (P < 0.05, χ2 test). No consensus was reached as to the type of higher degree that should be obtained. There was a differing of opinion on the major benefits of a period of research. Consultants disagreed with the concept of sacrificing a period of research when compared to trainees (P < 0.05, χ2 test).

Conclusions

A period of research during surgical training is highly desirable, duration and timing both flexible, has multiple benefits and should not be sacrificed.

Ann R Coll Surg Engl. 2007 Mar;89(2):182. doi: 10.1308/003588407X155554

TRPC1 and Kv1.3: Novel Molecular Targets for the Inhibition of Neointimal Hyperplasia in Surgical Bypass Grafts

Bhaskar Kumar 1, Samir Shah 1, Chris Munsch 1, David Beech 1

Introduction

Neointimal hyperplasia (NiH), due to the proliferation of vascular smooth muscle cells (VSMCs), leads to long-term failure of saphenous vein (SV) bypass grafts following coronary artery bypass surgery and peripheral vascular surgery. The ion channels TRPC1 and Kv1.3 are fundamental in calcium influx – an essential process in VSMC proliferation. We hypothesised that targeting TRPC1 and Kv1.3 may prove to be effective at reducing NiH in patients undergoing bypass surgery.

Patients and Methods

Human SV samples were obtained from patients undergoing bypass surgery following informed consent and ethical approval. Organ culture of human SV was performed over a 14-day period during which time specific blockers of TRPC1 and Kv1.3 were added. Real-time polymerase chain reaction (RT-PCR) was performed on total RNA from SV segments to detect mRNA encoding TRPC1 and Kv1.3. In vivo vascular injury was performed using a crushing method on rat carotid artery and balloon-angioplasty of pig coronary artery. Immunohistochemistry was performed using specific antibodies for TRPC1 and Kv1.3. NiH was measured on SV segments using the NiH software image J.

Results

Real-time RT-PCR showed an up-regulation of mRNA encoding TRPC1 and Kv1.3 in proliferative VSMCs (n = 5 patients). Immunostaining revealed a higher expression of Kv1.3 in the intimal layer of human SV when compared with the medial layer (n = 10 patients). Peri-adventitial injury of mouse carotid artery led to enhanced calcium entry (n = 3 mice; P < 0.05). Immunofluorescence staining confirmed a higher expression of TRPC1 protein in the injured vessel segments compared with control. Balloon angioplasty of pig coronary artery showed increased expression of TRPC1 in the neointimal layer. Antibody targeting TRPC1 showed a marked reduction of NiH in human SV from different patients (n = 8; P < 0.05). Targeting Kv1.3 using the blockers margatoxin (5 nM) and correolide C (1 nM) also showed a significant reduction of NiH in human SV (n = 8; P < 0.05).

Conclusions

Targeting TRPC1 and Kv1.3 is a novel, highly effective strategy for reducing NiH in the human SV. This novel strategy of inhibiting NiH may prove to be effective at prolonging the patency of vein grafts used for bypass surgery and warrants further clinical testing.

Ann R Coll Surg Engl. 2007 Mar;89(2):182–183. doi: 10.1308/003588407X155554

Predicting the Outcome of Native Radiocephalic Arteriovenous Fistulae

DA Russell 1, L Hostert 1, V Goulding 1, D Wilkinson 1, KG Mercer 1

Introduction

The standards and audit measures of The Renal Association recommend that functioning native arteriovenous fistulae should be used for 67% of patients commencing haemodialysis within 3 months of presentation, and 80% of prevalent patients. The aim of this study was to define the role of pre-, peri-, and postoperative factors in predicting fistula patency, which is a key determinant of adequate native arteriovenous fistula provision.

Patients and Methods

Pre-operative (sex, race, dialysis status, vessel diameter), perioperative (anaesthetic technique, completion thrill/pulse) and postoperative (Duplex) factors were recorded for 90 consecutive native radiocephalic fistulae constructed in 81 patients. Fistula patency and use were determined by interrogation of the haemodialysis database. All imaging and interventions were identified through the multidisciplinary meeting. Median follow-up was 271 days (i.q.r. 134–521 days). Primary and secondary patency Kaplan-Meier survival curves were analysed and compared using Mantel-Cox log rank.

Results

Primary patency rates were increased with pre-dialysis versus haemodialysis (P = 0.045), presence of postoperative thrill (P < 0.001) and efferent vein flow volumes > 400 ml/min on postoperative Duplex (P < 0.001). Secondary patency rates were increased with: pre-dialysis versus haemodialysis (P = 0.001), presence of postoperative thrill (P < 0.001) and efferent vein flow volumes > 400 ml/min on postoperative Duplex (P = 0.001). Patency of fistulae created using smaller diameter veins (< 2.5 mm) was not compromised.

Conclusions

Small calibre veins should not adversely affect the decision to perform a wrist fistula. However, fistulae without a palpable thrill at completion should be critically evaluated and on-table revision considered. Low flow volumes at postoperative Duplex predict poorer secondary patency and may be an indication for more vigorous intervention. Longer term follow-up of pre-dialysis patients is required to assess the impact of commencing dialysis on fistula patency.

Ann R Coll Surg Engl. 2007 Mar;89(2):183. doi: 10.1308/003588407X155554

Imprint Cytology – The Best of Both Worlds?

T Irvine 1, D Kulkarni 1, R Reyes 1

Introduction

The ‘one-stop’ breast clinic involves clinical, radiological and pathology assessment on the same day. Imprint cytology of the core biopsy specimen has the potential of offering same-day cytology result, and core sample increases accuracy and allows ER/PR status evaluation. This avoids multiple procedures before surgery and multiple out-patient visits. The aim of this study was to evaluate the role of imprint cytology in a district general hospital setting, and to create a sound evidence-base for practice.

Patients and Methods

This was a retrospective analysis of prospectively collected data using the pathology database and case notes over a period of 5 years (2000–2005). A core biopsy with the hand-held gun was performed for all breast patients requiring histological diagnosis, either image-guided or free-hand. The core biopsy tissue was immediately rolled on a glass slide to give a same-day cytology result. The cytology and histology specimens were analysed separately and the results compared.

Results

A total of 819 consecutive patients had imprint cytology of the core biopsy specimen. Adequate cellularity was found in 94.8% (778/819) samples. Out of these 778 lesions analysed, 432 were malignant (55.5%). The sensitivity, specificity, positive predictive value, negative predictive value and concordance were 97.7%, 94.2%, 93.1%, 98.1 % and 95.5%, respectively.

Conclusions

Imprint cytology is a simple technique which allows accurate diagnosis in the ‘one-stop’ setting with the extra histological information available from core biopsies. This reduces the number of invasive procedures, minimises diagnostic waiting times, and reduces the number of out-patient visits.

Ann R Coll Surg Engl. 2007 Mar;89(2):183–184. doi: 10.1308/003588407X155554

DNAs: Can We Make a Difference?

AMP Schizas 1, L Corfield 1, AB Williams 1

Introduction

Non-attendance in the out-patient department has substantial financial costs for the NHS and clinical implications to the non-attender and those awaiting an appointment. The aim of this audit was to quantify the percentage of non-attenders at colorectal clinics in a UK teaching hospital, assess which factors affected attendance, establish why individuals fall to attend, implement appropriate change and to complete the audit cycle by re-examining the non-attendance rate.

Patients and Methods

Initially, 686 appointments were studied. The number of ‘did not attends’ (DNAs) was recorded as were various variables such as the day of the week, time of day, weather conditions, sex and age of patients. Questionnaires were then sent to patients who did not attend asking why this was so. Those who did not return the questionnaire were contacted by telephone and asked the same questions. The study was then repeated following telephone reminders to 391 patients due to attend clinic, The DNA rates in the two limbs of the completed audit cycle were then compared.

Results

The initial study revealed a DNA rate of 21%, with significantly more males than females failing to attend (M = 28.6%, F = 16.9%; P = 0.001). The DNA rate was not significantly affected by the day of the week, time of appointment or by the weather. Of non-attenders, 32% responded to the postal questionnaire. Telephoning the remainder produced a 29% response rate: there was a 51.7% overall response rate. Of those that did reply, 27.7% did not receive an appointment letter or received it after the appointment. Only 18.4% had tried to cancel their appointments unsuccessfully. Hospital administration problems were cited as accounting for 34.2% of DNAs. When asked what would make patients more likely to attend, 22.4% were in favour of a telephone-call reminder. In the post-intervention limb, 87 patients (22%) replied to the reminder telephone call, 9 (10%) cancelled their appointment and 78 (90%) confirmed that they would attend. No telephone number was available for 25% of the patients. The DNA rate fell to 19.7% although this was not a significant reduction.

Conclusions

Telephoning patients before their appointments is labour-intensive and did not improve the DNA rate. A high percentage of patients are not contactable by telephone and it is likely that these are the individuals who will not attend. Although hospital administration errors account for a significant number of the DNAs, patients have a responsibility to attend or to notify the hospital if they are unable to do so and to inform of any change of contact details.

Ann R Coll Surg Engl. 2007 Mar;89(2):184. doi: 10.1308/003588407X155554

Incidence of Upper Gastrointestinal Cancers in East Kent

TE Rix 1, SAL Gibbs 1

Introduction

East Kent NHS Trust serves a population of 620,000 people. Upper gastrointestinal (UGI) cancer services are provided by one UGI surgeon supported by a multidisciplinary meeting. Approximately 3 new cases of stomach and oesophageal cancer are discussed each week. This is in line with national incidences, which also show a shift in incidence from stomach to oesophageal cancer. Romney Marsh is a sparsely-populated area of south-east Kent. In 2 years, 8 patients from one village on Romney Marsh presented for oesophageal cancer surgery. The aim of this study was to calculate the incidences of UGI cancer in Romney Marsh and East Kent and to compare these with national figures.

Patients and Methods

Pathology data from 2003–2005 were retrieved for all patients with biopsy or resection evidence of UGI cancer. The frequency of each pathology was measured, together with data on patients' age, sex and postcode. Population data were obtained from the 2001 census and used to calculate incidences.

Results

A total of 421 patients had histologically confirmed UGI cancers during this time period of which 62% were oesophageal cancers and 25% stomach cancers. Median age of patients was 72 years, and 70% were male. Of oesophageal cancers, 82% were adenocarcinomas in men, while in women, squamous-cell carcinoma was commonest (59%). The incidence of each cancer (per 100,000 people per annum) is shown in Table 1. Twenty-two patients came from Romney Marsh of whom 19 had oesophageal cancers, with a relative incidence of 2 compared to the whole region. One village had a relative incidence of 3.2 for oesophageal cancer. There were no apparent reasons for these findings.

Table 1.

Incidence of each cancer (per 100,000 people

Romney Marsh East Kent National figures
Stomach 4.8 8.9 15.5
Oesophagus 30.5 15.3 12.7
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Discussion

Adenocarcinoma of the oesophagus is a commoner disease in East Kent than nationally. Stomach cancer is less common. This effect is most pronounced in a rural area of Kent where there has been a cluster of recent oesophageal cancer cases. In women, the shift from squamous-cell carcinoma to adenocarcinoma of the oesophagus is happening less than in men. These findings may provide clues about why there is a rising incidence of oesophageal adenocarcinoma in this country.

Ann R Coll Surg Engl. 2007 Mar;89(2):184–185. doi: 10.1308/003588407X155554

A Randomised Controlled Trial of the Use of a Tourniquet to Reduce Blood Loss During Transtibial Amputation for Peripheral Arterial Disease

SA Choksy 1, P Lee Chong 1, C Smith 1, M Ireland 1, J Beard 1

Introduction

The aim of this study was to examine the effects of an exsanguination tourniquet on blood loss during transtibial amputation in patients with peripheral arterial disease (PAD) as a prospective, randomised, blinded, controlled trial.

Patients and Methods

A total of 64 patients undergoing transtibial amputation for non-reconstructible PAD were randomised to either tourniquet or no tourniquet (control) groups. Blood loss (primary outcome), fall in haemoglobin, transfusion requirements, wound healing, breakdown and revision (secondary outcomes) were also recorded.

Results

Twenty-five patients in the tourniquet group and 29 in the control group conformed to the trial protocol and completed the follow-up. Intra-operative blood loss (median and IQR) was significantly greater in the control group compared to the tourniquet group, respectively (550 ml [255–1050 ml] versus 255 ml [150-572.5 ml], P = 0.014, Mann Whitney). There was a significantly greater drop in haemoglobin concentration (median and IQR) in the control compared to the tourniquet group (1.8 g/dl [0–1.2 g/dl] versus 1.0 g/dl [0.6–2.4 g/dl], P = 0.035, t-test). Transfusion requirements were lower in the tourniquet group (P = 0.05, Mann Whitney). The rate of wound healing, breakdown and revision were similar in the tourniquet and control groups, respectively (59% versus 57%, 0% versus 9%,14% versus 9%, P = NS).

Conclusions

The use of a tourniquet during transtibial amputation for severe PAD reduces blood loss and need for blood transfusion.

Ann R Coll Surg Engl. 2007 Mar;89(2):185. doi: 10.1308/003588407X155554

Surgical Treatment of Primary Hyperparathyroidism: A Change in Practice

Jonathan RA Phillips 1, CS Ubhi 1

Introduction

The traditional surgical treatment for primary hyperparathyroidism has been bilateral exploration of the neck with the identification of all the parathyroid glands and removal of all abnormal glands. The introduction of Sestamibi scintigraphy and advances in ultrasonography has enabled pre-operative localisation of parathyroid adenomas, allowing targeted unilateral surgery to be performed. Localisation techniques were slowly introduced into our practice in 2003 so we have retrospectively reviewed our practice between January 2002 and January 2006. The pre-operative investigations were compared with the operative findings to determine the accuracy of Sestamibi and ultrasound in localising parathyroid adenomas.

Results

Eighty-six patients had parathyroid adenomas removed at operation and of these 77 patients had Sestamibi and 47 had ultrasound scans performed pre-operatively. Both Sestamibi and ultrasound scans were performed in 44 patients. Sestamibi alone was 79% accurate and ultrasound alone was 72% accurate in localising the correct side of the parathyroid adenoma. Ultrasound scans had 6.4% false positive rate (n = 3), i.e. localised the adenoma to the wrong side. Sestamibi and ultrasound scans were concordant in 26 patients with 100% localisation of adenomas to the same side.

Conclusions

These findings have now changed the practise at our unit to targeted, single-sided exploration in surgery for parathyroid adenomas in patients who have concordant Sestamibi and ultrasound scans.

Ann R Coll Surg Engl. 2007 Mar;89(2):185–186. doi: 10.1308/003588407X155554

Choices in Cancer Treatment: A Qualitative Study of the Older Women's (> 70 Years) Perspective

Lopa Husain 1, MWB Reed 1, K Collins 1, Lynda Wyld 1

Introduction

Primary endocrine therapy (PET) is the treatment of primary, operable breast cancer with the drug tamoxifen, omitting surgery altogether. It is in wide-spread use in the UK with 55% of over 80-year-olds (Monypenny I) and 40% of over 70-year-olds (Wyld L) being treated in this way. Despite this wide-spread use, PET is associated with inferior local control rates compared to standard surgical therapies (Mustacchi et al.). However, PET appears to carry no detriment in terms of survival (Hind D). Many women need to have a change of therapy after a few years of PET treatment, either with an alternate anti-oestrogen or with surgery. There has been no research on what older women think about these two types of treatment (surgery or PET) in terms of which they prefer and what may influence their preference and decision making. This study aims to address this deficiency.

Patients and Methods

In-depth qualitative interviews were undertaken to explore the views of a small group of purposively selected older women (> 70 years old). Twenty-one women, who had been treated by PET or surgery for their breast cancer, were recruited from a follow-up clinic at the Royal Hallamshire Hospital, Sheffield. The interviews were transcribed verbatim and analysed using Framework Analysis (Ritchie + Lewis).

Results

Some common themes were identified. These women's concerns for spread and recurrence of their disease appeared to override their concerns for any particular type of treatment. They had no age-specific fears for undergoing operative procedures. Their social circumstances did not play a part in any treatment decisions. Many were happy to be passive information seekers and did not question nor clarify information given. Much of the information was either forgotten or interpreted subjectively. They relied heavily on ‘expert’ advice and were grateful regardless of outcome.

Conclusions

It is important for medical professionals to ensure that their consultations with older women are adapted to reflect the passive acceptance of expert advice in this age group. The perception that a treatment choice has been offered may not be appreciated nor understood by older women. For older women, we need to be aware that their concerns are not necessarily related to the degree of medical intervention but rather to ensuring that their quality of life remains unaffected. We need to ensure that these women understand the long-term implications of their treatment choices, especially as many of them may not voice their concerns. Many of them may think they have little time left but in an ageing population, quality of life is an important factor in disease management across all surgical specialties.

Articles from Annals of The Royal College of Surgeons of England are provided here courtesy of The Royal College of Surgeons of England

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