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Annals of The Royal College of Surgeons of England logoLink to Annals of The Royal College of Surgeons of England
. 2008 May;90(4):352–355. doi: 10.1308/003588408X300920

Publication of Abstracts from the Best Regional Presentations

Editor: Linda de Cossart
PMCID: PMC2647223
Ann R Coll Surg Engl. 2008 May;90(4):352. doi: 10.1308/003588408X300920

Endovenous Laser Ablation of the Long Saphenous Vein Without Adjuvant Sclerotherapy

C Moffat 1, NC Hickey 1

Introduction

The objective of this work was to evaluate whether endovenous laser ablation (EVLA) of the long saphenous vein (LSV) could successfully treat varicose veins without adjuvant sclerotherapy.

Patients and Methods

A prospective audit of patients presenting to a single surgeon over 1 year. All were assessed by duplex ultrasound. Those with LSV incompetence were offered EVLA, surgery or foam sclerotherapy. EVLA was performed with an 810-nm laser, continuous 14 W power delivering 50–70 J/cm of vein. All the incompetent LSVs were treated, starting distally to the last varicosity.

Results

EVLA was attempted in 113 legs (96 patients, 17 bilateral) and completed in 111. A median of 46 cm (range, 20–60 cm) of LSV was treated at 58 J/cm (range, 41–75 J/cm). Overall, 110 LSVs were successfully obliterated at 6 weeks. There were no serious complications. Subsequent foam sclerotherapy was required in 9 legs (10.8%), 4 due to perforator or SSV incompetence and 5 (4.5%) for failure of LSV-related varicosities to shrink to the patient's satisfaction. All other varicosities shrank painlessly, without thrombophlebitis.

Conclusions

Patient selection combined with care to obliterate LSV incompetence completely (to below the final tributary) allow EVLA alone to treat over 95% of LSV-related varicose veins successfully without adjuvant sclerotherapy.

Ann R Coll Surg Engl. 2008 May;90(4):352–353. doi: 10.1308/003588408X300920

Skin-Reducing Mastectomy and Immediate Implant Reconstruction

P Buxton 1, P Matey 1

Introduction

Skin-reducing mastectomy (SRM) is a relatively uncommon procedure in the UK. The mastectomy is performed via a mammoplasty incision allowing all breast tissue to be excised and immediate prosthetic breast reconstruction. There is better coverage of implant with pectoralis major and de-epithelised skin flap, producing a better cosmetic outcome and decreases the risk of implant loss.1 We present our experience of this procedure over the last year.

Patients and Methods

Prospective data were collected from January 2006 to January 2007 on 19 women requiring mastectomy who underwent a SRM + ALNC followed by adjuvant therapy. All women were followed up and end-points looked at were cosmetic outcome, complications (capsular contracture, loss of implant) and recurrence.

Results

The mean age was 45.05 years (range, 22–68 years). There were 8 right, 8 left and 3 bilateral SRMs performed. Thirteen patients required chemotherapy as per local protocol (2 neoadjuvant); 11 women received adjuvant DXR and 2 had had previous DXR prior to surgery (1 for Hodgkin's lymphoma in 1990, 1 previous WLE). No local recurrences were reported. As complications, there were four seromas and two grade 1/2 capsular contractures. No implant loss was recorded. Cosmetic outcome was very good to excellent in 21% of patients, good in 79% with no poor results.

Conclusions

Long-term follow-up is required to assess recurrence rates and cosmetic outcomes, but we feel that this technique is a safe and reliable addition to any oncoplastic service.

Reference

  • 1.Hammond DC. Use of a skin-sparing reduction pattern to create a combination skin-muscle flap pocket in immediate breast reconstruction. Plast Reconstr Surg. 2002;110:206–11. doi: 10.1097/00006534-200207000-00035. [DOI] [PubMed] [Google Scholar]
Ann R Coll Surg Engl. 2008 May;90(4):353. doi: 10.1308/003588408X300920

Deregulated Iron Metabolism in Oesophageal Carcinogenesis

K Roberts 1, J Boult 1, M Brookes 1, T Iqbal 1, R Spychal 1, C Tselepis 1

Introduction

There is accumulating evidence implicating iron with oesophageal adenocarcinoma, though cellular mechanisms underlying this are unclear. This study investigated expression of iron transport proteins in oesophageal carcinogenesis and the effect of iron on oesophageal cell models.

Patients and Methods

mRNA expression in samples of Barrett's metaplasia matched with oesophageal adenocarcinoma and samples of Barrett's metaplasia without adenocarcinoma were examined by Q-RT-PCR. Immunohistochemistry was used to examine localisation and protein levels. Oesophageal cell lines OE33 and SEG-1 were cultured in iron and the effect on cellular migration, proliferation and anchorage-independent growth determined.

Results

We clearly demonstrated that, in the progression of Barrett's metaplasia to adenocarcinoma, there was an over-expression of DMT1, TfR1, DCYTB, ferroportin and Hferritin, and these changes were associated with increased iron deposition. Overexpression of DMT1 was further associated with metastatic adenocarcinoma. Iron loading of OE33 and SEG-1 cells mediated repression in TfR1 and DMT1 mRNA and increased ferritin protein expression. Furthermore, iron loading increased cellular proliferation, migration and anchorage-independent growth indicative of an aggressive phenotype.

Conclusions

Progression to adenocarcinoma is associated with a modulation in the expression of iron transport proteins. This increases intracellular iron load and may exacerbate carcinogenesis.

Ann R Coll Surg Engl. 2008 May;90(4):353–354. doi: 10.1308/003588408X300920

Pancreatic Cancer: Using the CA19.9 Tumour Marker to Stratify the Rational Use of Laparoscopic Assessment of Resectability

Christopher Halloran 1, Paula Ghaneh 1, Robert Sutton 1, John Neoptolemos 1, Michael Raraty 1

Introduction

Pancreatic cancer is a major cause of cancer-related mortality in the Western world. Despite the traditional concept of futility, current survival is around 20% at 5 years with appropriate surgery and adjuvant chemotherapy. Laparoscopy and laparoscopic ultrasound (L-LUS) are potentially useful in the selection of patients for surgery to resect peripancreatic malignancy, over and above contrast-enhanced CT (CE-CT). We suggest that CA19.9 levels should be used to select patients for L-LUS, and have assessed this strategy prospectively.

Patients and Methods

Data were collected prospectively (1997–2006) from patients referred to the Supra-Regional Pancreatic Service at the Royal Liverpool University Hospital from June 2004 up to December 2006. Patients with suspected peripancreatic malignancy that was resectable on CE-CT were selected to proceed straight to surgery if CA19.9 was low (≤ 150 kU/l or ≤ 300 kU/l if serum bilirubin was > 35 μmol/l), or to L-LUS if CA19.9 was high (> 150 kU/l or > 300 kU/l if serum bilirubin was > 35 μmol/l). Data were compiled to examine the clinical utility of this strategy.

Table 1.

Patient demographics

Total number of referred patients 497
Patients with CE-CT and CA19.9 336
Patients undergoing resection 164
Median age in years (range) 67 (27–96)
M:F ratio 165:171
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Results

Ninety-four patients went straight to surgery, of whom 65 proved resectable; 63 out of 80 with low CA19.9 (79%) but only 2 out of 14 with high CA19.9 and gastric outlet obstruction (14%). Fifty-five patients with high CA19.9 had L-LUS, which correctly identified 26 out of 31 resectable cases (84%) and 8 out of 24 unresectable cases (33%); P < 0.0001.

Conclusions

Selecting patients with CE-CT resectable pancreatic malignancy for immediate surgery or L-LUS depending on CA19.9 levels is an effective method of increasing the yield while reducing the number of laparoscopies, as well as increasing resection rates and decreasing unnecessary laparotomies.

Ann R Coll Surg Engl. 2008 May;90(4):354. doi: 10.1308/003588408X300920

The Apical Node: Time for a Change in Policy?

EM Tweedle 1, F Campbell 1, PS Carter 1, PS Rooney 1

Introduction

Malignant infiltration of the apical node (ApN) has a poor prognosis compared to other Dukes' C tumours. Curative resection and conventional adjuvant chemotherapy is the recommended management, yet the benefits in this patient group remain unproven. We compared 5-year survival of three groups: (i) N2 (≥ 4 positive nodes); (ii) apical node metastases; and (iii) distant metastases at diagnosis in order to see the affect of current treatment.

Patients and Methods

We analysed 561 patients who underwent resection of colorectal cancer between 1999 and 2003. Patients with positive resection margins, 83 of 561 (15%), were excluded. Patients were grouped into ApN positive (M0/ApN+), ApN negative with N2 disease (N2/M0/ApN−) or distant metastases (M+). The presence of distant metastases was confirmed from staging investigations or exploratory laparotomy. Survival data were obtained from hospital records and Statview was used for analysis.

Results

The M:F ratio was 4:3, and mean age 71 years (range, 34–93 years). N stage was as follows: N0, 275 of 478 (58%); N1, 130 of 478 (27%); and N2, 73 of 478 (15%). The ApN was positive in 26 cases, 6 N1 and 20 N2 tumours. Thirty patients had distant metastases including 8 ApN+, 10 N2/ApN, 7 N1/ApN−and 5 N0 patients. Median survival for the ApN+ group was 24 months compared to 37 months for the N2/ApN− patients (P = 0.02, Mantel-Cox), and 16 months for the patients with metastases (P = 0.171, Mantel-Cox).

Table 1.

Summary of results

Status Patient (n) Median survival (months) 5-year survival P-value (Mantel-Cox)
N2/ApN+ 18 24 11% –
N2/ApN− 43 37 49% 0.02
M+ 30 16 6% 0.17
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*

Compared to survival for N2/ApN+ patients (Mantel-Cox).

Conclusions

Patients with ApN+ have a significantly poorer survival than N2 patients and a similar prognosis to patients with metastases at diagnosis. Conventional adjuvant therapy in this patient group does not appear to modify the dismal prognosis. New approaches to adjuvant therapy should be considered for apical node positive patients.

Ann R Coll Surg Engl. 2008 May;90(4):354–355. doi: 10.1308/003588408X300920

The Prognostic Relevance of ‘Equivocal’ Resection Margins in Peri-Ampullary Cancer

G Powell 1, J Tang 1, R Smith 1, L Bosonnet 1, G Campbell 1, M Raraty 1, R Sutton 1, JP Neoptolemos 1, P Ghaneh 1

Introduction

Microscopic resection margin status (i.e. R0 versus R1 resection) is an important survival determinant following pancreatoduodenectomy (PD) for peri-ampullary cancer. Equivocal R1 cases exist with evidence of tumour extension within 1 mm of (but not breaching) a resection margin. Royal College of Pathologists guidelines recommend that these R1a resections should be considered synonymous with margin positive cases (R1b) but there is a lack of objective evidence for this recommendation.

Patients and Methods

Clinical and pathological data were retrieved from a prospectively maintained database. A total of 236 consecutive patients with histologically confirmed peri-ampullary adenocarcinoma underwent PD over a 10-year period. No R2 resections were included in this patient group.

Results

Of the 236 resected peri-ampullary cancers, 150 (63.6%) were R1 resections of which 54 were R1a and 96 were R1b. There was no significant difference in median survival between R1a resections and R1b resections in pancreatic ductal adenocarcinoma (PDAC) patients (15.4 versus 12.6 months, respectively; log rank, P = 0.376). Similar findings were identified for ampullary and intrapancreatic bile duct adenocarcinoma (P = 0.291 and 0.941, respectively). Both R1a and R1b cases were grouped together for subsequent analyses. When considering only PDAC cases with an R1 resection (n = 91), an involved pancreatic transection margin was found to confer a poorer survival outcome when compared with other involved margins (log rank, P = 0.036). As the number of involved margins in a single specimen increased, a trend towards poorer survival was exhibited (Cox, P = 0.045). Logistic regression demonstrated that increasing tumour size (P < 0.001), poor tumour differentiation (P = 0.005) and nodal status (P = 0.013) were all associated with an increased likelihood of an R1 resection for PDAC cases.

Conclusions

The findings from this study support the Royal College of Pathologists recommendations for classifying resection margin involvement in peri-ampullary cancer. The results highlight the importance of standardised criteria for histopathology reporting when comparing the outcomes of surgery between individual centres.

Ann R Coll Surg Engl. 2008 May;90(4):355. doi: 10.1308/003588408X300920

Quality of Life Analysis in Patients with Lower Limb Ischaemia: Revised Suggestions for European Standardisation

PA Coughlin, S Gulati, MNA Rahman, J Hatfield, PT McCollum, IC Chetter

Introduction

Generic quality of life (QoL) is a crucial outcome measure in patients with lower limb ischaemia (LLI) with the Short Form 36 (SF36) accepted as the ‘gold standard’ instrument. We aimed to assess whether the new, shorter, simplified Short Form 8 (SF8) is sufficiently responsive to replace SF36 in LLI.

Patients and Methods

A total of 193 patients, 135 men and 58 women, median age 66 years (range, 44–84 years) with LLI completed the SF36 and SF8. Patients were graded according to ISCVS suggested reporting standards (30 mild, 52 moderate, 73 severe claudicants; 16 rest pain and 21 tissue loss). Validity was determined using convergent–divergent and validity. Reliability was assessed using test–retest reliability in a subgroup of 60 patients. Responsiveness between severity of LLI was analysed with non-parametric statistical tests.

Results

Convergent–divergent validity: there was greater correlation between like domains of SF36 and the SF8 (0.594–0.792; P = 0.000) than the non-like domains suggesting good convergent–divergent validity.

Reliability: both the QoL instruments were significantly reliable (rs > 0.7).

Responsiveness: increasing LLI resulted in a statistically significant deterioration in all eight domains of both SF8 and SF36 (P < 0.05; Kruskal–Wallis ANOVA). The SF8 demonstrated similar responsiveness as the SF36 between varying grades of LLI.

The median time taken to complete the SF8 and SF36 was 2.5 min (range, 1.5–3.5 min) and 11 min (range, 8–20 min), respectively (P = 0.000). Of patients, 27% required assistance to complete the SF36 questionnaire as they found some questions confusing whereas none of the patient required assistance in completing the SF8 questionnaire (P = 0.001).

Conclusions

The SF8 is a valid and reliable generic QoL instrument in patients with LLI. It demonstrates similar responsiveness as the SF36 in these patients and as it is simpler, quicker to complete, analyse and score. We suggest SF8 replaces SF36 as the gold standard generic QoL analysis instrument in LLI.

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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