Showing papers by "Guy J. Maddern published in 2002"

A systematic review of stapled hemorrhoidectomy.

Abstract: Hypothesis Use of circular stapled hemorrhoidectomy will result in the same or improved safety and efficacy outcomes as those of the conventional methods for hemorrhoidectomy in patients with hemorrhoids. Data Sources Studies on stapled hemorrhoidectomy were identified using PREMEDLINE and MEDLINE (June 1966–June 2001), EMBASE (January 1980–June 2001), Current Contents (June 1993–June 2001), Ovid HEALTHSTAR (January 1975–June 2001), the National Institutes of Health Clinical Trials database (searched June 13, 2001), and The National Coordinating Centre for Health Technology Assessment database (searched June 14, 2001). The search terms were as follows: haemorrhoid * and ( stapl * or convent *) or hemorrhoid * and ( stapl * or convent *). The Cochrane Library (2001, issue 2) was searched using the search terms haemorrhoid * or hemorrhoid *. Study Selection Articles detailing randomized controlled trials were included if they compared circular stapled with conventional hemorrhoidectomy and provided relevant safety and efficacy outcome information. Data Extraction Data from all included studies were extracted using standardized data extraction tables that were developed a priori. In addition, the randomized controlled trials were examined with respect to the adequacy of allocation concealment, handling of those unavailable for follow-up, and any other aspect of the study design or execution that may have introduced bias. Data Synthesis Seven randomized controlled trials met the inclusion criteria. A meta-analysis was conducted when the studies had comparable outcomes, inclusion criteria, and follow-up. There was reasonably clear evidence in favor of the stapled procedure for bleeding at 2 weeks (relative risk, 0.55; 95% confidence interval, 0.37-0.82) and length of hospital stay (weighted mean difference, −0.89 days; 95% confidence interval, −1.42 to −0.36). Other less robust results in favor of the stapled hemorrhoidectomy related to pain, bleeding, anal discharge, wound healing, tenderness to per rectal examination, incontinence scores, earlier return of bowel function, analgesic requirement, and resumption of normal activities. One trial showed that prolapse occurred at significantly higher rates in the stapled hemorrhoidectomy group. However, the outcomes were poorly reported and generally showed statistically significant heterogeneity. Conclusions Stapled hemorrhoidectomy may be at least as safe as conventional hemorrhoidal surgical techniques. However, the efficacy of the stapled procedure compared with the conventional techniques could not be determined. More rigorous studies with longer follow-up periods and larger sample sizes need to be conducted.

The mystery of liver regeneration

Abstract: Background: Partial hepatectomy is the strongest stimulator of hepatic regeneration. The process of initiation and the control of the final size of the regenerated liver have been the subject of research for many years. A better understanding of this process and the effect of disease may allow better selection of patients for partial hepatectomy. It may also allow an insight into the possible application of clinical stimulation of regeneration. Methods: Data were reviewed from the published literature using the Medline database. Results: Most knowledge comes from in vitro studies and the study of resection in the rat model. A variety of cytokines, hormones and growth factors are involved in regeneration but very few have been found capable of stimulating regeneration in vitro. The exact interactions are not known, but there is probably a cascade involving different factors at differing stages of regeneration. Conclusion: Further in vivo research should allow greater understanding of liver regeneration, thereby providing a potential therapeutic tool in patients for whom regeneration has failed, or is likely to fail. Such research is also important in respect of liver support devices, which may inhibit liver regeneration by filtration of many of the factors involved. © 2002 British Journal of Surgery Society Ltd

Systematic review of dynamic graciloplasty in the treatment of faecal incontinence

Abstract: Background: The aim of this systematic review was to compare the safety and efficacy of dynamic graciloplasty with colostomy for the treatment of faecal incontinence. Methods: Two search strategies were devised to retrieve literature from the Medline, Current Contents, Embase and Cochrane Library databases up until November 1999. Inclusion of papers depended on a predetermined protocol, independent assessments by two reviewers and a final consensus decision. English language papers were selected. Acceptable study designs included randomized controlled trials, controlled clinical trials and case series. Forty papers met the inclusion criteria. They were tabulated and critically appraised in terms of methodology and design, outcomes, and the possible influence of bias, confounding and chance. Results: No high-level evidence was available and there were no comparative studies. Mortality rates were around 2 per cent for both graciloplasty and colostomy. Morbidity rates reported for graciloplasty appear to be higher than those for colostomy. Dynamic graciloplasty was clearly effective at restoring continence in between 42 and 85 per cent of patients, whereas colostomy is, by its design, incapable of restoring continence. However, dynamic graciloplasty is associated with a significant risk of reoperation. Conclusion: While dynamic graciloplasty appears to be associated with a higher rate of complications than colostomy, it is clearly a superior intervention for restoring continence in some patients. It is recommended that a comparative, but non-randomized, study be undertaken to evaluate the safety of dynamic graciloplasty in comparison to colostomy, and that the procedure should be performed only in centres where it is carried out routinely. © 2002 British Journal of Surgery Society Ltd

Management of thoracic duct injuries after oesophagectomy

Abstract: Background: Thoracic duct laceration is a rare but potentially life-threatening complication of oesophagectomy. The management of such an injury is uncertain in respect of the relative merits of conservative and surgical treatment. Methods: The literature was reviewed by searching Medline databases from 1966 to the present time. The majority of the evidence presented is level 3, as no randomized or controlled data are available. Results: Prolonged conservative treatment of thoracic duct injury is associated with a mortality rate of 50–82 per cent. The results of early surgical ligation of the duct are more encouraging, with a mortality rate of 10–16 per cent. Elective ligation of the duct reduces the incidence of postoperative chylothorax. Conclusion: The thoracic duct should be ligated during oesophagectomy. A high index of suspicion for duct injury must be maintained in all patients after operation. A policy of very early thoracic duct ligation at 48 h from diagnosis is proposed for duct injury if aggressive conservative management fails. © 2001 British Journal of Surgery Society Ltd

Treatment of non-resectable hepatocellular carcinoma with autologous tumor-pulsed dendritic cells

Abstract: Background: The response of hepatocellular carcinoma (HCC) to therapy is often disappointing and new modalities of treatment are clearly needed. Active immunotherapy based on the injection of autologous dendritic cells (DC) co-cultured ex vivo with tumor antigens has been used in pilot studies in various malignancies such as melanoma and lymphoma with encouraging results. Methods: In the present paper, the preparation and exposure of patient DC to autologous HCC antigens and re-injection in an attempt to elicit antitumor immune responses are described. Results: Therapy was given to two patients, one with hepatitis C and one with hepatitis B, who had large, multiple HCC and for whom no other therapy was available. No significant side-effects were observed. The clinical course was unchanged in one patient, who died a few months later. The other patient, whose initial prognosis was considered poor, is still alive and well more than 3 years later with evidence of slowing of tumor growth based on organ imaging. Conclusions: It is concluded that HCC may be a malignancy worthy of DC trials and sufficient details in the present paper are given for the protocol to be copied or modified. (C) 2002 Blackwell Publishing Asia Pty Ltd.

A systematic review of tension-free urethropexy for stress urinary incontinence: intravaginal slingplasty and the tension-free vaginal tape procedures.

Abstract: I would like to comment on this review [1] about both ethical and factual issues. This review comprises two different procedures, using different materials [2] and a different surgical approach. Most of the cited data are related to the tension-free vaginal tape (TVT) procedure. Although these data are of limited quality, it at least originates from many different sources, some of them unlikely to be subject to assessment bias. The data on the intravaginal slingplasty (IVS) procedure are exclusively derived from personal case-series of one surgeon, incidentally the protocol surgeon of this review. The protocol surgeon has had commercial interests in the manufacture, the marketing and the distribution of the IVS tape, and in the education of potential users of the device. I feel that there is no basis for an unbiased, balanced scientific review of efficacy and safety of the IVS procedure at present. As a result, it is probably inappropriate to review TVT and IVS jointly. I also consider that, as a matter of general principle, clinical research should be conducted by somebody who has no financial interest in the outcome of the research in question, because of the likelihood of bias. Even more importantly, reviews of available evidence, especially when commercially sensitive topics such as safety and efficacy are concerned, should not be undertaken by anybody with a strong bias or a financial interest. It is regrettable that the Australian Safety and Efficacy Register of New Interventional Procedures-Surgical did not share these views. The authors state in the Conclusions that ‘The Council of RACS endorsed the level 2 safety and efficacy classification allocated to the two tension-free urethropexy procedures’ with appendix 1 explaining that this means that ‘The safety and/or efficacy of the procedure cannot be determined at present’. This was a reasonable conclusion to draw from the available evidence at the time. However, the process through which this conclusion was reached appears to be seriously flawed.

Islet yield remains a problem in islet autotransplantation.

Abstract: For patients with chronic pancreatitis whose pain is inadequately controlled with opiate analgesia, surgical resection offers a good chance of symptomatic relief. However, the inevitable sequela is type 1 diabetes mellitus and its attendant long-term complications. Islet cell autotransplantation offers a theoretical "cure" for this iatrogenic diabetes but this end point has not been produced consistently in clinical practice. The main factor determining the likelihood of insulin independence after islet autotransplantation is the islet mass that is transplanted. This review examines the factors that affect the functional islet mass available for transplantation. Original articles and reviews from peer-reviewed journals were analyzed following a computer search of the MEDLINE database from 1966 to the present, we extracted mainly level 2 and level 3 data. Although improvements in collagenase consistency and purification techniques and reductions in cold ischemic times have all been shown to improve islet yield, there is still the need to optimize every stage in the islet isolation process. Increasing the proportion of potential islets in the final isolate is of particular importance in chronic pancreatitis because the total mass of islets initially available in the gland might be just sufficient to produce insulin independence after islet autotransplantation. We believe that reducing the warm ischemic time might significantly increase the likelihood of insulin independence after islet autotransplantation.

Use of electrolysis as an adjunct to liver resection

Abstract: Background: Patients with hepatic metastases are potentially curable if all the diseased tissue can be resected. Unfortunately, only 10–20 per cent of patients are suitable for curative resection. Electrolysis is a novel non-thermal method of tissue ablation. When used in conjunction with surgery it may increase the number of resectable liver tumours with curative treatment. Methods: All patients had been deemed inoperable using currently accepted criteria. Nine patients with hepatic deposits from colorectal carcinoma underwent combined surgical resection and electrolytic ablation of metastases. Results: The treatment was associated with minimal morbidity. Within the electrolytically treated area seven patients had no radiological evidence of recurrence at a median follow-up of 9 (range 6–43) months; local recurrence was detected in two patients. Six of the nine patients had metastases elsewhere in the liver with four having extrahepatic metastases. Three patients remain tumour free. Three patients died. The median survival was 17 (range 9–24) months from the time of treatment. Discussion: Electrolysis with resection may confer a disease-free and overall survival benefit. The small size of this initial study precludes statistical analysis, but preliminary results are encouraging. © 2002 British Journal of Surgery Society Ltd

Systematic review of beating heart surgery with the Octopus® Tissue Stabilizer

Abstract: The safety and efficacy of off-pump coronary artery bypass surgery with the aid of the Octopus Tissue Stabilizer (Octopus OPCAB), in comparison to conventional on-pump coronary artery bypass surgery (CPB-CABG), was examined by a systematic assessment of the peer-reviewed literature. The limited comparative data suggested that there was no difference in safety outcomes between Octopus OPCAB and CPB-CABG. The paucity of efficacy data reported in the higher level comparative studies meant that it was impossible to assess whether Octopus OPCAB was more efficacious than CPB-CABG. The evidence base for the procedure was deemed inadequate and an audit of the procedure was recommended.

Electrolytic ablation as an adjunct to liver resection: experimental studies of predictability and safety.

Abstract: Background: Combined liver resection and local ablation may offer the only chance of cure to patients with liver metastases who are presently deemed unresectable because of a single awkwardly placed metastasis. By definition, such a metastasis is often close to a major vein. An ablative technique is needed that is both predictable and safe in such a circumstance. Methods: Electrolytic liver lesions were created in 21 pigs using platinum electrodes, connected to a direct current generator. Both electrolytic ‘dose’ and electrode separation were varied to produce different sized lesions. The ‘dose’ was correlated with the volume of necrosis and any vascular damage was determined histologically. Results: There was a significant (P < 0·001) correlation between the electrolytic ‘dose’ and the volume of liver necrosis. For a given ‘dose’ the volume of necrosis was less when the electrodes were together, rather than separated. Liver enzymes were only transiently deranged. There were no significant vascular injuries. Conclusion: Predictable and reproducible necrosis is produced by electrolysis in the pig liver. The treatment appears to cause little or no damage to immediately adjacent liver or major vascular structures and, when combined with resection, may offer the chance of a cure to many patients who are currently unresectable. © 2002 British Journal of Surgery Society Ltd

Liver electrolysis: pH can reliably monitor the extent of hepatic ablation in pigs.

Abstract: Electrolysis is a method of tissue ablation that creates chemical species and a pH gradient in response to direct current. Initial studies of electrolysis in animal models and humans have shown that it is a safe, predictable and effective process for destroying normal and tumour-bearing liver in a linear, dose-dependent manner. Presently, the amount of current that is applied (in coulombs) has to be calculated using historical data, with inherent inaccuracy. The present study tested whether pH could be used as a real-time monitor in order to predict more accurately the extent of necrosis. A total of 70 electrolytic lesions were created in 14 pigs, with pH monitoring of the lesion edge. The normal range of pH values was 6.5-8.7. A pH of less than 6 (at the anode) or more than 9 (at the cathode) reflected total cellular necrosis. When a pH value was recorded between 6.0 and 6.5 at the anode or between 8.7 and 9.0 at the cathode, the presence of necrosis was variable. In conclusion, during electrolytic ablation, pH measurement can monitor the extent of the induced necrosis.

A novel technique for the laparoscopic resection of mesenteric cysts.

Abstract: Mesenteric cysts are rare, invariably benign intraabdominal tumors. Optimal surgical management requires complete excision of these lesions. The advent of laparoscopic surgery has allowed resection of these cysts to be achieved without full laparotomy. However, laparoscopic resection necessitates drainage of the cyst within the abdomen to facilitate extraction of the cyst through the laparoscopic ports. This article describes a novel technique in which the cyst was partially aspirated as the initial surgical maneuver. This in turn allowed traction to be applied to the cyst wall, such that it could be drawn up into the epigastric port, to aid the further dissection and removal of the cyst from the peritoneal cavity.

Electrolytic ablation as an adjunct to liver resection: Safety and efficacy in patients.

Abstract: Background: Electrolytic ablation is a relatively new method for the local destruction of colorectal liver metastases. Experimental work in animal models has shown this method to be safe and efficacious. However, before proceeding to clinical trials it was necessary to confirm these findings in a pilot study of five patients. Methods: Five patients with colorectal liver metastases were studied prospectively. Each patient underwent a potentially curative liver resection. One of the metastases to be removed was treated using electrolysis before resection. Each patient was monitored closely during and after electrolysis to determine any morbidity associated with the treatment. Once resected, the metastases were examined histologically for completeness of ablation. Results: All patients tolerated the electrolysis well; there were no deaths or complications related to the treatment. Histological examination of the resected metastases which had been treated electrolytically showed complete tissue destruction with no viable malignant cells remaining at the site of treatment. Discussion: This pilot study of electrolytic ablation of liver metastases in five patients showed the treatment to be well tolerated and safe. Additionally, it demonstrated total destruction of the malignant tissue at the site of electrolysis. Based on these encouraging results, clinical trials can now begin.

Australian audit for the endoluminal repair of abdominal aortic aneurysm: The first 12 months

Abstract: Maggi Boult, Wendy Babidge, John Anderson, Michael Denton, Robert Fitridge, John Harris, Michael Lawrence-Brown, James May, Kenneth Myers and Guy Maddern

Electrolysis and other local ablative treatments for non-resectable colorectal liver metastases.

Abstract: The present paper is a review of the current ablative treatment options for the treatment of colorectal liver metastases. Cryotherapy, microwave coagulation therapy, radiofrequency ablation and laser-induced thermotherapy are discussed. Electrolysis, a novel non-thermal ablative treatment, is described. Potential benefits of electrolysis include the apparent ability to safely and effectively treat lesions abutting major hepatic structures and the lack of a systemic inflammatory reaction following electrolytic ablation. Further studies in animals and humans are needed to confirm this potential and to further refine the methods of electrolytic treatment of colorectal liver metastases.

Surgical undergraduate education in rural Australia.

Abstract: Hypothesis Surgical undergraduate education in a rural setting is feasible and sound in terms of educational outcomes. Design The final-year surgical curriculum at the University of Adelaide, Adelaide, South Australia, was restructured to include the option of a rural surgical term. Setting Five provincial center hospitals in rural South Australia. Interventions Forty-three final-year medical students undertook rural surgical clerkships in 1998. Main Outcome Measures End-of-year results and subjective ward assessments were compared between the group of students who completed rural surgical terms and the remainder of the student group who participated in tertiary hospital-based electives. Subjective student feedback was obtained in a survey conducted by the Clinical Education Development Unit at the University of Adelaide. Results No significant ( P = .45) differences in examination results were noted between the rural and city groups. A significant ( P Conclusion Surgical undergraduate education is practical in a rural setting and, for educational outcome, seems to be at least as effective as city-based surgical clerkships in preparing students for final examinations.

Current and future trends in management and treatment of Klatskin tumour

Abstract: First resected by Brown in Melbourne in 1954, Klatskin tumors were defined as an adenocarcinoma of the hepatic duct at the bifurcation within the porta hepatis. They now, usually, include upper-third cancers of the common bile duct down to the junction with the cystic duct. They are also known as: proximal cancer of the biliary tract, cancer of the biliary confluence, cancer of the confluence of biliary tract, cancer of superior biliary confluence, and malignant stricture of biliary confluence. They must be differentiated from cholangiocarcinomas, which are adenocarcinomas involving intrahepatic bile ducts. Recently, the American College of Pathologists has insisted on using the term cholangiocarcinoma only for tumours of the intrahepatic bile ducts. Similary, cancer of the hepatic hilus can be defined by its location in front of the bifurcation of the portal vein, and can include cancer of the gallbladder and of the cystic duct. As the prognosis is so different, particularly for resection, this nomenclature is of little use. Cancer is often suspected by the diagnosis of a stricture to the upper third of the common bile duct. Diagnosis can only be made by the histology of the operative specimen. Sclerosing cholangitis can mimic such a cancer. Operability

Management of liver trauma with implications for the rural surgeon.

Abstract: Background: The majority of patients with liver trauma can be managed conservatively. However, the unstable patient requires emergency laparotomy to control bleeding. Controversy exists regarding the primary surgical management of these injuries. This is of particular relevance for the isolated rural general surgeon. Methods: The literature was reviewed by searching MEDLINE databases from 1966 to the present time. The majority of the evidence presented is level 3, with interpretations and recommendations based on the experience of the senior authors. Results: In the majority of patients, conservative management remains the mainstay of treatment. However, haemodynamic ­instability requires urgent laparotomy. Perihepatic packing should be used to arrest bleeding. Primary anatomical resection is rarely indicated, especially in non-specialist centres. Conclusion: In the remote rural setting, severe liver trauma remains a daunting condition for the general surgeon to manage. Primary surgical treatment should be perihepatic packing, stabilization and urgent transfer; there is no place for primary anatomical resection outside specialist units.

Surgical management of intractable pain in chronic pancreatitis: past and present.

Abstract: The surgical management of pain in patients with chronic pancreatitis continues to provide a formidable challenge. Despite recent advances in the area of the pathophysiolgical cause of the symptoms of chronic pancreatitis there is still controversy as to the exact mechanisms that result in pain in both large and small duct disease. In addition, the surgical community has very polarized views as to the correct management of these patients. In this review we have set out to summarize the treatment options available and provide comparative data where available. Data were found following a computer search of the Medline database from 1966 to the present. The information extracted comprises mainly level two and level three data. There is a continuing lack of a “gold standard” in the surgical management of pancreatic pain. This is mainly due to the paucity of randomized controlled trials in the field of pancreatic surgery. With only four randomized controlled trials reported in the world literature it is difficult to state categorically what is the optimal treatment for this difficult group of patients. Until there is increased standardization in the reporting of both the physiological outcomes and quality-of-life issues in the surgical management of chronic pancreatitis this will continue to be the situation.

Issues of consent and privacy affecting the functioning of ASERNIP-S.

Abstract: The Australian Safety and Efficacy Register for New Interventional Procedures - Surgical (ASERNIP-S) undertakes horizon scanning, systematic reviews and audits. By disseminating information derived from these processes, ASERNIP-S aims to improve the quality of health care. In the present article, we discuss some of the legal and ethical issues surrounding the collection of identified data for the purposes of audit. The individual's right to privacy is considered as well as the benefits of improving the quality of surgical health care.

A peeling mesh.

Abstract: A number of different materials are available for incisional hernia repair. Benefits of the various types are controversial and are partly dependent on the anatomical placement of the mesh [1]. Composite mesh has been introduced to provide tissue ingrowth for strength and a non-adherent side to protect the bowel, these layers being laminated together. This report is on the separation of layers in an infected mesh and adherence of the expanded polytetrafluoroethylene layer to the small bowel.

Direct Current Electrolysis for the Local Ablation of Liver Metastases

Abstract: The dictionary definition of electrolysis is the chemical decomposition by electrical action. World wide, direct current Electrolysis (also known as ‘Electrochemical Therapy’ or ‘ECT’) is probably the second most used form of localised hepatic ablation, after alcohol injection 1-4. The majority of reports are from China and it is unclear why the enormous potential of electrolysis has been overlooked in the West 5. Certainly the diverse nature of the tumours treated by the Chinese and the variably reported methodologies and results make interpretation of the efficacy of electrolysis difficult. It would however seem that there is a large body of anecdotal evidence supporting the safety and efficacy of electrolysis. The technique itself is easily available, simple, relatively cheap and lends itself to a percutaneous approach. In common with all forms of ablative technique, the clinical application has been introduced prior to rigorous scientific evaluation and despite many thousands of clinical cases, the use of ‘electrolysis’ must still be considered experimental.