British Journal of Surgery

Judson, I; Barriuso, J

doi: 10.1002/bjs.6176pmid: 18386767

May reduce micrometastases

Klinge, U

doi: 10.1002/bjs.6159pmid: 18344188

Randomized control trials may be inappropriate

Guller, U

doi: 10.1002/bjs.6156pmid: 18386768

The ability to appraise research literature critically is an invaluable tool in the era of evidence-based medicine. The objective of this educational article is to highlight certain caveats that are important to those who seek to interpret the surgical literature. These caveats are illustrated with intuitive examples drawn from the field of surgery. It is hoped that the article will help surgeons to recognize the common pitfalls encountered when interpreting scientific reports. This is important if research findings are to be transferred appropriately into the realm of clinical practice.

Ansari, B; Ogston, S A; Purdie, C A; Adamson, D J; Brown, D C; Thompson, A M

doi: 10.1002/bjs.6162pmid: 18386775

BackgroundThe need for sentinel lymph node (SLN) biopsy in patients with a preoperative diagnosis of ductal carcinoma in situ (DCIS) is debated. Advocates recommend such biopsy based on a high incidence of SLN involvement in some series. Opponents discourage SLN biopsy based on a perceived low incidence of nodal involvement in this setting. These contradictory arguments are generally based on small studies. The present study is a meta-analysis of the reported data on the incidence of SLN metastasis in patients with DCIS.MethodsA search of electronic databases identified studies reporting the frequency of SLN metastases in DCIS. The random-effects method was used to combine data.ResultsTwenty-two published series were included in the meta-analysis. The estimate for the incidence of SLN metastases in patients with a preoperative diagnosis of DCIS was 7·4 (95 per cent confidence interval (c.i.) 6·2 to 8·9) per cent compared with 3·7 (95 per cent c.i. 2·8 to 4·8) per cent in patients with a definitive (postoperative) diagnosis of DCIS alone. This was a significant difference with an odds ratio of 2·11 (95 per cent c.i. 1·15 to 2·93).ConclusionPatients with a preoperative diagnosis of DCIS should be considered for SLN biopsy.

Kushwaha, R; Hutchings, W; Davies, C; Rao, N G

doi: 10.1002/bjs.6113pmid: 18389499

BackgroundDay-care open haemorrhoidectomy under local anaesthesia (LH) may be the most cost-effective approach to haemorrhoidectomy. This prospective randomized trial compared outcome after LH from patients' and clinical perspectives with that after day-care open haemorrhoidectomy under general anaesthesia (GH).MethodsForty-one patients with third-degree haemorrhoids were randomized to LH (19) or GH (22). Patient demographics were comparable. A single haemorrhoid was excised in 15 patients, and two and three haemorrhoids in 13 each. Independent nurse-led assessment and clinical evaluation were carried out for 6 months. Outcome measures were mean and expected pain scores at 30, 60 and 90 min, then daily for 10 days, and satisfaction scores at 10 days, 6 weeks and 6 months. Secondary outcomes were journey time within the day-surgery unit and overall cost.ResultsPain was worse following LH than GH at 90 min after surgery (P = 0·028), but pain scores on reaching home were similar. Maximum pain was experienced on day 3 after LH and on day 6 after GH. From day 1 onwards, daily pain scores were lower in the LH group, and there was a significant difference on day 8 (mean (95 per cent confidence interval) 3·61 (2·74 to 4·48) for LH versus 5·29 (4·12 to 6·45) for GH; P = 0·027). Mean pain over 10 days, expectation and satisfaction scores were similar in the two groups. LH had a shorter journey time and was less expensive than GH.ConclusionLH has similar tolerance and clinical outcome to GH, and is associated with a shorter journey time and lower cost. Registration number: NCT00503269 (http://www.clinicaltrials.gov).

Wanhainen, A; Bylund, N; Björck, M

doi: 10.1002/bjs.6109pmid: 18300269

BackgroundThe aim was to study the epidemiology of abdominal aortic aneurysm (AAA) repair in Sweden.MethodsPrimary AAA repairs registered in the Swedish Vascular Registry between 1994 and 2005 were studied. Mortality data were obtained from the national population registry, and age- and sex-specific populations for each calendar year from Statistics Sweden.ResultsSome 10 691 primary AAA repairs were identified. In the population aged 60 years or over the incidence of intact AAA repair increased from 27·0 per 100 000 in 1994–1999 to 28·8 per 100 000 in 2000–2005 (P = 0·006), while the incidence of surgery for ruptured AAA (rAAA) remained stable (13·8 versus 14·1 per 100 000; P = 0·595). Open repair with a bifurcated graft decreased, whereas endovascular repair (EVAR) increased to 35·0 per cent of intact AAA and 10·3 per cent of rAAA procedures in 2005. Patients who had EVAR were older than those undergoing open repair (74·1 versus 71·9 years; P < 0·001). The 30-day mortality rate decreased over time for intact and ruptured aneurysm operations (P = 0·001). Age, female sex and open repair (compared with EVAR) were independently associated with a higher 30-day mortality rate in a logistic regression model.ConclusionThe introduction of EVAR was associated with an increasing incidence of intact AAA repair, whereas the rate of rAAA was stable. Perioperative mortality rates decreased over time.

Ravn, H; Wanhainen, A; Björck, M

doi: 10.1002/bjs.6074pmid: 18306151

BackgroundThe risk of developing a new aneurysm after surgery for popliteal artery aneruysm (PAA) is not well known. The aim was to study this risk in a cohort of patients.MethodsA total of 571 patients who had primary operation for PAA (717 legs) between 1987 and 2002 were identified from the Swedish Vascular Registry (Swedvasc). Of these, 190 patients were re-examined by ultrasonography after a median of 7 (range 2·9–18·7) years.ResultsThe number of patients with at least one aneurysm in addition to the PAA was 108 (56·8 per cent) at the index operation and 131 (68·0 per cent) at re-examination. The overall number of aneurysms increased by 41·8 per cent, from 244 to 346. Among the 82 patients who had an isolated PAA at the index operation, 23 developed a new aneurysm; these patients tended to be older (P = 0·004). Bilateral PAA at the index operation was associated with a later development of abdominal aortic aneurysm (P = 0·004). Age (P = 0·004) and hypertension (P = 0·012) at the time of the index operation were associated with multianeurysm disease at any time. Six (4·3 per cent) of 138 legs treated by venous bypass grafts had developed a graft aneurysm by the time of re-examination. No normal arterial segment developed an aneurysm that required surgery within 3 years.ConclusionThe development of new aneurysms was common in patients with a PAA; lifelong surveillance may be warranted.

Russell, D A; Abbott, C R; Gough, M J

doi: 10.1002/bjs.6100pmid: 18344184

BackgroundVascular endothelial growth factor (VEGF) promotes events favouring carotid plaque instability: inflammatory chemoattraction, thrombogenesis, and upregulation of matrix metalloproteinases and cell adhesion molecules. The aim of this study was to assess neovascularization, VEGF and its receptors in high-grade stable and unstable carotid plaques.MethodsImmunohistochemical staining for CD34, VEGF, VEGF receptor (VEGFR) 1 and VEGFR2 was performed in 34 intact carotid endarterectomy specimens, and compared in sections demonstrating maximal histological instability (cap rupture/thinning) or, if stable, maximal stenosis.ResultsVEGF staining was increased in 12 unstable compared with 22 stable plaques (median (interquartile range, i.q.r.) plaque score 4·0 (4·0–4·0) versus 3·0 (2·0–3·0); P = 0·002) with upregulation of VEGFR1 (plaque score 4·0 (2·0–4·0) versus 2·0 (1·0–3·0); P = 0·016). In unstable plaques this was associated with increased microvessel density in the cap (median (i.q.r.) 12·1 (4·0–30·0) versus 1·1 (0·0–7·3) microvessels/mm2; P = 0·017) and shoulder regions (7·7 (3·4–21·4) versus 3·1 (0·4–10·8) microvessels/mm2; P = 0·176).ConclusionIncreased VEGF and receptor staining were seen in histologically unstable carotid plaques. Although these differences could reflect cytokine-driven inflammatory events accompanying plaque instability, VEGF and VEGFR1 could be key mediators.

Spark, J I; Yeluri, S; Derham, C; Wong, Y T; Leitch, D

doi: 10.1002/bjs.6052pmid: 18344206

BackgroundThe aim was to assess the results of a decellularized bovine ureter graft (SynerGraft®) for complex venous access.MethodsBovine ureter conduits were implanted in patients with a failed fistula or access graft in whom native vessels were unsuitable as conduits. Graft histories were obtained from all patients who had undergone this procedure at one institution. Failed grafts were explanted and subjected to histological examination. A sample of fresh bovine ureter was immunostained for galactose (α1 → 3) galactose (α-Gal).ResultsNine patients with a median age of 46 (range 25–70) years underwent complex venous access surgery between August 2004 and November 2006 using a SynerGraft®. Graft types included loop superficial femoral artery to stump of long saphenous vein (four patients), loop brachial artery to vein (two), brachial artery to axillary vein (two) and left axillary artery to innominate vein (one). Three grafts developed aneurysmal dilatation and two thrombosed. Histological assessment of the explanted bovine ureters revealed acute and chronic transmural inflammation. Immunostaining of fresh bovine ureter suggested residual cells and the xenoantigen α-Gal.ConclusionGraft failure with aneurysmal dilatation and thrombosis in complex arteriovenous conduits using bovine ureter may be due to residual xenoantigens.

Machens, A; Hauptmann, S; Dralle, H

doi: 10.1002/bjs.6075pmid: 18300267

BackgroundIn medullary thyroid cancer (MTC), there is a concordance between central and lateral neck involvement, but this relationship has not been assessed quantitatively.MethodsAfter compartment-oriented lymphadenectomy for untreated MTC, the numbers of central lymph node metastases with ipsilateral (195 patients) and contralateral (185 of 195 patients) lateral lymph node metastases were analysed retrospectively.ResultsWith one to three positive central lymph nodes, involvement of the ipsilateral lateral neck increased from 10·1 per cent (with no central node involvement) to 77 per cent, and from a mean of 0·6 to 3·7 nodal metastases (P < 0·001). With four or more central nodes, the rate was 98 per cent, with 10·7 nodal metastases (P = 0·001). A weaker increase was observed in the contralateral lateral neck: with one to nine positive central nodes, contralateral lateral neck involvement increased from 4·9 to 38 per cent, and from a mean of 0·6 to 2·3 nodal metastases (P = 0·011). With ten or more positive central nodes, the rate rose to 77 per cent, with 6·2 nodal metastases (P = 0·009). With one exception, contralateral lateral nodal metastases coexisted with metastases in the central and ipsilateral lateral neck.ConclusionThese data may lay the groundwork for more informed decision-making regarding dissection of the lateral neck compartments.