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Biomedical subjects

S Connor

Publications and source records attributed to S Connor.

At least 19 recordsLinked to original sources
PubMed2006

Palliation for suspected unresectable hilar cholangiocarcinoma.

AIM: The aim of this study was to evaluate the outcome of different techniques of palliation for patients with hilar cholangiocarcinoma. METHOD: All patients treated with palliative intent between 1988 and 2004 at the Royal Infirmary of Edinburgh were reviewed. Patients were analysed on an intention to treat basis. Demographics, procedure and outcome (including re-admissions) were recorded. RESULTS: Two hundred and thirty-three patients underwent palliative treatment for suspected hilar cholangiocarcinoma. The diagnosis was confirmed histologically in 109 patients. The procedure related morbidity and mortality was 54/225 and 18/207 respectively. Seventy-one patients required re-admission. Twenty patients underwent surgical biliary bypass for jaundice. Those undergoing surgical palliation had a longer median (95% CI) time to re-admission (16 (0-36) vs.7 (2-12) weeks, p=0.001). Endoscopic retrograde cholangio-pancreatography (ERCP) and stenting was only successful in 28 patients and was associated with a significantly higher re-admission rate compared to patients in whom ERCP was not performed (60/179 vs. 4/27, p=0.050). The overall median (95% CI) survival was 145 (124-185) days. CONCLUSION: Current options for palliation of hilar cholangiocarcinoma provide good short term success but are all associated with significant early and late morbidity. Due to its low success and association with an increased re-admission rate, ERCP for definitive palliation should not be used in the first line staging and management of these patients.

Aged↗
PubMed2006

Follow-up and outcomes for resection of colorectal liver metastases in Edinburgh.

AIM: The aim of this study was to assess the value of a defined follow-up protocol for patients undergoing potentially curative hepatic resection for colorectal hepatic metastases. METHODS: A standard protocol for the duration of the study consisted of clinical assessment, serum carcinoembryonic antigen (CEA) and computed tomography. Patterns of recurrence, method and timing of diagnosis and outcome were recorded. RESULTS: One hundred and ninety-one patients underwent potentially curative resection from 1989 to 2004 of whom 103 developed recurrence. The median (inter-quartile range) follow-up was 24.4 (6.5-42.3) months. The median (IQR) time to recurrence and overall survival was 25.0 (10 -not yet reached) and 45.2 (21-123) months, respectively. Seventeen patients (8.9%) underwent further surgery with curative intent. Fifty-five patients (57.9%) had recurrence diagnosed at routine follow-up with 71% (44/62) being diagnosed by CEA and CT. The CEA was elevated in 85.7% (72/84 patients) at the time of diagnosis of recurrence. CONCLUSION: Although the detection of recurrent disease is common during follow-up after hepatic resection for colorectal metastases, few patients will be suitable for further intervention with curative intent. The exact nature of the follow-up protocol remains to be determined but if it is going to be performed it should be most intensive within the first 3 years.

Aged↗
PubMed2006

Bile duct injury in the era of laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy is the standard of care for symptomatic cholelithiasis, but it is associated with a higher incidence of bile duct injury than the open approach. METHODS: A review was performed of the English language literature on the management of bile duct injury listed on Medline databases. RESULTS AND CONCLUSION: There is consensus that careful dissection and correct interpretation of the anatomy avoids the complication of bile duct injury during cholecystectomy. Routine intraoperative cholangiography is associated with a lower incidence and early recognition of bile duct injury. Early detection and repair is associated with an improved outcome, and the minimum standard of care after the recognition of a bile duct injury is immediate referral to a surgeon experienced in bile duct injury repair. Surgery provides the mainstay of treatment, with proximal hepaticojejunostomy Roux en Y being the operation of choice; a selective role for endoscopic or radiological treatment exists. The outcome after bile duct injury remains poor, especially in relation to the initial expectation of the cholecystectomy. Patients are often committed to a decade of follow-up.

Bile Ducts↗
PubMed2006

Meta-analysis of endoscopy and surgery versus surgery alone for common bile duct stones with the gallbladder in situ.

BACKGROUND: There is no clear consensus on the better therapeutic approach (endoscopic versus surgical) to choledocholithiasis. This study is a meta-analysis of the available evidence. METHODS: A search of the Medline and ISI databases identified 12 studies that met the inclusion criteria for data extraction. The analysis was performed using a random-effects model. The outcome was calculated as an odds ratio (OR) or relative risk (RR) with 95 per cent confidence intervals (c.i.). RESULTS: Outcomes of 1357 patients were studied. There was no significant difference in successful duct clearance (OR 0.85 (95 per cent c.i. 0.64 to 1.12); P = 0.250), mortality (RR 1.79 (95 per cent c.i. 0.66 to 4.83); P = 0.250), total morbidity (RR 0.89 (95 per cent 0.71 c.i. to 1.13); P = 0.350), major morbidity (RR 1.34 (95 per cent c.i. 0.92 to 1.97); P = 0.130) or need for additional procedures (OR 1.37 (95 per cent c.i. 0.82 to 2.29); P = 0.230) between the endoscopic and surgical groups. There was also no significant difference between the endoscopic and laparoscopic surgery groups. CONCLUSION: Both approaches have similar outcomes, and treatment should be determined by local resources and expertise.

Cholecystectomy, Laparoscopic↗
PubMed2006

Long-term potentiation is associated with changes in synaptic ultrastructure in the rat neocortex.

Long-term potentiation (LTP) in the sensorimotor cortex of freely moving rats has been associated with changes in dendritic morphology and dendritic spine density. The current research examined changes in synaptic number and ultrastructure associated with LTP in this cortical region. LTP was induced over a 1 h period and the animals were sacrificed 2 h after the initial stimulation of the LTP group. Synapses within the terminal area of the apical dendrites from layer III pyramidal neurons were quantified by determining the total number of synapses per neuron, the number of excitatory and inhibitory contacts, number of synapses with different curvature subtypes, number of perforated synapses, and synaptic length. Several changes in synaptic morphology of excitatory synapses were revealed but no overall increase in the number of synapses per neuron was evident. Specifically, the induction of LTP was associated with an increased number of excitatory perforated and concave shaped synapses. Increased numbers of perforated concave synapses were also found to be significantly correlated with the degree of potentiation in the LTP animals. These and previous results suggest similar synaptic changes in both the cortex and hippocampus during the early phases of LTP maintenance and distinct synaptic changes during later phases of LTP maintenance.

Analysis of Variance↗
PubMed2006

Growing skull fracture in the absence of a dural tear.

A case of growing skull fracture associated with unrecognized extradural haematoma is presented together with the relevant radiology. The pathophysiology of growing skull fracture is reviewed in light of this previously unreported case.

Cerebral Hemorrhage↗
PubMed2005

Serum CA19-9 measurement increases the effectiveness of staging laparoscopy in patients with suspected pancreatic malignancy.

BACKGROUND/AIMS: Staging laparoscopy for suspected pancreatic neoplasia is not widely accepted due to its low yield. The aim of this study was to determine if serum carbohydrate antigen (CA19-9) levels could be used to improve the selection of patients for staging laparoscopy. METHODS: The data from a prospectively collected database (1997-2004) with 159 patients who had computed tomography-predicted resectable disease and who had undergone laparoscopic staging were analysed to determine if a low preoperative CA19-9 level (< or =150 kU/l, or < or =300 kU/l with a bilirubin >35 micromol/l) identified patients in whom laparoscopy was not useful. RESULTS: The CA19-9 level was >150 kU/l in 96 patients of whom 75 (78%) were considered resectable following laparoscopic assessment. There were 63 patients with a CA19-9 < or =150 kU/l of whom 60 (95%) were considered resectable following laparoscopic assessment. The sensitivity, specificity, positive predictive value and negative predictive value for CA19-9 < or =150 kU/l in predicting that laparoscopic assessment would judge patients as resectable were 44, 88, 95 and 22%, respectively. A cut-off level of < or =300 kU/l in patients with a bilirubin >35 micromol/l produced values of 30, 94, 94 and 28%, respectively. By using CA19-9 < or =150 kU/l, laparoscopy could have been avoided in 40% of patients, increased to 55% of patients with adjustment for the presence of jaundice; concomitantly, the yield from laparoscopy would have been increased from 15 to 22 and 25%, respectively. CONCLUSION: Use of serum CA19-9 levels would increase the efficiency of laparoscopic staging in patients with suspected pancreatic malignancy.

Bile Duct Neoplasms↗
PubMed2005

Positron emission tomography does not add to computed tomography for the diagnosis and staging of pancreatic cancer.

BACKGROUND: Positron emission tomography (PET) has been proposed for pancreatic cancer diagnosis and staging. METHODS: 112 patients with suspected pancreatic cancer underwent 18F-fluoro-2-deoxy-D-glucose gamma camera PET and computed tomography (CT), of whom 62 also had laparoscopic ultrasonography and 70 underwent abdominal exploration for potential resection. The final diagnosis was malignancy in 78 and benign disease in 34 patients (25 with chronic pancreatitis). RESULTS: The diagnostic sensitivity and specificity for PET were 73 and 60% compared to 89 and 65% for CT respectively (Cohen's kappa = 0.59). In 30 patients CT was equivocal with cancer in 14 and benign disease in 16. PET correctly diagnosed 13 of these patients (cancer in 6 and benign disease in 7), interpreted 4 as equivocal (cancer in 3 and benign disease in 1) but was incorrect in the remaining 13 patients (cancer in 5 and benign disease in 8). The sensitivity and specificity for detecting small volume metastatic disease were 20 and 94% for CT and 22 and 91% for PET, respectively. CONCLUSION: PET had a similar accuracy to that of CT for imaging pancreatic cancer but it did not provide any additional information in patients with equivocal CT findings and currently would seem of little benefit for the staging of pancreatic cancer.

Adult↗
PubMed2005

Meta-analysis of the value of somatostatin and its analogues in reducing complications associated with pancreatic surgery.

BACKGROUND: The role of somatostatin and its analogues in reducing complications after pancreatic resection is controversial. This is a meta-analysis of the evidence of benefit. METHODS: A literature search using Medline and ISI Proceedings with exploration of the references identified 22 studies. Of these, ten met the inclusion criteria for data extraction. Estimates of effectiveness were performed using fixed- and random-effects models. The effect was calculated as an odds ratio (OR) with 95 per cent confidence intervals (c.i.) using the Mantel-Haenszel method. Level of significance was set at P < 0.050. RESULTS: Outcomes for 1918 patients were compared. Somatostatin and its analogues did not reduce the mortality rate after pancreatic surgery (OR 1.17 (0.70 to 1.94); P = 0.545) but did reduce both the total morbidity (OR 0.62 (0.46 to 0.85); P = 0.003) and pancreas-specific complications (OR 0.56 (0.39 to 0.81); P = 0.002). Somatostatin and its analogues reduced the rate of biochemical fistula (OR 0.45 (0.33 to 0.62); P < 0.001) but not the incidence of clinical anastomotic disruption (OR 0.80 (0.44 to 1.45); P = 0.459). CONCLUSION: Somatostatin and its analogues reduce the incidence of complications after surgery.

Humans↗
PubMed2005

A comparison of two invasive techniques in the management of intractable pain due to inoperable pancreatic cancer: neurolytic celiac plexus block and videothoracoscopic splanchnicectomy.

BACKGROUND AND AIMS: Pancreatic cancer is characterized by a constant deterioration in quality of life, excruciating pain and progressive cachexia. The aim of this study was to compare the effectiveness of two invasive methods of pain treatment in these patients: neurolytic coeliac plexus block (NCPB) and videothoracoscopic splanchnicectomy (VSPL) to a conservatively treated control group concerning pain, quality of life and opiates' consumption. PATIENTS AND METHODS: Fifty nine patients suffering from pain due to inoperable pancreatic cancer were treated invasively with NCPB (N=35) or VSPL (N=24) in two non-randomised, prospective, case-controlled protocols. Intensity of pain (VAS-pain), quality of life (FACIT and QLQ C30) and opioid intake were compared between the groups and to a control group of patients treated conservatively before the procedure and after 2 and 8 weeks of follow-up. The analysis was performed retrospectively using meta-analysis statistics. RESULTS: Both methods of invasive pain treatment resulted in significant reduction of pain (VSPL effect size=11.27, NCPB effect size=7.29) and fatigue (effect sizes, respectively, 1.23 and 3.37). NCPB improved also significantly physical, emotional and social well-being (effect sizes, respectively, 2.37, 4.13 and 7.51) which was not observed after VSPL. No influence on ailments characteristic for the disease was demonstrated. Mean daily opioid consumption was significantly decreased after both procedures. There was no perioperative mortality and no major morbidity. CONCLUSION: Both NCPB and VSPL provide significant reduction of pain and improvement of quality of life in inoperable pancreatic cancer patients. They present rather similar efficacy, but lower invasiveness of NCPB, in combination with its more positive effect on quality of life, pre-disposes it as being the preferred method.

Adult↗
PubMed2005

Early and late complications after pancreatic necrosectomy.

BACKGROUND: Surgery for pancreatic necrosis is associated with a high morbidity and mortality. The aim of this study was to review the incidence of early and late complications after pancreatic necrosectomy in a large contemporary series of patients. METHODS: The clinical outcomes of 88 patients who underwent pancreatic necrosectomy between 1997 and 2003 were reviewed. RESULTS: The median age was 55.5 (range, 18-85) years, 54 (61%) were males, 68 (77%) had primary pancreatic infection, 71 (81%) had >50% necrosis, and the median admission Acute Physiology and Chronic Health Evaluation score was 9 (range, 1-21). Median time to surgery was 31 (range, 1-161) days; 47 patients underwent minimally invasive necrosectomy and 41 open necrosectomy; 81 (92%) of patients had complications postoperatively, and 25 (28%) died. Multiorgan failure (odds ratio = 3.4, P = .05) and hemorrhage (odds ratio = 6.1, P = .03) were the only independent predictors of mortality. During a median follow-up of 28.9 months, 39 (62%) of 63 surviving patients had one or more late complications: biliary stricture in 4 (6%), pseudocyst in 5 (8%), pancreatic fistula in 8 (13%), gastrointestinal fistula in 1 (2%), delayed collections in 3 (5%), and incisional hernia in 1 (2%); intervention was required in 10 (16%) patients. Sixteen (25%) of 63 surviving patients developed exocrine insufficiency, and 19 (33%) of 58 without prior diabetes mellitus developed endocrine insufficiency. CONCLUSIONS: Almost all patients undergoing necrosectomy developed significant early or late complications or both. Multiorgan failure and postoperative hemorrhage were independent predictors of mortality. Long-term follow-up was important because 62% developed complications, and 16% of those with complications required surgical or endoscopic intervention.

APACHE↗
PubMed2005

Surgery in the treatment of acute pancreatitis--minimal access pancreatic necrosectomy.

Between 5% and 10% of patients with acute pancreatitis will develop infected pancreatic necrosis. Traditional open surgery for this condition carries a mortality rate of up to 50%, and therefore a number of less invasive techniques have been developed, including radiological drainage and a minimal access retroperitoneal approach. No randomised controlled trials have been published which compare these techniques. Indications for minimal access surgery are the same as for open surgery, i.e. infected pancreatic necrosis or failure to improve with extensive sterile necrosis. Access is obtained to the pancreatic necrosis via the left loin and necrosectomy performed using an operating nephroscope, and this often requires several procedures to remove all necrotic tissue. The cavity is continuously irrigated on the ward in between procedures. The results of this approach are encouraging, with less systemic upset to the patient, a lower incidence of post-operative organ failure when compared with open surgery, and a reduced requirement for ITU support. There is also a trend towards a lower mortality rate, although this does not reach statistical significance on the data published so far. Current evidence suggests that a minimal access approach to pancreatic necrosis is feasible, well tolerated and beneficial for the patient when compared with open surgery.

Dilatation↗
PubMed2004

Fungal infection but not type of bacterial infection is associated with a high mortality in primary and secondary infected pancreatic necrosis.

INTRODUCTION: Knowledge of microbiology in the prognosis of patients with necrotizing pancreatitis is incomplete. AIM: This study compared outcomes based on primary and secondary infection after surgery for pancreatic necrosis. METHOD: From a limited prospective database of pancreatic necrosectomy, a retrospective case note review was performed (October 1996 to April 2003). RESULTS: 55 of 73 patients had infected pancreatic necrosis at the first necrosectomy. 25 of 47 patients had resistant bacteria to prophylactic antibiotics (n = 21) or did not receive prophylactic antibiotics (n = 4), but this was not associated with a higher mortality (9 of 25) compared to those with sensitive organisms (4 of 22). Patients with fungal infection (n = 6) had a higher initial median (95% CI) APACHE II score compared to those without (11 (9-13) verus 8.5 (7-10), p = 0.027). Five of six patients with fungal infection died compared to 13 of 47 who did not (p = 0.014). With the inclusion of secondary infections 21 (32%) of 66 patients had fungal infection with 10 (48%) deaths compared to 11 (24%) of 45 patients without fungal infection (p = 0.047). CONCLUSION: Whether associated with primary or secondary infected pancreatic necrosis, fungal but not bacterial infection was associated with a high mortality.

Bacterial Infections↗
PubMed2004

Laparoscopy and laparoscopic ultrasound in the evaluation of pancreatic and periampullary tumours.

BACKGROUND AND AIMS: The pre-operative determination of resectability of pancreatic and peri-ampullary neoplasia assists the selection of patients for surgical or non-surgical treatment. This study investigated whether the addition of laparoscopy with laparoscopic ultrasound to dual-phase helical CT could improve the accuracy of assessment of resectability. PATIENTS AND METHODS: Prospective study of 305 patients referred to a single unit for consideration of pancreatic resection who underwent dual-phase helical CT scanning +/- laparoscopy with laparoscopic ultrasound. Data were collected on patient demographics, CT findings, assessment of operability, laparoscopic assessment (LA), surgical procedures and histology. RESULTS: LA was undertaken in 239/305 patients, 190 of whom were considered CT resectable, and 49 CT unresectable. Of the 190 CT resectable patients, LA correctly identified unresectability in 28 (15%: metastases in 15; vascular encasement in 6; anaesthesia for laparoscopy found 7 unfit for major resection) and incorrectly in 2 (vascular encasement), but did not identify unresectability in 33; LA correctly confirmed resectability in the remainder (prediction improved, chi(2) = 9.73, p < 0.01). Of the 49 CT unresectable patients, LA correctly identified resectability in 4, and incorrectly in 12, and correctly identified unresectability in the remaining 33. Sixty-six of the 305 patients did not undergo LA, of whom 23 underwent resection. CONCLUSION: When added to dual-phase helical CT, laparoscopy with laparoscopic ultrasound provides valuable information that significantly improves the selection of patients for surgical or non-surgical treatment.

Adult↗
PubMed2004

Diagnosis, treatment and outcome of pancreatoblastoma.

BACKGROUND: Pancreatoblastoma is a rare tumour mainly presenting in childhood but also in adults. OBJECTIVES: The aim was to determine the clinical course of pancreatoblastoma by an analysis of reported cases. METHODS: Patients with pancreatoblastoma were identified from Medline and combined with patients identified from the Royal Liverpool University Hospital. RESULTS: There were 153 patients with a median (range) age at presentation of 5 (0-68) years and a male:female ratio of 1.14:1. The most frequent site was the head of pancreas (48/123, 39%). The median and 5-year (95% CI) survival rates were 48 months and 50% (37-62%) respectively. At presentation there were 17 (17%) out of 101 patients with metastases, the liver being the commonest site (15/17, 88%). On univariate analysis, factors associated with a worse prognosis were synchronous (p = 0.05) or metachronous metastases (p < 0.001), non-resectable disease at presentation (p < 0.001) and age > 16 years at time of presentation (p = 0.02). On multivariate analysis, resection (p = 0.006) and metastases post-resection (p = 0.001) but not local recurrence influenced survival. CONCLUSIONS: Pancreatoblastoma is one of the pancreatic tumours with a relatively good prognosis. The treatment of choice is complete resection with long-term follow-up aiming to treat any early local recurrence or metastasis.

Child↗
PubMed2004

Hereditary pancreatic endocrine tumours.

The two main types of hereditary pancreatic neuroendocrine tumours are found in multiple endocrine neoplasia type 1 (MEN-1) and von Hippel-Lindau disease (VHL), but also in the rarer disorders of neurofibromatosis type 1 and tuberous sclerosis. This review considers the major advances that have been made in genetic diagnosis, tumour localization, medical and surgical treatment and palliation with systemic chemotherapy and radionuclides. With the exception of the insulinoma syndrome, all of the various hormone excess syndromes of MEN-1 can be treated medically. The role of surgery however remains controversial ranging from no intervention (except enucleation for insulinoma), intervening for tumours diagnosed only by biochemical criteria, intervening in those tumours only detected radiologically (1-2 cm in diameter) or intervening only if the tumour diameter is > 3 cm in diameter. The extent of surgery is also controversial, although radical lymphadenectomy is generally recommended. Pancreatic tumours associated with VHL are usually non-functioning and tumours of at least 2 cm in diameter should be resected. Practice guidelines recommend that screening in patients with MEN-1 should commence at the age of 5 years for insulinoma and at the age of 20 years for other pancreatic neuroendocrine tumours and variously at 10-20 years of age for pancreatic tumours in patients with VHL. The evidence is increasing that the life span of patients may be significantly improved with surgical intervention, mandating the widespread use of tumour surveillance and multidisciplinary team management.

Endocrine Gland Neoplasms↗