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ABSTRACT: BACKGROUND: Non-resectional strategies (NRS) have improved outcomes for a sub-group of patients with perforated diverticulitis. NRS are applicable to patients with non-faeculant peritonitis (Hinchey II and III). Success is dependent on the initial perforation sealing, which Hinchey estimated occurred 'most of the time'. An exact percentage remains ill-defined. OBJECTIVE: We aimed to define the percentage and clinical significance of a persistent perforation in non-faeculant diverticular peritonitis. DESIGN: A retrospective review was conducted of all patients admitted with a diagnosis of perforated diverticulitis between January 1999 and July 2010. Patients undergoing an emergency operation were analysed according to Hinchey and physiological and operative severity scores and compared with histological findings. RESULTS: One hundred fifteen patients were identified. Fifty-three patients underwent a 'resectional' procedure. At surgery, 15 patients had faeculent peritonitis, 27 patients had purulent peritonitis and 11 patients had a contained abscess. Of the patients with non-faeculant peritonitis, 2/9 (22.2 %) Hinchey II and 10/27 (37.1 %) Hinchey III patients had persistent perforation on review of histology. Persistent perforation was associated with a significant increase in morbidity, length of stay, physiological and operative severity score (p = 0.015, 0.011, 0.049 and 0.002, respectively). CONCLUSION: A proportion of patients with non-faeculant peritonitis have a persistent perforation which is associated with a poorer outcome and is likely to result in failure of a non-resectional management strategy. Updated classification systems and tailored peri-operative investigations are required to identify this sub-group of patients and improve patient outcomes.
Journal of Gastrointestinal Surgery 09/2012; · 2.83 Impact Factor
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British Journal of Surgery 09/2012; 99(9):1314. · 4.61 Impact Factor
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Irish Journal of Medical Science 05/2012; 174:30-30. · 0.58 Impact Factor
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ABSTRACT: IntroductionParaneoplastic neurological disorders are rare complications of breast carcinoma. Lambert–Eaton Myasthenic Syndrome (LEMS)
is most commonly associated with small cell lung cancer. However, a combination of LEMS and subacute cerebellar degeneration
as paraneoplastic syndromes is extremely rare, and has never been described in association with breast cancer.
CaseWe report for the first time an unusual association of LEMS and paraneoplastic subacute cerebellar degeneration with breast
carcinoma.
ConclusionIn patients with atypical LEMS, when there is no evidence of respiratory malignancy, breast cancer should be included in the
differential diagnosis.
KeywordsBreast neoplasms–Lambert–Eaton Myasthenic Syndrome–Paraneoplastic cerebellar degeneration
Irish Journal of Medical Science 04/2012; 180(2):569-571. · 0.58 Impact Factor
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ABSTRACT: HTS significantly enhances neutrophil-mediated intracellular killing of bacteria. This provides further evidence of the beneficial
effects of hypertonic resuscitation in the critically ill patient.
Irish Journal of Medical Science 04/2012; 171:10-10. · 0.58 Impact Factor
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ABSTRACT: These findings demonstrate for the first time that taurolidine can inhibit angiogenesis in a dose-dependent manner. Taurolidine
may prevent VEGF-mediated angiogenesis and thus it may potentially inhibit the growth of dormant micrometastases following
surgical removal of a primary tumour.
Irish Journal of Medical Science 04/2012; 171:10-11. · 0.58 Impact Factor
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Irish Journal of Medical Science 04/2012; 171:11-11. · 0.58 Impact Factor
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ABSTRACT: BackgroundRuptured abdominal aortic aneurysm (RAAA) presents with increased frequency in the winter and spring months. Seasonal changes
in atmospheric pressure mirrors this pattern.
AimTo establish if there was a seasonal variation in the occurrence of RAAA and to determine if there was any association with
atmospheric pressure changes.
MethodsA retrospective cohort-based study was performed. Daily atmospheric pressure readings for the region were obtained.
ResultsThere was a statistically significant monthly variation in RAAA presentation with 107 cases (52.5%) occurring from November
to March. The monthly number of RAAA and the mean atmospheric pressure in the previous month were inversely related (r = 0.752, r
2 = 0.566, P = 0.03), and there was significantly greater daily atmospheric pressure variability on days when patients with RAAA were
admitted.
ConclusionThese findings suggest a relationship between atmospheric pressure and RAAA.
Irish Journal of Medical Science 04/2012; 177(3):217-220. · 0.58 Impact Factor
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Irish Journal of Medical Science 04/2012; 171:49-50. · 0.58 Impact Factor
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ABSTRACT: These findings identify a novel pathway through which open surgery and laparoscopy differentially modulate perioperative tumour
angiogenesis and growth.
Irish Journal of Medical Science 04/2012; 171:50-51. · 0.58 Impact Factor
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ABSTRACT: Paediatric foreign body (FB) ingestion is a common problem and while most can be managed conservatively, a sub-population require intervention.
To establish clear guidelines for management of paediatric FB ingestion.
A retrospective chart review analysing all paediatric admissions with FB ingestion over a 10-year period from 1990 to 1999.
Of 339 patients presenting to the accident and emergency department with FB ingestion, 59 required admission. Ingestion was accidental in 93.0% of patients. The reasons for admission were as follows: large FBs; dangerous FBs; and living far from the hospital. Nineteen patients (32.2%) were discharged without intervention. Thirty-seven (62.7%) required endoscopic retrieval. In two, the FB was not identified at endoscopy. Only three (5%) required surgery.
Conservative management of FB ingestion in the paediatric population is possible in the majority of cases. However, a minority require intervention. While guidelines for intervention are ill-defined, definitive indications include symptomatic patients, or dangerous objects.
Irish Journal of Medical Science 04/2012; 170(2):100-2. · 0.58 Impact Factor
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Irish Journal of Medical Science 04/2012; 171:32-33. · 0.58 Impact Factor
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ABSTRACT: BackgroundPatients with Ulcerative Colitis (UC) have inherent prothrombotic tendencies. It is unknown whether this necessitates the
use of additional perioperative anti-thrombotic prophylaxis when such patients require major surgery.
MethodsThe postoperative courses of 79 patients with UC undergoing 180 major abdominal and pelvic operations were examined for clinical
and radiological evidence of venous thrombosis. Eighteen patients with Familial Adenomatous Polyposis (FAP) having surgery
(35 operations) of similar magnitude were also studied. Standard anti-thrombosis prophylaxis was utilised in all patients.
ResultsNine patients with UC were clinically suspected of developing postoperative venous thrombosis, but only three (3.8%) had their
diagnosis confirmed radiologically (all had a pulmonary embolus).Therefore, the overall postoperative thrombosis rate, on
an intention to treat basis, was 1.7% (3/180). No patient with FAP developed significant venous thrombosis.
ConclusionStandard perioperative antithrombotic modalities are sufficient to maintain any potential increase in postoperative thrombotic
risk at an acceptable level in patients with UC undergoing operative intervention.
Irish Journal of Medical Science 04/2012; 174(3):20-22. · 0.58 Impact Factor
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ABSTRACT: This study provides a novel insight into the adhesion molecule profile of micrometastatic epithelial cells in women with breast
cancer. The upregulation of ICAM-1 and αVβ3 reveals new evidence for the pro-angiogenic nature of micrometastatic cells and
may offer further therapeutic options.
Irish Journal of Medical Science 04/2012; 171:45-46. · 0.58 Impact Factor
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ABSTRACT: PurposeThis study analyzed whether prehospital or in-hospital delay was the more significant influence on perforation rates for acute
appendicitis and whether any clinical feature designated patients requiring higher surgical priority.
MethodsA retrospective analysis was conducted over one year at a tertiary referral hospital without a dedicated emergency surgical
theater. Admission notes, theater logbook, and the Hospital Inpatient Enquiry system were reviewed to identify the characteristics
and clinical course of patients aged greater than 16years who were operated upon for histologically confirmed acute appendicitis.
ResultsOne hundred and fifteen patients were studied. The overall perforation rate was 17 percent. The mean duration of symptoms
prior to hospital presentation was 38.1 hours with the mean in-hospital waiting time prior to operation being 23.4 hours.
Although body temperature on presentation was significantly greater in patients found to have perforated appendicitis (P < 0.05), only patient heart rate at presentation and overall duration of symptoms, but not in-hospital waiting time, independently
predicted perforation by stepwise linear regression modeling.
ConclusionIn-hospital delay was not an independent predictor of perforation in adults with acute appendicitis although delays may contribute
if patients are left to wait unduly. Tachycardia at presentation may be a quantifiable feature of those more likely to have
perforation and who should be given higher surgical priority.
Diseases of the Colon & Rectum 04/2012; 51(12):1823-1827. · 3.13 Impact Factor
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ABSTRACT: BackgroundRecombinant interleukin-2(rIL-2) therapy in metastatic melanoma is limited by toxicities, particularly vascular leak syndrome(VLS).
Taurolidine potentiates the anti-neoplastic effects of IL-2 while reducing its associated endothelial cell dysfunction in
experimental settings. We hypothesized that co-administration of rIL-2 with taurolidine could enhance tolerability without
weakening effectiveness.
MethodsEleven patients with progressive metastatic melanoma received high-dose rIL-2 with co-infusion of taurolidine. Patients were
monitored for the development of toxicities and evidence of response.
ResultsTen patients tolerated twenty-nine courses of high-dose rIL-2 without dose-reduction. Most toxicities were low-grade. No patient
developed VLS. Seven patients died from disease progression. Two had complete clinical and radiological responses to treatment.
Two patients remain alive despite evidence of disease progression a mean of 175 months after diagnosing metastatic disease.
ConclusionCo-administration of taurolidine with high-dose rIL-2 in stage IV melanoma patients appears to greatly enhance the tolerability
of this regime without diminishing its therapeutic value.
Irish Journal of Medical Science 04/2012; 175(1):10-14. · 0.58 Impact Factor
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ABSTRACT: BackgroundVolatile anaesthetic agents influence neutrophil function, and potentially, the inflammatory response to surgery.
AimThe objective of this study was to determine the effect of isoflurane (1–4%) on human polymorphonuclear neutrophil apoptosisin vitro.
MethodsVenous blood from 12 healthy volunteers was exposed to 0, 1, and 4% isoflurane delivered via a 14G Wallace flexihub internal
jugular cannula, at a fresh gas flow of 0.51/min for 5 minutes. Isolated neutrophils were assessed for apoptosis at 1, 12,
and 24 hours in culture using dual staining with annexin V-FITC and propidium iodide (Annexin-V FITC assay). Data were analysed
using paired, one-tailed Student’s t-tests. p<0.05 was considered significant.
ResultsAt 1 hour apoptosis was inhibited in the 1% (5.1 [6.8]%; p=0.017) and 4% (4.8 [4.5]%; p=0.008) isoflurane groups compared
to control (11.3 [6.9]%). At 12 and 24 hours, a dose-dependent inhibition of apoptosis was demonstrated, i.e. 4% > 1% > 0%.
ConclusionHuman neutrophil apoptosis is inhibited in a concentration-dependent mannerin vitro by isoflurane in clinical concentrations.
Irish Journal of Medical Science 04/2012; 170(1):41-44. · 0.58 Impact Factor
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ABSTRACT: Investigation of lower extremity pain is compromised by comorbid disorders that may interfere with conventional testing.
To compare pedal ergometry with conventional treadmill testing.
A prospective study was performed where patients presenting with a diagnosis of intermittent claudication were assessed by both methods of testing.
Of 78 patients studied with both tests, no exercise-induced ankle pressure changes occurred in 26, two were unable to complete either test despite normal pressure measurements, while 24 had exercise-induced pressure drop detected by both tests. Of patients who completed pedal ergometry, 21 were unable to complete the treadmill test, 14 of whom had negative ergometry, while seven had a pressure drop detected by pedal ergometry. Three had pressure changes with pedal ergometry, but not with treadmill testing and two had pressure changes on the treadmill not reproduced by pedal ergometry.
Pedal ergometer is more sensitive than treadmill testing in detecting arterial insufficiency, as indicated by a 20% or greater fall in ankle pressure, and more suitable in a subgroup of patients unable to tolerate conventional treadmill testing.
Irish Journal of Medical Science 04/2012; 170(3):169-71. · 0.58 Impact Factor
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ABSTRACT: To evaluate the role, if any, of sentinel lymph node mapping (SLNM) with biopsy (SLNB) in patients with thick cutaneous melanoma.
Consecutive patients with thick (Breslow ≥4 mm) cutaneous melanoma, undergoing SLNB were identified from a departmental database comprising 550 patients in total from 2000 to 2010. Factors examined included demographic data, histological subtype, site and depth of lesion, percentage of positive SLNs, regional recurrence in the setting of a negative SLNB result (false-negative rate), complications, further lymphadenectomy, and follow-up (disease free and overall survival), where available.
Sixty-four eligible patients (37 men, 27 women) underwent primary excision and SLNM. Median patient age was 59 years (range 8-82 years). Mean Breslow depth was 7 mm (range 4-19 mm). Thirty melanomas were located on the limbs, 19 on the head and neck and 15 on the trunk. Twenty-three (35%) were ulcerated. Of the 57 patients who had a sentinel node identified, 18 (31%) had metastatic melanoma identified. The mean survival time for patients with a negative SLN was 79 months versus 18 months for those with a positive node. Patients with a negative SLN have a 5 year disease free survival of 79% versus 11% (p < 0.001) and an overall 5 year survival rate of 85% versus 32% when compared to node positive patients.
The status of the SLN is predictive of disease recurrence and overall survival in patients with a thick primary cutaneous melanoma. This modality should be employed, where applicable, in this cohort of patients.
The surgeon: journal of the Royal Colleges of Surgeons of Edinburgh and Ireland 04/2012; 10(2):65-70. · 1.41 Impact Factor
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ABSTRACT: Axillary ultrasonography (AUS) and fine-needle aspiration cytology (FNAC) can establish axillary lymph node status before surgery, although this technique is hampered by poor adequacy rates. To achieve consistently high rates of FNAC adequacy, rapid on-site evaluation (ROSE) of FNAC samples was introduced.
This single-centre, retrospective observational study of patients with newly diagnosed breast cancer undergoing preoperative AUS and FNAC between February 2008 and November 2010 examined the effect of the introduction of ROSE.
A total of 381 patients were included. AUS revealed 152 axillae with suspicious radiological features. FNAC was positive for malignant cells in 75 (49·3 per cent) of 152 samples. Sentinel lymph node mapping was avoided in 75 patients, representing 19·7 per cent of the entire study population. Adequacy rates increased from 78 per cent to 96 per cent following the introduction of ROSE (P = 0·001). The overall sensitivity and specificity of AUS and FNAC was 80·6 and 100 per cent respectively. A lymph node diameter equal to or larger than 10 mm and extranodal extension were significantly associated with positive FNAC (P < 0·001 and P = 0·012 respectively). Maximum lymph node diameter of at least 10 mm was an independent predictor of positive FNAC (odds ratio 11·2, 95 per cent confidence interval 3·32 to 37·76; P < 0·001).
AUS with FNAC provided accurate preoperative staging of the axilla for metastatic breast disease and avoided unnecessary sentinel lymph node mapping. The introduction of ROSE ensured the efficiency of AUS and FNAC.
British Journal of Surgery 03/2012; 99(6):807-12. · 4.61 Impact Factor
