P J Guillou

Leeds Teaching Hospitals NHS Trust, Leeds, England, United Kingdom

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Publications (199)915.15 Total impact

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    ABSTRACT: New editions of the TNM staging system for colorectal cancer have been subject to extensive criticism. In the current study, we evaluate each edition of TNM and analyze stage migration caused by the different versions. Two independent test populations were used: participants derived from a randomized surgical trial from the United Kingdom (n = 455) and patients from a population-based series from Sweden (n = 505). All slides from these patient cases were reviewed with special attention for the presence of tumor deposits. Tumor deposits were classified according to the fifth, sixth, and seventh editions of TNM and correlated with prognosis. Every change in edition of TNM led to a stage migration of between 33% and 64% in patients with tumor deposits. Reproducibility was best in the fifth edition of TNM. The prognostic value of the seventh edition was best only when all tumor deposits irrespective of size or contour were included as lymph nodes. The prognostic value of the fifth edition was better than that of the sixth. We demonstrate there is a place for tumor deposits in the staging of patients with colorectal cancer. However, many questions remain about their definition and the reproducibility and use of this category in special situations, such as after neoadjuvant treatment. These should be the subject of additional research before use as a factor in TNM staging. This work demonstrates the necessity of testing modifications before their introduction.
    Journal of Clinical Oncology 06/2011; 29(18):2487-92. · 18.04 Impact Factor
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    ABSTRACT: The UK Medical Research Council CLASICC trial assessed the safety and efficacy of laparoscopically assisted surgery in comparison with open surgery for colorectal cancer. The results of the 5-year follow-up analysis are presented. Five-year outcomes were analysed and included overall and disease-free survival, and local, distant and wound/port-site recurrences. Two exploratory analyses were performed to evaluate the effect of age (70 years or less, or more than 70 years) on overall survival between the two groups, and the effect of the learning curve. No differences were found between laparoscopically assisted and open surgery in terms of overall survival, disease-free survival, and local and distant recurrence. Wound/port-site recurrence rates in the laparoscopic arm remained stable at 2.4 per cent. Conversion to open operation was associated with significantly worse overall but not disease-free survival, which was most marked in the early follow-up period. The effect of surgery did not differ between the age groups, and surgical experience did not impact on the 5-year results. The 5-year analyses confirm the oncological safety of laparoscopic surgery for both colonic and rectal cancer. The use of laparoscopic surgery to maximize short-term outcomes does not compromise the long-term oncological results. Registration number: ISRCTN74883561 (http://www.controlled-trials.com).
    British Journal of Surgery 11/2010; 97(11):1638-45. · 4.84 Impact Factor
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    ABSTRACT: This study investigated adhesive intestinal obstruction (AIO) and incisional hernia (IH) in patients undergoing laparoscopically assisted and open surgery for colorectal cancer. In a case-note review of patients randomized to the Medical Research Council's Conventional versus Laparoscopic-Assisted Surgery In Colorectal Cancer (CLASICC) trial, primary and key secondary endpoints were AIO and IH admission rates respectively. Of 411 patients, 11 were admitted for AIO: four (3.1 per cent) of 131 patients in the open arm of the trial versus seven (2.5 per cent) of 280 in the laparoscopic arm (difference 0.6 (95 per cent confidence interval (c.i.) - 2.9 to 4.0) per cent). Thirty-six patients developed IH: 12 (9.2 per cent) after open versus 24 (8.6 per cent) after laparoscopic surgery (difference 0.6 (95 per cent c.i. - 5.3 to 6.5) per cent). Results by actual procedure showed higher AIO and IH rates in the 24.5 per cent of patients who converted from laparoscopic to open surgery (AIO: 2.3, 2.0 and 6 per cent; IH: 8.6, 7.4 and 11 per cent-for open, laparoscopic and converted operations respectively). Although this study has not confirmed that laparoscopic surgery reduces rates of AIO and IH after colorectal cancer surgery, trends suggest that a reduction in conversion to open surgery and elimination of port-site hernias may produce such an effect. Registration number for CLASICC trial: ISRCTN74883561 (http://www.controlled-trials.com).
    British Journal of Surgery 01/2010; 97(1):70-8. · 4.84 Impact Factor
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    ABSTRACT: To understand the role of hypoxia in cancer progression of primary colorectal cancer and colorectal liver metastases. To look at associations of hypoxia with more aggressive phenotypes. Archival tissue was retrieved from 55 patients and tissue micro arrays were constructed using tissue from the margin and the centre of the tumour. Hypoxia markers Hif-1alpha, Vegf, CA-9, VHL and Glut-1 were visualised using immunohistochemical detection and quantified using semi-quantitative analysis of the digitised images. Clinical details and outcome data were retrieved by case note review and collated with hypoxia markers data in a statistical database. Significantly increased expression of all markers were found at the tumour margin compared to the tumour centre, both in primary colorectal cancer (CRC) and liver metastases. Pushing margin CRC was associated with increased Vegf expression. Positive correlations were observed between Hif-1alpha and Vegf (p<0.001), and Hif-1alpha and VHL (p<0.001) in primary CRC, but no relationship was seen between Hif-1alpha and either Glut-1 or CA-9. A significant trend to worse disease-free survival was also noted with increased margin expression of Hif-1alpha (p<0.001) and VHL (p=0.02) in primary CRC, but not for any of the other markers. This study underlines the importance of the invasive margin in colorectal cancer biology. It is the area most responsive to hypoxic influences and its dependence on its ability to up-regulate Hif-1alpha has a significant impact on disease-free survival.
    European journal of surgical oncology: the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology 06/2009; 35(12):1286-94. · 2.56 Impact Factor
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    ABSTRACT: Introduction: The benefits of neoadjuvant therapy in the treatment of patients with resectable oesophageal carcinoma are controversial. Patients with locally advanced carcinomas were entered into a phase II trial of preoperative chemotherapy and radiotherapy followed by oesophagectomy.Methods: Fifty-five patients aged <70 years with T3 ± N1 oesophageal tumours were recruited between February 1998 and July 2001. Patients received 12 weeks of chemotherapy with four cycles of cisplatin 60 mg m−2 plus infusional 5FU (300 mg m−2, days 1–42; 225 mg m−2, days 43–75). Radiotherapy 45Gy was administered on days 43–75. Two stage en-bloc oesophagectomy with two field lymphadenectomy was undertaken 6 weeks after neoadjuvant therapy.Results: Forty-one patients (74 per cent) completed the treatment. Two patients (3.6 per cent) died during neoadjuvant therapy (SVC obstruction, perforated diverticular disease), while four withdrew due to toxicity. In eight patients (14.5 per cent), the tumour progressed on therapy. Overall mortality was 5/55 (9.1 per cent) with a postoperative mortality of 3/41 (7.3 per cent). Significant postoperative morbidity was observed in 19/41 (46.3 per cent). The tumour was downstaged in 34/41 (83 per cent) with a pathological complete response in 26.8 per cent. Median lymph node yield was 18, there was no proximal or distal margin involvement and a positive circumferential margin in 25 per cent. Median survival on an intention to treat basis was 26 months, and it was 38 months in the patients who underwent surgical resection.Conclusions: Preoperative neoadjuvant therapy followed by en-bloc oesophagectomy can be undertaken with acceptable levels of morbidity and mortality. The survival data appears promising and this study should act as a platform for the initiation of a phase III multicentre trial.
    British Journal of Surgery 01/2009; 89(S1):35 - 36. · 4.84 Impact Factor
  • British Journal of Surgery - BRIT J SURG. 01/2009; 89:46-47.
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    ABSTRACT: The morphology of the invasive margin in colorectal cancer can be described as either pushing or infiltrative. These phenotypes carry prognostic significance, particularly in node negative disease, and provide an excellent model for the study of invasive behaviour in vivo. The marginal edges of 16 stage-matched tumours exhibiting these contrasting growth patterns were microdissected. The extracted mRNA was amplified and hybridised to a 9546 feature oligonucleotide array. Selected differentials were validated using real-time polymerase chain reaction and the protein product was interrogated by using immunohistochemistry. After stringent quality control and filtering of data generated, 39 genes were identified as being significantly differentially expressed between the two types of marginal edge. Several genes involved in cellular metabolism were identified as differentials including lactate dehydrogenase B (LDHB) and modulators of glucose transport. The LDH expression profile differs between the invasive phenotypes. A hypothesis is proposed in which altered metabolism is a cause of contrasting invasive behaviour independent of the hypoxia-inducible factor mediated hypoxic response, consistent with the Warburg phenomenon.
    Gut 11/2008; 58(3):404-12. · 10.73 Impact Factor
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    ABSTRACT: Tumour hypoxia has been shown to be a predictor of early distant relapse in node-negative breast and cervical cancer. The purpose of the present study was to determine the role of hypoxia in predicting patients who are at high risk of disease recurrence in Dukes B colorectal cancers. Archival tissue was retrieved from 52 patients who had undergone surgical resection for primary colorectal cancer. Tissue micro-arrays were constructed using tissue from the margin and the centre of the tumour. Hypoxia markers hypoxia-inducible factor (Hif)-1 alpha, vascular endothelial growth factor (VEGF), carbonic anhydrase (CA)-9 and glucose transporter (Glut)-1 were visualised using immunohistochemical detection and quantified using semi-quantitative analysis of the digitised images. Clinical details and outcome data were retrieved by case note review and collated with hypoxia markers data in a statistical database. Primary colorectal cancers with a high Hif-1 alpha expression tended to have a significantly worse disease-free survival (log rank p < 0.001) and overall survival (log rank p = 0.012). VEGF was also a significant predictor of disease recurrence in primary colorectal cancers (p = 0.015). Significant correlations were also noted between Hif-1 alpha and VEGF (Pearson's p = 0.009). Glut-1 and CA-9 did not show a similar pattern with no differences in the expression pattern and no correlation observed with any of the markers. Multivariate analysis of prognostic factors showed vascular invasion (p < 0.001) and Hif-1 alpha at the tumour margin (p < 0.001) to be independent predictors for the development of liver metastases. These results suggest an important role for Hif-1 alpha and VEGF in colorectal cancer progression, with both markers biological mechanisms directly interlinked through the hypoxic pathway. Identification of high-risk patients using the above factors will improve treatment strategies in node-negative disease and help improve patient outcome.
    International Journal of Colorectal Disease 08/2008; 23(11):1049-55. · 2.24 Impact Factor
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    ABSTRACT: Intraoperative conversion from laparoscopically assisted to open surgery for colorectal cancer is thought to be influenced by several patient factors. Analysis of the Conventional versus Laparoscopic-Assisted Surgery In Colorectal Cancer (CLASICC) Trial data aimed to identify these risk factors. Of 488 laparoscopically assisted procedures attempted, 143 (29.3 per cent) were converted to open operation. Patient factors considered in multivariable analyses were age, sex, previous abdominal incisions, body mass index (BMI), tumour site, tumour diameter, pathological tumour (pT) and pathological node (pN) stage, extent of tumour spread from the muscularis propria, liver and peritoneal metastases, and American Society of Anesthesiologists (ASA) grade. As BMI was missing for 30.7 per cent of patients, two approaches were employed: one considered BMI as a possible risk factor and one did not. When BMI was taken into consideration, male sex (odds ratio (OR) 2.07; P = 0.020), BMI (OR 1.10; P = 0.006) and extent of tumour spread from the muscularis propria (OR 1.08; P < 0.001) were independent predictors of conversion. When BMI was not considered, extent of tumour spread (OR 1.07; P < 0.001) and male sex (OR 2.05; P = 0.004) were again identified, as were tumour site (OR 2.11; P = 0.005) and ASA grade (II versus I, OR 0.92; III versus I, OR 2.74; P = 0.012). Intraoperative conversion is more likely with larger BMI, in men, patients with rectal cancer, those graded ASA III or when there is greater local tumour spread.
    British Journal of Surgery 02/2008; 95(2):199-205. · 4.84 Impact Factor
  • Journal de Chirurgie. 02/2008; 145(1):80.
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    ABSTRACT: The aim of the current study is to report the long-term outcomes after laparoscopic-assisted surgery compared with conventional open surgery within the context of the UK MRC CLASICC trial. Results from randomized trials have indicated that laparoscopic surgery for colon cancer is as effective as open surgery in the short term. Few data are available on rectal cancer, and long-term data on survival and recurrence are now required. The United Kingdom Medical Research Council Conventional versus Laparoscopic-Assisted Surgery in Colorectal Cancer (UK MRC CLASICC; clinical trials number ISRCTN 74883561) trial study comparing conventional versus laparoscopic-assisted surgery in patients with cancer of the colon and rectum. The randomization ratio was 2:1 in favor of laparoscopic surgery. Long-term outcomes (3-year overall survival [OS], disease-free survival [DFS], local recurrence, and quality of life [QoL]) have now been determined on an intention-to-treat basis. Seven hundred ninety-four patients were recruited (526 laparoscopic and 268 open). Overall, there were no differences in the long-term outcomes. The differences in survival rates were OS of 1.8% (95% CI, -5.2% to 8.8%; P = .55), DFS of -1.4% (95% CI, -9.5% to 6.7%; P = .70), local recurrence of -0.8% (95% CI, -5.7% to 4.2%; P = .76), and QoL (P > .01 for all scales). Higher positivity of the circumferential resection margin was reported after laparoscopic anterior resection (AR), but it did not translate into an increased incidence of local recurrence. Successful laparoscopic-assisted surgery for colon cancer is as effective as open surgery in terms of oncological outcomes and preservation of QoL. Long-term outcomes for patients with rectal cancer were similar in those undergoing abdominoperineal resection and AR, and support the continued use of laparoscopic surgery in these patients.
    Journal of Clinical Oncology 08/2007; 25(21):3061-8. · 18.04 Impact Factor
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    ABSTRACT: The nature of the invasive growth pattern and microvessel density (MVD) have been suggested to be predictors of prognosis in primary colorectal cancer (CRC) and colorectal liver metastases. The purpose of the present study was to determine whether these two histological features were interrelated and to assess their relative influence on disease recurrence and survival following surgical resection. Archival tissue was retrieved from 55 patients who had undergone surgical resection for primary CRC and matching liver metastases. The nature of the invasive margin was determined by haematoxylin and eosin (H&E) histochemistry. Microvessel density was visualised using immunohistochemical detection of CD31 antigen and quantified using image capture computer software. Clinical details and outcome data were retrieved by case note review and collated with invasive margin and MVD data in a statistical database. Primary CRCs with a pushing margin tended to form capsulated liver metastases (P<0.001) and had a significantly better disease-free survival than the infiltrative margin tumours (log rank P=0.01). Primary cancers with a high MVD tended to form high MVD liver metastases (P=0.007). Microvessel density was a significant predictor of disease recurrence in primary CRCs (P=0.006), but not liver metastases. These results suggest that primary CRCs and their liver metastases show common histological features. This may reflect common mechanisms underlying the tumour-host interaction.
    British Journal of Cancer 04/2007; 96(7):1112-7. · 5.08 Impact Factor
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    ABSTRACT: To perform a meta-analysis of trials randomizing patients with colon cancer to laparoscopically assisted or open colectomy to enhance the power in determining whether laparoscopic colectomy for cancer is oncologically safe. The databases of the Barcelona, Clinical Outcomes of Surgical Therapy (COST), Colon Cancer Laparoscopic or Open Resection (COLOR), and Conventional vs Laparoscopic-Assisted Surgery in Patients With Colorectal Cancer (CLASICC) trials were the data sources for the study. Patients who had at least 3 years of complete follow-up data were selected. Patients who had undergone curative surgery before March 1, 2000, were studied. Three-year disease-free survival and overall survival were the primary outcomes of this analysis. Of 1765 patients, 229 were excluded, leaving 796 patients in the laparoscopically assisted arm and 740 patients in the open arm for analysis. Three-year disease-free survival rates in the laparoscopically assisted and open arms were 75.8% and 75.3%, respectively (95% confidence interval [CI] of the difference, -5% to 4%). The associated common hazard ratio (laparoscopically assisted vs open surgery with adjustment for sex, age, and stage) was 0.99 (95% CI, 0.80-1.22; P = .92). The 3-year overall survival rate after laparoscopic surgery was 82.2% and after open surgery was 83.5% (95% CI of the difference, -3% to 5%). The associated hazard ratio was 1.07 (95% CI, 0.83-1.37; P = .61). Disease-free and overall survival rates for stages I, II, and III evaluated separately did not differ between the 2 treatments. Laparoscopically assisted colectomy for cancer is oncologically safe.
    Archives of Surgery 04/2007; 142(3):298-303. · 4.10 Impact Factor
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    ABSTRACT: Pancreatic body carcinoma has a poor prognosis with advanced disease at presentation. Recent experience at multidisciplinary team (MDT) meetings suggests increasing prevalence. Our aim was to determine if introduction of MDT meetings has affected the natural history of this disease. Retrospective diagnostic and survival data were collected from 1995 to 2006 at two large teaching hospitals, and divided into pre- and post 2003 groups (based on MDT introduction). Thirty-one patients with pancreatic body carcinoma (median age at diagnosis 72 years; range 43-87 years). Commonest symptoms at presentation were abdominal pain and weight loss. Eight patients (25.8%) were diagnosed pre MDT (median age 71.5 years, range: 60-87 years) and 23 patients (74.2%) were diagnosed post MDT (median age 67 years, range: 43-85 years; P=0.299 vs. pre MDT). There was a significantly (P=0.024) greater prevalence of more advanced tumours post MDT (stage IV: 15/23, 65.2%) than pre MDT (stage IV: 2/8, 25.0%). Neither tumour markers nor liver biochemistry differentiated tumour stage. Best supportive care was offered to 16 patients (51.6%) while 12 patients (38.7%) were suitable for chemotherapy: 2 out of 8 pre MDT (25.0%) and 10 out of 23 (43.5%) post MDT (P=0.433). For stage III tumours, post MDT patients tended to be younger (median 59 years vs. 74.5 years, P=0.042). Survival was not significantly increased after MDT introduction but chemotherapy offered significant survival benefit on multivariate analysis (P=0.042; hazard ratio: 0.39, 95% CI: 0.16-0.97). The trend is towards increased prevalence of pancreatic body cancer and more advanced disease at presentation. Chemotherapy was associated with a survival benefit, although the introduction of the MDT has not significantly altered disease management.
    JOP: Journal of the pancreas 02/2007; 8(3):312-9.
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    ABSTRACT: Resection margin (RM) status in pancreatic head adenocarcinoma is assessed histologically, but pathological examination is not standardized. The aim of this study was to assess the influence of standardized pathological examination on the reporting of RM status. A standardized protocol (SP) for pancreaticoduodenectomy specimen examination, involving multicolour margin staining, axial slicing and extensive tissue sampling, was developed. R1 resection was defined as tumour within 1 mm of the RM. A prospective series reported according to this protocol (SP series, n = 54) was compared with a historical matched series in which a non-standardized protocol was used (NSP series, n = 48). Implementation of the SP resulted in a higher R1 rate overall, and for pancreatic (22 of 26 85 per cent) compared with ampullary (four of 15) and bile duct (six of 13) cancer. Sampling of the circumferential RM was more extensive in the SP series and correlated with RM status. RM involvement was often multifocal (14 of 32), affecting the posterior RM most frequently (21 of 32). Survival correlated with RM status for the entire SP series (P < 0.001), but not for the NSP series. There was a trend towards better median and actuarial 5-year survival after R0 resection in the SP pancreatic cancer subgroup. Standardized examination influences the reporting of RM status.
    British Journal of Surgery 11/2006; 93(10):1232-7. · 4.84 Impact Factor
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    ABSTRACT: The short-term clinical results of the CLASICC trial indicated that clinical outcomes were similar between laparoscopic and open approaches. This study presents the short-term (3 month) cost analysis undertaken on a subset of patients entered into the CLASICC trial (682 of 794 patients). As expected the costs associated with the operation were higher in the 452 patients randomised to laparoscopic surgery (lap) compared with the 230 randomised to open procedure (open), Pounds 1703 vs Pounds 1386. This was partially offset by the other hospital (nontheatre) costs, which were lower in the lap group (Pounds 2930 vs Pounds 3176). The average cost to individuals for reoperations was higher in the lap group (Pounds 762 vs Pounds 553). Overall costs were slightly higher in the lap group (Pounds 6899 vs Pounds 6631), with mean difference of Pounds 268 (95%CI -689 to 1457). Sensitivity analysis made little difference to these results. The cost of rectal surgery was higher than for colon, for lap (Pounds 8259 vs Pounds 5586) and open procedures (Pounds 7820 vs Pounds 5503). The short-term cost analysis for the CLASICC trial indicates that the costs of either laparoscopic or open procedure were similar, lap surgery costing marginally more on average than open surgery.
    British Journal of Cancer 08/2006; 95(1):6-12. · 5.08 Impact Factor
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    ABSTRACT: Solid pseudopapillary tumour of the pancreas is an uncommon tumour, which predominantly occurs in young females and is of unknown origin. We describe five cases with diverse clinical and/or histological features, including one unusually aggressive case resulting in early death. There is great variability in the presentation and clinical course of these tumours with further research needed to define their histogenesis and biological behaviour.
    JOP: Journal of the pancreas 02/2006; 7(6):635-42.
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    ABSTRACT: This paper reports a series of patients with Mirizzi's syndrome (MS) who were managed at our institution over an 11-year (1994-2005) period. Retrospective case note study of patients with a definitive or possible diagnosis of MS stated in radiology reports were identified using the hospital's radiology computer coding system. 33 patients were identified with a median age of diagnosis of 70 (35-90) years and male to female ratio of 15:18. Liver function tests were deranged in all patients. Pre-operative radiological diagnosis was achieved in 28 patients: ultrasound scan (n = 4), computer tomography (n = 3), magnetic resonance cholangiopancreatography (n = 10) and endoscopic retrograde cholangiopancreatography (n = 11). Five patients were diagnosed intra-operatively. Type I MS was reported in 27 patients. Laparoscopic cholecystectomy was attempted in 18 patients with 6 being converted to open cholecystectomy. Six patients had biliary stent insertion only and 3 were conservatively managed. Six patients had type II MS, 4 were treated with open cholecystectomy and Roux-en-Y hepaticojejunostomy, 1 underwent an open subtotal cholecystectomy with fistula closure and 1 had percutaneous biliary stent insertion only. The median follow-up period was 2 (1-7) months (n = 18). 10 patients are currently under follow-up. Overall morbidity was 27% (n = 8) and mortality was 7% (n = 2). Pre-operative diagnosis of MS can be achieved using MRCP. Laparoscopic cholecystectomy for type I MS is a safe option and type II MS can be treated with Roux-en-Y hepaticojejunostomy or subtotal cholecystectomy with fistula closure.
    HPB 02/2006; 8(6):474-9. · 1.94 Impact Factor
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    ABSTRACT: Although there exists multiple modalities of managing traumatic pancreatic pseudocysts it remains a diagnostic and therapeutic challenge. We report herein a case that was successfully managed by endoscopic ultrasound guided transgastric stent placement. A 28-year-old female jockey presented with abdominal pain after being kicked by a horse. Computerised tomography and magnetic resonance imaging revealed pancreatitis which resolved with conservative treatment. She proceeded to develop a pancreatic pseudocyst demonstrated on a magnetic resonance cholangiopancreatogram. This was managed by transgastric placement of two double pigtail stents into the pseudocyst by endoscopic ultrasound guidance. Rapid recovery followed with the patient remaining well on follow up. EUS guided transgastric stent placement for drainage of pancreatic pseudocysts is recommended particularly if they are in close proximity to the stomach.
    JOP: Journal of the pancreas 02/2006; 7(4):423-6.
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    D Gomez, SH Rahman, PJ Guillou
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    ABSTRACT: Mesenteric haematomas are a rare surgical presentation and are associated with trauma, pancreatitis or anticoagulation treatment. We report two cases diagnosed as spontaneous mesenteric haematomas. In both cases, MRI was diagnostic of a mesenteric haematoma and both cases were managed conservatively with interval imaging until complete resolution of the haematomas. We discuss the clinical features, diagnostic modalities and management options of mesenteric haematomas in the light of the literature. We emphasise the importance of radiological imaging to delineate the underlying pathology and appropriate management strategies. In the absence of obvious underlying pathology, spontaneous mesenteric haematomas can be managed conservatively.
    01/2006;

Publication Stats

6k Citations
915.15 Total Impact Points

Institutions

  • 2002–2010
    • Leeds Teaching Hospitals NHS Trust
      • Department of Pathology
      Leeds, England, United Kingdom
  • 1986–2009
    • University of Leeds
      • • Leeds Institute of Health Sciences (LIHS)
      • • Division of Clinical Trials Research
      • • School of Medicine
      Leeds, England, United Kingdom
  • 1990–2008
    • Saint James School Of Medicine
      Park Ridge, Illinois, United States
    • St. Vincent's Private Hospital
      Dublin, Leinster, Ireland
  • 2006
    • University of West London
      Londinium, England, United Kingdom
  • 2005
    • Nottinghamshire Healthcare NHS Trust
      Nottigham, England, United Kingdom
  • 1999
    • St. James University
      Saint James, New York, United States
  • 1995
    • University of Hull
      Kingston upon Hull, England, United Kingdom
  • 1989–1995
    • Imperial College Healthcare NHS Trust
      Londinium, England, United Kingdom
  • 1994
    • Ashford Hospital
      Tarndarnya, South Australia, Australia