British Journal of Surgery

Watt, S M; Fox, A

doi: 10.1002/bjs.5238pmid: 16308849

Abstract This article continues the Journal's ‘Scientific Surgery’ series of leaders. The aim of the series, published throughout 2005, has been to highlight areas of bioscience that, while still largely confined to the experimental laboratory, may soon be brought into the clinical domain. In this month's paper Watt and Fox offer an up to date insight into the processes of tissue healing and suggest possible future therapeutic strategies. An organized cascade of cellular and biochemical events, triggered by injury, results in a healed wound1. From wounding to complete healing, the injured tissue progresses through a continuum of timed and balanced events. For easier conceptualization, the wound healing response has traditionally been divided into distinct, but overlapping, phases: coagulation, which begins immediately after injury; an inflammatory response proportionate to the extent of injury; cell migration and proliferation beginning within hours to days; and, finally, tissue remodelling, which may take up to a year or more. Normal wound repair includes an angiogenic response that allows delivery of nutrients, mediators and cells to injured tissue1. This response facilitates the removal of debris, development of granulation tissue and repair of the blood vessels themselves. Growth regulators, inflammatory cells, stromal cells and stem/progenitor cells orchestrate and coordinate these processes. The ability to provide an adequate local microcirculation is pivotal not only to the wound healing occurring in numerous physiological and pathological processes, but also for the survival and progressive expansion of tumour cells in various malignancies. Once the vascular system has formed in the developing embryo2, further neovascularization in response to tissue damage proceeds by one of two potential mechanisms3–5. The first of these is angiogenesis, or the formation of new vessels by sprouting from pre-existing vessels. The second is vasculogenesis, or the de novo differentiation of endothelial cells from their precursors, which can circulate in the peripheral blood. It is well established that haemopoietic and endothelial stem cells (HSCs and ESCs respectively) develop in a highly coordinated manner during embryonic development, arising from either a common precursor, the haemangioblast2,3, or with HSCs arising from haemogenic endothelium6. Although the stages of lineage development from HSCs to mature haemopoietic end cells are well defined, those from ESCs to mature functioning endothelial cells are not. In addition, the postnatal origin of endothelial stem/precursor cells remains a matter of some debate. Murasawa and Asahara4 were first to demonstrate that endothelial precursor cells could be isolated from human postnatal peripheral blood. Subsequently, it became clear in bone marrow-transplanted patients that these circulating endothelial precursors originated both from existing vessel walls and from the transplanted bone marrow itself, with the latter having much greater proliferative potential3–7. Indeed, human endothelial progenitors could be differentiated into endothelial cells in vitro and, in non obese diabetic/severe combined immunodeficient (NOD/SCID) murine models of bone marrow transplantation, could become incorporated into areas of active angiogenesis3–7. This was later confirmed in canine models3–7. Some recent studies support the proposal that endothelial precursors are derived from postnatal bone marrow3,8, but others do not3,5,9. For example, using an in vivo model of graded vascular ischaemia, Tepper et al.8 demonstrated that genetically marked endothelial precursors derived entirely from transplanted bone marrow contributed to neovascularization of the wound. In contrast, using other cell tracking techniques, endothelial precursors from the bone marrow have been shown to play a less significant role in neovascularization of tumours and damaged tissues3,9. The resolution of these issues rests on a more robust definition of the endothelial precursor cell hierarchy, the stages of their lineage development, their functional capacities, the niches in which they normally reside, the type of tissue damage and the timing of the analyses. Three or four types of endothelial precursor cell that are the progeny of ESCs have been defined experimentally on the basis of phenotype and/or proliferative ability in vitro. Those most commonly cited, endothelial outgrowth cells (EOCs), endothelial progenitor cells (EPCs) and circulating endothelial cells (CECs), have been described fully elsewhere3–7. CECs are thought to represent the most mature of these precursors, displaying limited proliferative potential in vitro. EPCs are reported to be either primitive CD133-positive precursors or cells expressing the ‘monocytic’ marker CD14. The EOC subset is reported to be derived from bone marrow. In an attempt to define the developmental lineage of these precursors more precisely, Yoder's group has made a concerted effort to analyse their proliferative potential in defined clonogenic assays in vitro5. They have demonstrated that high proliferative potential endothelial colony-forming cells (HPP-ECFCs) give rise to low proliferative potential endothelial colony-forming cells (LPP-ECFCs) that subsequently generate endothelial cell clusters and then mature endothelial cells. This hierarchy is reminiscent of that of the myeloid lineage within the haemopoietic system6. The endothelial precursors are found both in the circulation postnatally and as resident cells lining the aorta and umbilical veins5. HPP-ECFCs generate secondary HPP-ECFC-derived colonies on replating, whereas LPP-ECFCs give rise to endothelial clusters with fewer numbers of cells. Interestingly, cord blood HPP-ECFCs have a higher proliferative capacity than those from adult peripheral blood, with approximately 60 per cent of the colonies derived from cord blood HPP-ECFCs containing between 2000 and 10 000 cells, and some containing approximately 1012 cells. The relationship of EOCs, EPCs and CECs to the hierarchy of cells defined by Yoder and colleagues remains to be established, and awaits a combination of cell marker-based cell sorting and transplantation strategies. The local microenvironment plays a critical role in regulating the function of endothelial precursors, but its elements are not yet fully understood. Wounding, for example, alters this environment causing the local production of chemokines and cytokines (for example vascular endothelial growth factor, CXC chemokine ligand CXCL-12, platelet-derived growth factor, fibroblast growth factor, angiopoietins, transforming growth factor β, tumour necrosis factor α) that provide the stimulus for the mobilization of endothelial progenitors from bone marrow, and/or for circulating or resident endothelial precursors to travel to the damaged tissue and effect vessel repair3–7. Tepper et al.8 have demonstrated, in response to ischaemic injury, that chemokines activate the local endothelium within the damaged tissue and attract circulating endothelial precursors that adhere to the activated endothelium at the site of injury, proliferate in response to the hypoxic environment and generate a new blood supply. There are essentially three potential therapeutic strategies for the use of endothelial precursors in wound healing and tissue repair. First, they may be used as biomarkers to predict risk of, or response to, tissue injury10. Second, endothelial precursors mobilized into the circulation by growth regulators may provide a source of vascular progenitors to facilitate neovascularization. This has obvious therapeutic potential where skin wound healing is delayed, for instance in diabetes mellitus, burns and ischaemic cardiovascular disease3–7,10. Although endothelial precursors represent less than 0·5 per cent of all circulating cells, they may be expanded ex vivo and subsequently transplanted to enhance neovascularization in humans. Indeed, clinical trials are already investigating the therapeutic and diagnostic potential of these cells3–7. The third strategy is to manipulate these precursor cells in vivo to enhance their ability for vascular repair. Ongoing research will clarify the mechanisms of postnatal vasculogenesis, and the degree to which this process contributes to new vessel formation in pathophysiological states, such as delayed or excessive wound healing. A better understanding of the type and origin of the endothelial precursors, and the signalling pathways involved in their mobilization, homing, survival and proliferation, will eventually allow optimization of their therapeutic value. Acknowledgements The authors' work is funded by the NHS Research and Development Directorate, the Network for Translational Research and Cancer, the Leukaemia Research Fund, the Medical Research Council, the British Heart Foundation and the Wellcome Trust. A.F. is a Duke of Kent Fellow and receives support from the Royal College of Surgeons of Edinburgh, the Robert McAlpine Foundation and the Stoke Mandeville Burns and Reconstructive Surgery Research Trust. Only selected articles have been cited here owing to space constraints, but the authors acknowledge all researchers who have contributed to this field. References 1 RAF Clark . The Molecular and Cellular Biology of Wound Repair (2nd edn). Plenum Publishing : New York , 1998 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 2 Cogle CR , Scott EW. The hemangioblast: cradle to clinic . Exp Hematol 2004 ; 32 : 885 – 890 . Google Scholar OpenURL Placeholder Text WorldCat 3 Rumpold H , Wolf D, Koeck R, Gunsilius E. Endothelial progenitor cells: a source for therapeutic vasculogenesis? J Cell Mol Med 2004 ; 8 : 509 – 518 . Google Scholar OpenURL Placeholder Text WorldCat 4 Murasawa S , Ashahara T. Endothelial progenitor cells for vasculogenesis . Physiology (Bethesda) 2005 ; 20 : 36 – 42 . Google Scholar OpenURL Placeholder Text WorldCat 5 Ingram DA , Caplice NM, Yoder MC. Unresolved questions, changing definitions and novel paradigms for defining endothelial progenitor cells . Blood 2005 ; 106 : 1525 – 1531 . Google Scholar OpenURL Placeholder Text WorldCat 6 Watt SM , Contreras M. Stem cell medicine: umbilical cord blood and its stem cell potential . Semin Fetal Neonatal Med 2005 ; 10 : 209 – 220 . Google Scholar OpenURL Placeholder Text WorldCat 7 Urbich C , Dimmeler S. Endothelial progenitor cell characterisation and role in vascular biology . Circ Res 2004 ; 95 : 324 – 332 . Google Scholar OpenURL Placeholder Text WorldCat 8 Tepper OM , Capla JM, Galiano RD, Ceradini DJ, Callaghan MJ, Kleinman ME et al. Adult vasculogenesis occurs through in situ recruitment, proliferation, and tubulization of circulating bone marrow-derived cells . Blood 2005 ; 105 : 1068 – 1077 . Google Scholar OpenURL Placeholder Text WorldCat 9 Stadtfeld M , Graf T. Assessing the role of hematopoietic plasticity for endothelial and hepatocyte development by non-invasive lineage tracing . Development 2005 ; 132 : 203 – 213 . Google Scholar OpenURL Placeholder Text WorldCat 10 Werner N , Kosiol S, Schiegl T, Ahlers P, Walenta K, Link A et al. Circulating endothelial progenitor cells and cardiovascular outcomes . N Engl J Med 2005 ; 353 : 999 – 1007 . Google Scholar OpenURL Placeholder Text WorldCat Copyright © 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Copyright © 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Roblick, U J; Auer, G

doi: 10.1002/bjs.5239pmid: 16308851

Abstract This article concludes the Journal's ‘Scientific Surgery’ series of leaders. The series, published throughout 2005, has highlighted areas of bioscience that may soon be transferred from the laboratory into the clinical sphere. In this final paper Roblick and Auer consider the future role of the surgeon in the era of the ‘diagnostic chip’. The term ‘proteome’ was coined to describe a set of proteins that is encoded by a genome. It is the dynamic component that continuously changes in the phenomenon that is cell life. Proteomic research approaches issues that cannot be addressed by DNA investigations, for instance protein abundance, post-translational polypeptide modification and protein–protein interactions, as well as functional and dynamic processes within the cell. The two fundamental areas in proteome research are protein profiling and functional proteomics. Protein profiling, or expression proteomics, can evaluate protein expression in diseased tissue (such as tumour), in normal tissue and in body fluid samples1. It is a technique that is typically used to screen for expression differences between tumour samples and healthy controls to define disease markers. Functional proteomics, on the other hand, evaluates protein–protein and protein–non-protein (RNA, DNA etc.) interactions, and protein post-translational modifications. Here, experimental design is aimed at the molecular pathways that drive cellular activities in health and disease. Proteome science is on the way to revolutionizing molecular medicine. In the next 5 years the translation of proteomic data and its transfer ‘from bench to bed’ is expected to provide those who develop cancer treatments with new knowledge. Information about a neoplasm's biological behaviour will become available, with new insight into disease progression and response to different treatment strategies; new diagnostic tools will be discovered. A number of studies have already demonstrated that entity-specific protein profiles can distinguish normal tissue from tumour samples2–6. In addition, histological subtypes of tumours can be distinguished, based on their specific patterns of expression. Diagnosis at this molecular level greatly improves classification, and this is true even for poorly differentiated tumours, which are still a diagnostic challenge for routine pathology. Although an understanding of the link between protein expression pattern and prognosis is still at an early stage, several recent publications suggest a profound future impact of proteome science6–9. But what is the surgeon's role in all of this? To answer this one must remember that it is the surgeon who guides the multidisciplinary treatment of a patient, and so it is the surgeon who may build the necessary bridge between cancer victim and proteomic research. Events will rely on the surgeon's ability to collect representative clinical material, which must be correlated with clinical outcome and response to treatment. It is the surgeon who must organize the logistic pathway, from obtaining a patient's written consent, to sample collection in the operating room, and delivery to the pathologist and the proteomic laboratory. If protein denaturation is to be avoided, he or she must guarantee efficient sampling, with short ischaemic times, addition of protease inhibitors and immediate freezing. In addition, a major role for the surgeon within the field of clinical proteomics lies in focusing the basic scientist on clinically relevant problems. Past experience suggests that the surgical specialist's opinion plays a pivotal role in planning the experimental set-up. This requires a basic understanding of proteomic principles on the part of the surgeon if he or she is to interact competently with the molecular biologist. For effective proteomic–translational research, specialized ‘systems biology’ facilities are needed and these include multidisciplinary collaborators. Surgeons (sample collection, clinical background and follow-up, experimental design), pathologists (tissue charcterization, immunohistochemistry, staging, grading), molecular biologists and chemists (drug design) must work side by side. Such collaboration will, in the future, become the basis of proteomic centres. As the human genome project nears completion, proteomic results will be included to provide new information about dynamic cell processes. The aim of the Human Proteome Organization, to identify the human proteome, is a challenging one, and the evaluation of polypeptide functions and their function-related structures may take many years. Still, the power of laser capture microdissection, two-dimensional gel electrophoresis, protein chip technologies and, especially, advances in mass spectrometry have combined to enhance throughput and reproducibility in protein science. Molecular profiling may soon eliminate subjective pathological classification and improve on the diagnostic accuracy obtained through conventional histopathological and immunohistochemical techniques. The upcoming ‘diagnostic chip’ era, based on proteome research inter alia, should permit a clinical approach to cancer management that is tailored to a specific tumour, which in turn will ensure that the individual patient derives the maximum benefit. The clinical management of cancer today is based on rigid therapeutic regimens that often overtreat the many in order to help the few. Proteomics will help to identify those patients who are likely to derive the greatest benefit from specific treatment options (surgical excision, radiation, chemotherapy). This field of research will bring the discovery of new biological markers for cancer, with more specific tumour classification as a consequence. Individualized treatment strategies will result. The technical challenges in proteomics must be addressed in an interdisciplinary way; more and larger studies are needed and the surgeon's role in all of this should not be underestimated. References 1 Celis JE , Gromov P. Proteomics in translational cancer research: toward an integrated approach . Cancer Cell 2003 ; 3 : 9 – 15 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Roblick UJ , Hirschberg D, Habermann JK, Palmberg C, Becker S, Kruger S et al. Sequential proteome alterations during genesis and progression of colon cancer . Cell Mol Life Sci 2004 ; 61 : 1246 – 1255 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 3 Alaiya AA , Roblick UJ, Franzen B, Bruch HP, Auer G. Protein expression profiling in human lung, breast, bladder, renal, colorectal and ovarian cancers . J Chromatogr B Analyt Technol Biomed Life Sci 2003 ; 787 : 207 – 222 . Google Scholar Crossref Search ADS PubMed WorldCat 4 Alaiya AA , Oppermann M, Langridge J, Roblick U, Egevad L, Brindstedt S et al. Identification of proteins in human prostate tumor material by two-dimensional gel electrophoresis and mass spectrometry . Cell Mol Life Sci 2001 ; 58 : 307 – 311 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Alaiya A , Roblick U, Egevad L, Carlsson A, Franzen B, Volz D et al. Polypeptide expression in prostate hyperplasia and prostate adenocarcinoma . Anal Cell Pathol 2000 ; 21 : 1 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 6 Adam L , Kassouf W, Dinney CP. Clinical applications for targeted therapy in bladder cancer . Urol Clin North Am 2005 ; 32 : 239 – 246 . Google Scholar Crossref Search ADS PubMed WorldCat 7 Alaiya A , Al-Mohanna M, Linder S. Clinical cancer proteomics: promises and pitfalls . J Proteome Res 2005 ; 4 : 1213 – 1222 . Google Scholar Crossref Search ADS PubMed WorldCat 8 Baak JP , Janssen EA, Soreide K, Heikkilae R. Genomics and proteomics—the way forward . Ann Oncol 2005 ; 16 ( Suppl 2 ): ii30 – ii44 . Google Scholar Crossref Search ADS PubMed WorldCat 9 Espina V , Geho D, Mehta AI, Petricoin EF, Liotta LA, Rosenblatt KP. Pathology of the future: molecular profiling for targeted therapy . Cancer Invest 2005 ; 23 : 36 – 46 . Google Scholar Crossref Search ADS PubMed WorldCat Copyright © 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Copyright © 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Tan, P H; Chan, C L H; Chan, C; George, A J T

doi: 10.1002/bjs.5181pmid: 16273530

Abstract Background The completion of the sequencing of the human genome in 2003 marked the dawn of a new era of human biology and medicine. Although these remarkable scientific advances improve the understanding of human biology, the question remains how this rapidly expanding knowledge of functional genomics affects the role of surgeons. This article reviews the potential therapeutic application of gene therapy for various surgical conditions. Methods The core of this review was derived from a Medline database literature search. Results and conclusion The currently available vectors in the field of gene therapy and their limitations for clinical applications were analysed. The achievements of gene therapy in clinical trials and the future ramifications for surgery were also explored. Whether gene therapy takes a major role in surgical practice will depend greatly on the success of future vector development. Advances in viral vector technology to reduce the inflammatory effect, and improvements in the efficiency of gene delivery using non-viral vector technology, would allow this form of therapy to become more clinically applicable. Introduction With the completion of the human genome sequence1, its impact on future therapies in surgery can be contemplated. The first, unsuccessful, attempt at gene therapy took place in 1970 when two subjects who lacked the enzyme argininase were given the Shope papilloma virus, which is known to carry the argininase gene2. The first approved gene therapy clinical trial took place 25 years later when patients with adenosine deaminase-deficient severe combined immune deficiency (ADA-SCID) were treated with T lymphocytes engineered with a retroviral vector carrying a normal ADA gene3. Despite much promise, this form of therapy has yet to make an impact in clinical practice. Gene delivery methods The technologies available to deliver a gene into the cell nucleus can be divided into viral and non-viral vectors. The vectors carry exogenous genetic materials in the form of DNA or RNA (including short interfering RNA (siRNA) and antisense oligodeoxynucleotides) across the cell membrane into the nucleus to allow transcription. siRNA and antisense oligodeoxynucleotides can interfere with the complementary mRNA in the cytoplasm, reducing the amount of mRNA available for translation. At various stages, the vectors have to escape from different cellular compartments and unpackage their genetic message (Fig. 1). The hostile environments of the endolysosomes and cytoplasm actively degrade free nucleic acid. Those vectors or genetic materials that have escaped the degradation process still need to cross the nuclear envelope, either by passive diffusion through the nuclear pore complex or by an energy-dependent translocation that requires importins4. The importins target proteins to the nuclear pore complex and facilitate their translocation across the nuclear envelope. Fig. 1 Open in new tabDownload slide Transfection process. For a successful gene-based approach, a number of cellular barriers must be overcome. First, the vector must enter the cell by crossing the lipid bilayer, typically by endocytosis into an endosome or lysosome. This is followed by escape from endosomes and lysosomes into the cytoplasm. Finally, the DNA material, which is either still in the vector or unpackaged, has to cross the nuclear envelope in order for transcription of therapeutic gene to take place Viruses have evolved multiple mechanisms to infect their host cells efficiently, either by fusion with the cell membrane or by receptor-mediated endocytosis, followed by nuclear localization of the viral genome. As a result, viral vectors in general have much higher transfection rates than non-viral vectors. Most modern viral vectors are unable to replicate freely owing to the deletion of essential genes, and carry little risk of proliferation or reversion to wild type. Their main drawback is that they tend to be immunogenic, which limits their in vivo potential5. In addition, viral vectors can alter cellular function after transduction6. Several non-viral strategies have been developed to circumvent the problem of immunogenicity (Table 1). These rely on mechanical delivery of the DNA7–11 or the use of enhancing chemicals12. Non-viral vectors are less able than their viral counterparts to overcome the problems of binding, escape from endosomes, uncoating and transport into the nucleus. They thus possess lower transfection efficiency. As a result, new strategies to improve internalization and endosomal escape of non-viral vectors are being developed13,14. Table 1 Currently available viral and non-viral vectors Viral vectors . Non-viral vectors . Retroviral superfamily (MMLV and lentivirus) Mechanical Adenovirus  Microinjection Adeno-associated virus  Pressure Herpes simplex virus  Particle bombardment Sendai virus  Ultrasound Polio virus Electrical Vaccinia virus  Electroporation (high or low voltage) Semliki Forest virus Chemical  DEAE  Calcium phosphate  Artificial lipids  Proteins  Dendrimers  Other polymers Viral vectors . Non-viral vectors . Retroviral superfamily (MMLV and lentivirus) Mechanical Adenovirus  Microinjection Adeno-associated virus  Pressure Herpes simplex virus  Particle bombardment Sendai virus  Ultrasound Polio virus Electrical Vaccinia virus  Electroporation (high or low voltage) Semliki Forest virus Chemical  DEAE  Calcium phosphate  Artificial lipids  Proteins  Dendrimers  Other polymers MMLV, Maloney murine leukaemia virus; DEAE, diethylaminoethyl-dextran. Open in new tab Table 1 Currently available viral and non-viral vectors Viral vectors . Non-viral vectors . Retroviral superfamily (MMLV and lentivirus) Mechanical Adenovirus  Microinjection Adeno-associated virus  Pressure Herpes simplex virus  Particle bombardment Sendai virus  Ultrasound Polio virus Electrical Vaccinia virus  Electroporation (high or low voltage) Semliki Forest virus Chemical  DEAE  Calcium phosphate  Artificial lipids  Proteins  Dendrimers  Other polymers Viral vectors . Non-viral vectors . Retroviral superfamily (MMLV and lentivirus) Mechanical Adenovirus  Microinjection Adeno-associated virus  Pressure Herpes simplex virus  Particle bombardment Sendai virus  Ultrasound Polio virus Electrical Vaccinia virus  Electroporation (high or low voltage) Semliki Forest virus Chemical  DEAE  Calcium phosphate  Artificial lipids  Proteins  Dendrimers  Other polymers MMLV, Maloney murine leukaemia virus; DEAE, diethylaminoethyl-dextran. Open in new tab All genes are associated with specialized DNA sequences (termed promoters and enhancers) that support transcription. Once in the nucleus, exogenous DNA requires a strong promoter and enhancer upstream of the gene of interest (termed a transgene) for its expression (Fig. 1). For both viral and non-viral vectors, the human cytomegalovirus (CMV) promoter has been used extensively to drive the expression of transgenes in mammalian cells. However, these viral promoters result in uncontrolled expression of transgenes. Technological development of promoters has now allowed a more regulated expression of transgenes15. Role of gene therapy in surgery When gene therapy was first proposed as a form of treatment, it received an encouraging reception from both clinicians and the general public16. However, after more than three decades, gene therapy has yet to make a substantial impact on clinical practice. Surgical oncology For operable malignancies, radiotherapy and/or chemotherapy is often used as adjunctive treatment, depending on the stage of the disease. Current adjuvant therapies adopt a relatively unfocused approach to cell killing and cause significant side-effects in normal tissues. Thus, new methods that specifically target adjuvant treatment directly to the malignant cell by genetic manipulation are being investigated. Cytotoxic gene therapy Cytotoxic gene therapy involves introducing genes that encode enzymes capable of transforming a non-toxic prodrug to an active cytotoxic compound in the tumour cell. When patients are treated with the prodrug, successfully transfected tumour cells are killed. Various combinations of enzyme and prodrug are available to produce cancer cell death (Table 2). Table 2 Enzymes and prodrugs that are effective in cancer gene therapy Enzymes . Prodrugs . Active drugs . Alkaline phosphatase Phenolmustard phosphate Phenolmustard Doxorubin phosphate Doxorubicin Mitomycin phosphate Mitomycin Etoposide phosphate Etoposide Azoreductase Azobenzene mustards Phenylenediamine mustard β-Glucuronidase Phenolmustard glucuronide Phenolmustard β-Lactamase Vinca-cephalosporin 4-Desacefylvinblastine-3-carboxyhydrazide Phenylenediamine mustard cephalosporin Phenylenediamine mustard Carboxypeptidase G2 Benzoic acid mustard glutamates Benzoic acid mustards Cytosine deaminase 5-Fluorocytosine 5-Fluorouracil DT diaphorase 5-(Aziridin-1-yl)-2,4-dinitrobenzamide 5-(Aziridin-1-yl)-4-hydroxylamino-2-nitrobenzamide Plasmin Peptidyl-p-phenylene diamine mustard Phenylenediamine mustard Thymidine kinase Ganciclovir Ganciclovir triphosphate Enzymes . Prodrugs . Active drugs . Alkaline phosphatase Phenolmustard phosphate Phenolmustard Doxorubin phosphate Doxorubicin Mitomycin phosphate Mitomycin Etoposide phosphate Etoposide Azoreductase Azobenzene mustards Phenylenediamine mustard β-Glucuronidase Phenolmustard glucuronide Phenolmustard β-Lactamase Vinca-cephalosporin 4-Desacefylvinblastine-3-carboxyhydrazide Phenylenediamine mustard cephalosporin Phenylenediamine mustard Carboxypeptidase G2 Benzoic acid mustard glutamates Benzoic acid mustards Cytosine deaminase 5-Fluorocytosine 5-Fluorouracil DT diaphorase 5-(Aziridin-1-yl)-2,4-dinitrobenzamide 5-(Aziridin-1-yl)-4-hydroxylamino-2-nitrobenzamide Plasmin Peptidyl-p-phenylene diamine mustard Phenylenediamine mustard Thymidine kinase Ganciclovir Ganciclovir triphosphate Open in new tab Table 2 Enzymes and prodrugs that are effective in cancer gene therapy Enzymes . Prodrugs . Active drugs . Alkaline phosphatase Phenolmustard phosphate Phenolmustard Doxorubin phosphate Doxorubicin Mitomycin phosphate Mitomycin Etoposide phosphate Etoposide Azoreductase Azobenzene mustards Phenylenediamine mustard β-Glucuronidase Phenolmustard glucuronide Phenolmustard β-Lactamase Vinca-cephalosporin 4-Desacefylvinblastine-3-carboxyhydrazide Phenylenediamine mustard cephalosporin Phenylenediamine mustard Carboxypeptidase G2 Benzoic acid mustard glutamates Benzoic acid mustards Cytosine deaminase 5-Fluorocytosine 5-Fluorouracil DT diaphorase 5-(Aziridin-1-yl)-2,4-dinitrobenzamide 5-(Aziridin-1-yl)-4-hydroxylamino-2-nitrobenzamide Plasmin Peptidyl-p-phenylene diamine mustard Phenylenediamine mustard Thymidine kinase Ganciclovir Ganciclovir triphosphate Enzymes . Prodrugs . Active drugs . Alkaline phosphatase Phenolmustard phosphate Phenolmustard Doxorubin phosphate Doxorubicin Mitomycin phosphate Mitomycin Etoposide phosphate Etoposide Azoreductase Azobenzene mustards Phenylenediamine mustard β-Glucuronidase Phenolmustard glucuronide Phenolmustard β-Lactamase Vinca-cephalosporin 4-Desacefylvinblastine-3-carboxyhydrazide Phenylenediamine mustard cephalosporin Phenylenediamine mustard Carboxypeptidase G2 Benzoic acid mustard glutamates Benzoic acid mustards Cytosine deaminase 5-Fluorocytosine 5-Fluorouracil DT diaphorase 5-(Aziridin-1-yl)-2,4-dinitrobenzamide 5-(Aziridin-1-yl)-4-hydroxylamino-2-nitrobenzamide Plasmin Peptidyl-p-phenylene diamine mustard Phenylenediamine mustard Thymidine kinase Ganciclovir Ganciclovir triphosphate Open in new tab Human trials with the herpes simplex virus thymidine kinase (HSV-tk) gene, with subsequent systemic ganciclovir administration, have been reported for metastatic melanoma17 and ovarian cancer18. Cytosine deaminase gene therapy has been tried for metastatic colonic carcinoma19. In a phase I–II trial, genetically modified allogeneic cells that express a cytochrome P-450 enzyme were delivered by supra-selective angiography into the blood supply of pancreatic carcinoma. These cells were locally activated following the systemic administration of ifosfamide. The results were promising, with four tumours undergoing disease regression and the other ten remaining stable20. One way to increase specificity is to use a promoter that is expressed only in tumour cells. Thus, the tumour-specific erbB-2 promoter has been used to effect enzyme expression in breast carcinoma21. Immunological gene therapy Immunological gene therapy has the theoretical advantage of targeting specificity and amplifying the response against malignant cells. Ex vivo approaches include the transfer of genes encoding proinflammatory cytokines (interleukin (IL) 222, IL-423, IL-724, IL-1225, interferon (IFN) γ26 and granulocyte–macrophage colony-stimulating factor (GM-CSF)27), antigens (such as Epstein–Barr virus (EBV) antigen)28, allogeneic major histocompatibility complex (MHC) molecules29, CD40 ligand (CD154)30 and CD8031 into autologous tumour cells or immune cells. These transfected cells are then introduced into patients to enhance the immune response to the tumour. This therapy has been tried for malignant melanoma; in one study, melanoma cells obtained during surgery were injected as a vaccine, resulting in good antitumour response24. Autologous fibroblasts transfected with IL-12 and IL-2 genes together with irradiated tumour cells have been used in the treatment of metastatic melanoma25 and colorectal carcinoma32, with significant tumour size reduction. Unfortunately, the development of autologous tumour vaccines is complex. First, tumour cells need to be harvested from individual patients and then genetically modified ex vivo. The modified cells are then injected back into the patient to stimulate the immune system. Thus, tumour cell lines and an efficient ex vivo transfection system are required for each patient. In an attempt to avoid the need for patient-specific tumour cell lines, allogeneic and xenogeneic cells have also been used. Human trials using IL-2 transfected xenogeneic fibroblast cells for the treatment of subcutaneous metastatic disease33, IL-4 transduced and irradiated allogeneic melanoma cells for treatment of melanoma34, irradiated allogeneic pancreatic tumour cells with GM-CSF for treatment of pancreatic cancer35, and the mixture of allogeneic and xenogeneic MHC-transfected cells for the treatment of cutaneous metastasis36 have been reported. In vivo strategies include direct tumour modification with immunostimulatory genes such as IL-237, IL-738, IL-1239, IFN-γ40, GM-CSF41, allogeneic MHC42 and antigen (EBV)43 in order to enhance a specific immune response to the tumour. A trial of direct tumour injection of vectors encoding IFN-γ40 and GM-CSF44 in patients with melanoma resulted in a strong humoral response. IL-2 gene therapy trials have been reported in melanoma37, breast cancer37, renal cell carcinoma45, sarcoma45 and irresectable intestinal cancer46. Fifty-two patients with melanoma were recruited into a phase II trial with direct intratumour injection of allovectin 7, which contains a plasmid DNA encoding the genes for HLA-B7/β2-microglobulin complexed with cationic lipids. This resulted in a regression of tumour in 18 per cent of patients47. Similar trials have also been reported for metastatic renal cell lesions48, hepatic metastases of colorectal carcinoma29, melanoma42, and head and neck cancer49. Corrective gene therapy Corrective gene therapy aims to normalize the genotype of malignant or potentially malignant cells, either by replacing defective tumour suppressor genes (p53) or by inactivating proto-oncogenes using antisense oligodeoxynucleotides or siRNA technology. The major current problem with corrective gene therapy is the inability of available vectors to target every cell at risk. A theoretical concern is that gene correction of only some cells may lead to a competitive advantage for rapidly replicating untreated cells, resulting in the selection of a fast growing, highly malignant group of cells within a tumour. However, it may not be necessary to treat every cell, as reducing the rate of tumour growth may be an acceptable endpoint even if complete elimination of a cancer is unattainable. Preclinical in vitro and in vivo studies have shown that restoration of p53 function can induce apoptosis in cancer cells50. Human trials involving the use of the corrective gene p53 (Canji, San Diego, California, and Schering-Plough, Kenilworth, New Jersey, USA) have been conducted for the treatment of various cancers51. In 2003, the first gene therapy product was approved for sale in China; it was an adenoviral vector carrying a p53 gene for the treatment of cancer. A phase II trial in primary hepatocellular carcinoma and in patients with liver metastases from colorectal carcinoma demonstrated a good safety profile and antitumour effect52. In addition, similar phase II trials have been conducted in patients with ovarian cancer51, recurrent head and neck cancer53 and oesophageal carcinoma54, with great success. BRCA1 (tumour suppressor gene) gene therapy has been used in a phase I trial to inhibit ovarian and breast cancer in women carrying the BRCA1 gene mutation (Myriad Genetics, Salt Lake City, Utah, USA)55. Targeted Genetics Corporation (Seattle, Washington, USA) is developing a tumour suppressor (tumour inhibitor) gene therapy formulated in a non-viral, lipid-based system termed tgDCC-E1A. This system has shown promise in murine models of breast, ovarian, and head and neck squamous cell carcinoma, inhibiting the expression of the oncogene, reducing tumour size and increasing survival56. This therapy has been employed in phase I trials in patients with recurrent breast and ovarian carcinoma57. All trials showed promising results, and a further trial enrolling up to 60 patients is to be conducted in six medical institutions in the USA58. Similar phase I–II trials have also been conducted in patients with intrapleural or intraperitoneal metastases of breast or ovarian carcinoma59. Introduction of drug resistance genes A major limitation of current chemotherapy regimens is the toxicity to normal dividing cells. Gene therapy may have a role in protecting normal tissue by the introduction of specific genes, such as the human multidrug resistance gene60. Retroviruses carrying the multidrug resistance 1 gene have been used to transduce haematopoietic stem cells in an attempt to prevent marrow failure in patients undergoing radical chemotherapy or bone marrow transplantation61. The infusion of multidrug resistance 1-transfected cells was associated with no harmful effects and led to prompt haematopoietic recovery61. Oncolytic viruses Oncolytic (cancer cell killing) viruses have been developed as a potential form of treatment. These viruses are engineered to replicate selectively in, and kill, targeted cancer cells, leaving normal cells largely unharmed. The understanding of the genetic and molecular components of these viruses has increased to the point where they can be manipulated and made safe for use in humans. This has led to a revival in the concept of conditionally replication-competent viruses and ‘suicide gene’ therapy. A mutant recombinant adenovirus (Cell Genesys, San Francisco, California, USA), which replicates in p53-deficient cells62 causing cytopathogenicity in certain cancer cells63, was evaluated in trials of primary and secondary liver cancer64, recurrent head and neck squamous cell carcinoma65,66 and locally advanced pancreatic adenocarcinoma67. This virus appeared safe to use, and resulted in a reduction of tumour size. Transplantation surgery Transplantation is one form of treatment for organ failure. Traditional immunosuppression is effective at preventing acute rejection, but chronic allograft rejection and side-effects remain unresolved problems. Gene therapy may be used to enhance the success of surgical transplantation by preventing tissue or organ damage during isolation from donor and subsequent preservation, promoting engraftment and survival of the tissue or organ during and after transplantation surgery, or conferring protection from the immune response. Possible targets for gene transfer to transplanted organs or to antigen presenting cells (APCs) are listed in Table 3. Table 3 Molecular pathways for potential intervention using gene transfer in transplantation Pathways that can be blocked or modulated to protect transplanted organ or tissue from IRI or rejection . Interaction between APCs and effector T lymphocytes that can be targeted . Secretion of immunosuppressive cytokines Secretion of immunosuppressive cytokines Secretion of inhibitors of APC activation Secretion of co-stimulation antagonist Secretion of cell–cell interaction inhibitors Secretion of cell–cell adhesion inhibitors Secretion of inhibitors of chemotaxis Expression of death ligands (APC) Anti-inflammatory genes Production of alloantigen Secretion of death receptor antagonist Intracellular apoptosis inhibitors Complement inhibition (xenografts) Pathways that can be blocked or modulated to protect transplanted organ or tissue from IRI or rejection . Interaction between APCs and effector T lymphocytes that can be targeted . Secretion of immunosuppressive cytokines Secretion of immunosuppressive cytokines Secretion of inhibitors of APC activation Secretion of co-stimulation antagonist Secretion of cell–cell interaction inhibitors Secretion of cell–cell adhesion inhibitors Secretion of inhibitors of chemotaxis Expression of death ligands (APC) Anti-inflammatory genes Production of alloantigen Secretion of death receptor antagonist Intracellular apoptosis inhibitors Complement inhibition (xenografts) IRI, ischaemia–reperfusion injury; APC, antigen presenting cell. Open in new tab Table 3 Molecular pathways for potential intervention using gene transfer in transplantation Pathways that can be blocked or modulated to protect transplanted organ or tissue from IRI or rejection . Interaction between APCs and effector T lymphocytes that can be targeted . Secretion of immunosuppressive cytokines Secretion of immunosuppressive cytokines Secretion of inhibitors of APC activation Secretion of co-stimulation antagonist Secretion of cell–cell interaction inhibitors Secretion of cell–cell adhesion inhibitors Secretion of inhibitors of chemotaxis Expression of death ligands (APC) Anti-inflammatory genes Production of alloantigen Secretion of death receptor antagonist Intracellular apoptosis inhibitors Complement inhibition (xenografts) Pathways that can be blocked or modulated to protect transplanted organ or tissue from IRI or rejection . Interaction between APCs and effector T lymphocytes that can be targeted . Secretion of immunosuppressive cytokines Secretion of immunosuppressive cytokines Secretion of inhibitors of APC activation Secretion of co-stimulation antagonist Secretion of cell–cell interaction inhibitors Secretion of cell–cell adhesion inhibitors Secretion of inhibitors of chemotaxis Expression of death ligands (APC) Anti-inflammatory genes Production of alloantigen Secretion of death receptor antagonist Intracellular apoptosis inhibitors Complement inhibition (xenografts) IRI, ischaemia–reperfusion injury; APC, antigen presenting cell. Open in new tab Preservation of organ and tissue integrity and function Once the donor organ has been harvested, the lack of oxygen supply triggers cellular and tissue degeneration through the production of superoxide, free radicals, nitric oxide and a cascade of pro-apoptotic events. Reperfusion causes further damage. This ischaemia–reperfusion injury is attributed to neutrophil and natural killer cell infiltration, consequent on the effects of proinflammatory cytokines and oxygen free radicals. Considering the underlying mechanisms, it may be feasible to block or prevent cytokine–receptor interactions68, neutrophil activation and chemotaxis69, natural killer cell activation70, induction of apoptosis71 or superoxide and peroxide generation72. Inhibition of leucocyte-mediated rejection Any damage during transplantation, whether due to surgical trauma or preservation, acts as a danger signal for macrophages, natural killer cells, neutrophils and dendritic cells. These cells then initiate an inflammatory cascade resulting in a second wave of infiltrate whose constituent cells, such as T and B lymphocytes, as well as macrophages and dendritic cells, can mediate more specific antigen destruction of a graft. The perfusion of host leucocytes results in their transmigration into tissues across the endothelium via cell surface adhesion molecules73 and integrins74. One potential strategy could involve ex vivo perfusion of the organ with vectors that encode inhibitors of endothelium–leucocyte interactions75. The immune response against the allograft requires a degree of orchestration by cytokines and other immunoregulatory signalling molecules. In most instances, a proinflammatory cascade is initiated with IL-1 and tumour necrosis factor (TNF) α. Thus, blocking the binding of cytokines to their receptors with decoy receptor-encoded genes may reduce the immune response. In addition, the expression of cytokines may downregulate amplification of the initial response. Of the cytokines, transforming growth factor (TGF) β76 and the viral homologue of IL-10 (vIL-10)77 have been shown to prolong allograft survival. Inhibition of co-stimulation In addition to interacting with the MHC–peptide complex on APCs, T lymphocytes require co-stimulatory signals to become fully activated. In the absence of co-stimulation, the T lymphocytes enter T cell hyporesponsiveness (termed anergy). Upon initial activation, T lymphocytes upregulate CD40 ligand (CD40L), which binds to CD40 expressed by APCs or graft parenchymal cells. APCs also upregulate surface expression of CD80 and CD86, an important pair of co-stimulatory molecules78. For full activation, a T lymphocyte must interact with CD80/86 via CD28. In addition, T lymphocytes possess another cell surface molecule, cytotoxic T lymphocyte-associated protein 4 (CTLA), which binds with higher affinity to CD80/86. Unlike CD28–CD80/86 interaction, the signalling through CTLA-4 attenuates T cell activation. The blockade of both CD40–CD40L and CD80/86–CD28 pathways has been used to prolong allograft survival in animal models of transplantation79. More recently, transfer of CTLA-4–Ig cDNA has resulted in the prolongation of allograft survival80. Recent data have suggested that CTLA-4–Ig binding to CD80/86 can also upregulate indoleamine 2,3-dioxygenase (IDO), an immunomodulatory enzyme81. Immunomodulation using genetically engineered antigen presenting cells Dendritic cells are now regarded not only as the initiators or regulators of immune responses, but also as potentially powerful tools for therapeutic manipulation of immune reactivity. They are important in intrathymic self-tolerance and in the regulation of peripheral tolerance, and are an attractive target for genetic manipulation as they are the most potent APCs. Candidate genes that can have a tolerance effect on T cells include vIL-1082, TGF-β82,83, FasL82, IDO84, CTLA-4–Ig85 and CTLA-4–KDEL (a novel intracellular fusion protein gene that blocks expression of CD80/86)86. Inhibition of the immune response via apoptosis or inhibition of apoptosis Activated lymphocytes can be eliminated by apoptosis following the ligation of cell surface Fas by its ligand (FasL/CD95L)87. This may be of use as an immune protective molecule, as renal allograft survival is prolonged when FasL is genetically expressed on the donor kidney88. Paradoxically, when islets transfected with FasL were transplanted into allogeneic diabetic hosts, the FasL-transfected islets underwent accelerated neutrophilic rejection89. Graft protection could be conferred by the introduction of transgenes encoding for antagonists to Fas-induced apoptosis in donor tissues. Possibilities include soluble chimeric Fas–Ig fusion90, signalling-defective, dominant negative variants of Fas, mutant downstream effectors such as Fas-associated death domain protein (FADD), a docking protein involved in linking the intracytoplasmic domain of Fas to the death-effector molecules91, inhibitors of the pro-apoptotic cascade, such as crmA encoded by cowpox92, and bcl-2 family members (such as bcl-xL)93,94. Success of gene therapy in transplantation Current clinical trials in transplantation involve retransplantation of genetically modified autologous cells to treat monogenic diseases including ADA-SCID3,95 and X-linked SCID96, lysosomal storage disorder (Gaucher's disease)97, leucocyte defects (chronic granulomatous disease)98 and Fanconi's anaemia99. The role of gene therapy in solid organ transplant has yet to be established. No clinical trials have been reported that used gene-based approaches to treat or prevent solid organ rejection. Cardiac and vascular surgery Gene therapy can be applied directly to the arterial wall using a double-ballooned endoluminal catheter (Boston Scientific, St Albans, UK), where gene transfer solution is introduced into a luminal space created between two inflated balloons. Alternatively, a perivascular collar–capsule (Eurogene, York, UK) can be used, in which the gene transfer solution is introduced between a biodegradable collar–capsule and the vessel exterior at the time of open arterial surgery. A number of approaches to gene therapy for cardiovascular disease have been devised (Table 4). The gene addition approach consists of inserting a new gene or additional copies of a gene into cells, for example the addition of vascular endothelial growth factor (VEGF) or basic fibroblast growth factor, which both induce angiogenesis, in an attempt to reduce the effects of ischaemia. Genes encoding nitric oxide synthase may aid vessel dilatation and regulation of vascular tone. An alternative approach is control of gene expression. The expression of a particular gene is modulated by targeting either the upstream regulatory genes or the mRNA, to prevent protein production. The third approach is gene replacement, with substitution of a non-active or defective gene by a new or additional functional copy of the gene. Table 4 Therapeutic genes that may be useful in cardiovascular disease Causes . Mechanisms . Ischaemia Genes to stimulate new blood vessel growth (therapeutic angiogenesis) Genes to help vasodilatation Atherosclerosis Reduce oxidative stress Increase oxygenation Reduce lipid uptake Modulate lipid modification, metabolism or oxidation Smooth muscle cell (promoting stenosis or restenosis) Gene to prevent smooth muscle cell proliferation Gene to block proliferative signals Apoptosis-inducing genes Tumour suppressor genes Gene involved in intracellular signalling or cycle regulation Thrombosis Reduce thrombogenicity Modulate thrombosis Aneurysm formation Modulate vessel wall remodelling Prevent enzymatic degradation of vessel walls Causes . Mechanisms . Ischaemia Genes to stimulate new blood vessel growth (therapeutic angiogenesis) Genes to help vasodilatation Atherosclerosis Reduce oxidative stress Increase oxygenation Reduce lipid uptake Modulate lipid modification, metabolism or oxidation Smooth muscle cell (promoting stenosis or restenosis) Gene to prevent smooth muscle cell proliferation Gene to block proliferative signals Apoptosis-inducing genes Tumour suppressor genes Gene involved in intracellular signalling or cycle regulation Thrombosis Reduce thrombogenicity Modulate thrombosis Aneurysm formation Modulate vessel wall remodelling Prevent enzymatic degradation of vessel walls Open in new tab Table 4 Therapeutic genes that may be useful in cardiovascular disease Causes . Mechanisms . Ischaemia Genes to stimulate new blood vessel growth (therapeutic angiogenesis) Genes to help vasodilatation Atherosclerosis Reduce oxidative stress Increase oxygenation Reduce lipid uptake Modulate lipid modification, metabolism or oxidation Smooth muscle cell (promoting stenosis or restenosis) Gene to prevent smooth muscle cell proliferation Gene to block proliferative signals Apoptosis-inducing genes Tumour suppressor genes Gene involved in intracellular signalling or cycle regulation Thrombosis Reduce thrombogenicity Modulate thrombosis Aneurysm formation Modulate vessel wall remodelling Prevent enzymatic degradation of vessel walls Causes . Mechanisms . Ischaemia Genes to stimulate new blood vessel growth (therapeutic angiogenesis) Genes to help vasodilatation Atherosclerosis Reduce oxidative stress Increase oxygenation Reduce lipid uptake Modulate lipid modification, metabolism or oxidation Smooth muscle cell (promoting stenosis or restenosis) Gene to prevent smooth muscle cell proliferation Gene to block proliferative signals Apoptosis-inducing genes Tumour suppressor genes Gene involved in intracellular signalling or cycle regulation Thrombosis Reduce thrombogenicity Modulate thrombosis Aneurysm formation Modulate vessel wall remodelling Prevent enzymatic degradation of vessel walls Open in new tab To date, human trials in cardiothoracic or vascular surgery using gene addition and control of gene expression have been undertaken. The delivery of VEGF encoded by adenovirus100 or naked plasmid DNA101 via mini-thoracotomy was conducted in a phase I trial in patients with chronic angina, refractory to standard medical therapy and not amenable to conventional revascularization. This resulted in improvement of the symptoms with minimal side-effects. In addition, catheter-mediated VEGF transfer with liposomes to human coronary arteries after routine angioplasty was conducted safely in 15 patients102. In patients with critical leg ischaemia, the VEGF gene administered intramuscularly in an adenoviral vector103 or as naked plasmid DNA104 resulted in augmentation of lower-extremity flow reserve. The naked plasmid DNA encoding VEGF has also been used to treat Buerger's disease105. The transfer of a decoy oligodeoxynucleotide that binds and inactivates cell-cycle transcriptional factor, E2F (Corgentech, San Francisco, California, and Bristol-Myers Squibb, New York, USA), ex vivo to vein grafts in order to inhibit intimal hyperplasia was validated in a randomized controlled trial106. The 41 patients in this study had a significantly reduced incidence of bypass graft failure at 12 months106. Thoracic surgery Thoracic surgeons are presently focusing on tumour gene therapy for mesothelioma. The National Cancer Institute in North America is sponsoring a phase I trial in 21 patients of recombinant adenovirus containing the HSV-TK gene, with subsequent tumour killing by ganciclovir107. In addition to the intratumour approach, a cell-based ‘suicide gene’ therapy utilizing the ‘bystander effect’ with the gene-modified ovarian cancer cell line (PA1-STK) has been tested108. These genetically modified cells migrated successfully to human pleural mesothelioma after injection, and caused tumour destruction108. Orthopaedic surgery Gene therapy may be useful not only in the treatment of hereditary diseases109 such as osteogenesis imperfecta110, but also for treating osteoarthritis111, osteoporosis112, enhancing tissue repair and regeneration113, and in orthopaedic sports medicine114. Impressive preclinical progress has been made in several of these areas. Gene therapy also holds great promise in the treatment of soft tissue sarcoma. Based on the concept of immunological gene therapy, a phase I trial was conducted to evaluate the use of the radiation-activated promoter Egr-1 to regulate expression of the TNF gene in an adenoviral vector given by injection into the tumour115. Similarly, a corrective gene therapy trial evaluated efficacy and toxicity in metastatic osteosarcoma116. The use of gene therapy to promote fracture healing with osteogenic growth factors117, ligament healing with antisense oligodeoxynucleotide therapy118, wound healing with growth factors113, and nerve or muscle regeneration119 has had encouraging results in animal models. Urological surgery The potential of gene therapy as a preventive strategy or adjunctive treatment for prostate adenocarcinoma120, bladder transitional carcinoma121 and renal cell carcinoma122 is increasingly recognized. Its potential to modulate erectile dysfunction has also been reported123. Cytoreductive gene therapies, in which gene transfer is attempted in vivo to trigger cell death, are in clinical development. The use of an adenoviral vector with the HSV-TK gene (suicide gene)120, given by intraprostatic injection, followed by intravenous administration of ganciclovir, resulted a greater than 50 per cent decline in serum levels of prostate-specific antigen (PSA)120. In an application of immunological gene therapy, 24 patients with locally advanced prostatic carcinoma were enrolled in a trial of IL-2 gene transfer with liposomes (Vical, San Diego, California, USA) injected into the prostate; 67 per cent of patients had improved serum PSA levels124. Metastatic prostatic cancer has also been evaluated for target-specific gene therapy with an adenoviral vector under the osteocalcin promoter125. Adenovirus-mediated p53 gene transfer (Introgen Therapeutics, Austin, Texas, USA) demonstrated a promising anticancer effect when injected into prostate tissue in early clinical trials126. Intraprostatic injection of a replication-restricted cytolytic virus, CN706 (Calydon, Sunnyvale, California, USA)127, constructed using PSA transcriptional promoter–enhancer sequences to drive virulence gene transcription selectively in PSA-producing cells, is in phase I clinical trials127. Prostate cancer vaccines using prostate cancer cells genetically modified to secrete immunostimulatory cytokines (Cell Genesys, Foster City, California, USA) such as GM-CSF128 (a recently launched phase III trial), created by ex vivo loading of dendritic cells with prostate antigens (Dendreon Corporation, Seattle, and Northwest Biotherapeutics, Bothell, Washington, USA) or generated using prostate antigen genes in other vaccine vehicles, are in clinical trials for advanced prostatic cancer. Gene therapy has also been explored in other urological malignancies. One trial in patients with stage IV renal cell cancer reported vaccination with irradiated GM-CSF122 or MHC antigen-transduced autologous renal cancer cells. The vector, Ad5CMV-p53, has been administered into the bladder of patients with bladder cancer in another phase I trial121. Neurosurgery Clinical trials in patients with recurrent malignant glioblastoma showed that transduction of the HSV-TK gene with subsequent prodrug activation by ganciclovir was safe129, but the clinical response was poor130. The adenoviral vector carrying the TK gene was better than the retroviral vector in improving patient survival131. In addition, immunological gene therapy trials have been reported for the treatment of recurrent or progressive malignant gliomas with immunostimulatory genes such as IFN-γ132, and for neuroblastoma with the IL-2 gene133. Combined suicide and immunological gene therapy (IL-4–HSV-TK) was also validated in a phase I study134. Many approaches have been employed in treating various brain tumours. A pilot study involving the use of antisense oligodeoxynucleotide directed against the insulin-like growth factor type I receptor in malignant astrocytomas resulted in transient radiographic and clinical improvement135. Vaccines generated using irradiated autologous glioma and dendritic cells admixed with IL-4-transduced fibroblasts136 and allogeneic MHC-transfected glioma137 are currently in clinical trial. However, to date no study has convincingly demonstrated the superiority of gene-based treatment over conventional management138. To achieve continuous, site-specific delivery of therapeutic molecules including neurotrophic factors, neurotransmitters and hormones to the central nervous system, a new therapeutic approach has been developed that combines in vitro gene transfer with a new delivery device. Xenogeneic cells genetically modified to secrete the bioactive substances were encapsulated into polymer-based fibres to avoid immune attack (CytoTherapeutics, Munich, Germany)139. Perspectives of gene therapy in surgery Although viral and non-viral strategies for gene delivery complement one another, neither is currently ideal for clinical use. The ideal vector for gene therapy should combine the best features of both viral and non-viral methods. It will probably be difficult to design a virus-like synthetic vector that is as efficient as a true viral particle, because of the structural and functional complexity of the virus and limits to in vitro self-assembly. Thus, whether gene therapy becomes part of surgical practice will depend greatly on the success of future vector development. Despite clinical successes in treating patients with ADA-SCID3, fatal congenital disease140, haemophilia141,142 and X-linked SCID143, gene therapy is not without risk. Three children developed a leukaemia-like disease after receiving gene therapy with a viral method96,144. The death of a teenage volunteer in a gene therapy trial has also raised questions about the use of viral methods145. Despite the use of a less toxic vector, a severe immune reaction to the virus resulted in the death of a volunteer. More problems followed when the Federal overseers asked the investigators to put a clinical trial using an adeno-associated virus vector to treat haemophilia B146 on hold, as there were signs of the vector in patients' semen, raising concerns that the vector might have altered the men's inheritable DNA147. The side-effects of viral vectors have limited their in vivo application, but as non-viral methods do not have these characteristics they may have advantages. Further development of viral vector technology may represent an alternative approach to allow in vivo use of these vectors. Despite the problems with vectors, at least 2000 laboratories worldwide are engaged in gene therapy research. The National Institutes of Health (NIH) funding for laboratory-based or clinical research increased from US$349 ·4 million in 2001 to US$427 ·4 million in 2003, and more than 600 gene therapy trials are ongoing worldwide. However, none of the large phase III trials has been completed to achieve Food and Drug Administration (FDA) approval, although the first phase III clinical trial is now under way for the treatment of brain cancer148. Theoretically, all diseases can be treated with gene therapy as long as the molecular pathways are well characterized. Many examples, including cancers and cardiovascular diseases, have indicated how close gene-based treatments are to being translated into clinical use. At March 2004, 619 gene therapy clinical protocols had been submitted to the NIH and FDA for approval: 65 per cent for cancer and 11 per cent for peripheral artery and coronary artery disease149. It is anticipated that the first gene therapy product approval will take place in the USA in the next 2–3 years. Gene-based treatment may represent a better approach than drug-based therapy as the body generates its own therapeutic molecules. This avoids the pharmacokinetics associated with drug treatment. The slow success of gene therapy in the clinical arena may be attributed to the lack of ideal vectors that are efficient and non-pathogenic. More research is needed in developing vectors before gene therapy is likely to be used widely in surgical practice. Acknowledgements The authors thank Professor J. A. Bradley, University Department of Surgery, Cambridge University, and Mr Andrew McClaren, Stoke Mandeville Hospital, for helpful suggestions for this review. Because of space restrictions, the authors were able to cite only a fraction of the relevant literature and apologize to any colleagues whose contributions may not be acknowledged appropriately. P.H.T. was funded by the UK Medical Research Council and the Royal College of Surgeons of Edinburgh as a Clinical Research Training Fellow (2001–2004). A.J.T.G. is a Research Development Fellow of the Biotechnology and Biological Sciences Research Council. 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This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Copyright © 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Shanmugam, V; Thaha, M A; Rabindranath, K S; Campbell, K L; Steele, R J C; Loudon, M A

doi: 10.1002/bjs.5185pmid: 16252313

Abstract Background and method This review compares the two most popular treatments for haemorrhoids, namely rubber band ligation (RBL) and excisional haemorrhoidectomy. Randomized trials were identified from the major electronic databases. Symptom control, retreatment, postoperative pain, complications, time off work and patient satisfaction were assessed. Relative risk (RR) and weighted mean difference with 95 per cent confidence interval (c.i.) were estimated using a random-effects model for dichotomous and continuous outcomes respectively. Results Three trials met the inclusion criteria and all were of poor methodological quality. Complete remission of haemorrhoidal symptoms was better after haemorrhoidectomy (RR 1·68 (95 per cent c.i 1·00 to 2·83)). There was significant heterogeneity between the studies (I2 = 90·5 per cent; P < 0·001). Fewer patients required retreatment after haemorrhoidectomy (RR 0·20 (95 per cent c.i 0·09 to 0·40)), but anal stenosis, postoperative haemorrhage and incontinence to flatus were more common with this operation. Conclusions Haemorrhoidectomy produced better long-term symptom control in patients with grade III haemorrhoids, but was associated with more postoperative complications than RBL. Introduction The treatment of haemorrhoidal disease is essentially directed at alleviating its varying symptomatology. Most conventional treatment methods either fix the haemorrhoidal cushions by scarring or ablate them by formal excision. Rubber band ligation (RBL) is the most popular of the non-surgical interventions1–3 but, despite its simplicity, the procedure is known for its diminishing long-term efficacy. Furthermore, there is an association, albeit rare, with serious adverse events including pelvic sepsis, and Fournier's gangrene4. Formal excisional haemorrhoidectomy, on the other hand, seems to produce the most sustainable symptom control with less need for retreatment5 and is considered by many the ‘gold standard’ treatment for symptomatic haemorrhoids6. However, Salmon's original technique7 and its various subsequent modifications8–10 incur postoperative pain, a long recovery time and a significant level of complications11,12. This systematic review evaluates evidence from randomized controlled trials (RCTs) comparing these two common techniques for treating haemorrhoids with a view to ascertaining which is better. Materials and methods Search strategy A comprehensive search of all the major electronic databases (Medline, Embase, Cumulative Index to Nursingand Allied Health Literature (CINAHL) and Controlled Clinical Trial Register (CCTR)) was carried out using an optimally sensitive search strategy developed by two authors (K.S.R. and V.S.) based on the recommendations of the Cochrane collaboration, to identify RCTs comparing RBL and excisional haemorrhoidectomy. This was further augmented by searching the National Research Register, Controlled Clinical Trials, bibliographies of the retrieved full-text articles and by contacting experts in the field. Two of the authors (V.S. and M.A.T.) carried out independent searches to identify the studies for potential inclusion. No language restriction was applied. Inclusion and exclusion criteria All RCTs comparing RBL and excisional haemorrhoidectomy for symptomatic haemorrhoids in adult human patients were eligible for inclusion if any of the required outcomes were measured. The exact technique of excision (open, semiclosed, closed) and type of instrument used for excision (scissor, diathermy, laser, stapler) were not criteria for exclusion. Non-randomized and quasi-randomized studies were excluded. Quality assessment Methodological quality of the included studies was assessed using the following criteria: (1) allocation concealment, (2) blinding of participants, investigators and outcome assessors, (3) intention to treat analysis, and (4) completeness of follow-up. Investigators of the included studies were contacted if data were incomplete or missing. Outcomes assessed Control of haemorrhoidal disease was the primary outcome measured, along with the outcome related to the degree of haemorrhoids. Disease control was grouped into two categories (for dichotomous output). Patients were considered cured or improved if they were symptom free or had minimal residual symptoms not requiring further treatment at the end of the study period. They were considered unchanged or worse if they experienced no symptom improvement or had deterioration of symptoms requiring further intervention or suffered complications of the procedure. Other outcome measures included retreatment rate, duration of pain after the procedure, complications (postoperative bleeding requiring readmission, incontinence, anal stenosis, sepsis), patient satisfaction, time to return to normal activities and quality of life. Complications were analysed and reported individually. In addition, they were grouped into early (urinary retention, postoperative haemorrhage, acute anal fissure) and delayed (anal stenosis, incontinence to flatus, low back pain, skin bridge across anus) groups, and also reported accordingly. Statistical analysis Relative risk (RR) and 95 per cent confidence interval (c.i.) were used to summarize treatment effects when the outcomes were dichotomous, and weighted mean difference (WMD) and 95 per cent c.i. when the outcome was continuous. The estimates from individual RCTs were pooled using the DerSimonian and Laird random-effects model when appropriate13. The Mantel–Haenszel fixed-effect model was also used to evaluate robustness and susceptibility to outliers. Statistical heterogeneity was explored by χ2 test and expressed as I2 and P value (considered significant if P < 0·050). Attempts were made to assess for publication bias using a funnel plot. The limited availability of studies restricted the performance of subgroup analysis, but power calculation for sample size was performed. All analyses were undertaken using RevMan 4.2.6 (The Cochrane Collaboration, Wintertree Software Inc., UK). Results A total of 729 articles were identified from the relevant electronic searches. Full-text assessment of 26 potentially eligible studies identified three eligible RCTs14–16 (Fig. 1). The remaining studies were excluded6,17–37 along with one publication38 describing long-term results in a group previously reported14. The overall quality of the three included trials was considered inadequate when assessed by the criteria noted above. Fig. 1 Open in new tabDownload slide Flow chart of literature search The three trials contained a total of 216 patients with different degrees of haemorrhoids. Of these, 63 and 58 were men in the RBL and haemorrhoidectomy groups respectively. Symptoms at initial recruitment into the studies are shown in Table 1. The mean duration of symptoms ranged from 54 to 94 months in the RBL group, and 60 to 112 months in the haemorrhoidectomy group. A total of fourteen patients (6·5 per cent) were lost to follow-up. Table 1 Demographics and symptoms Reference . Procedure . No. of patients . Degree of haemorrhoids . Symptoms . Duration of symptoms (months)* . Follow-up . Age (years)* . . . . . . . II . III . Other . Bleeding . Prolapse . Murie et al.14 RBL 50 16 27 7 42 43 94(115)112(104)} 1 year 53(15) EH 50 16 29 5 42 45 50(12) Cheng et al.15 RBL 30 30 0 0 20 10 5460} 1 year 40 EH 30 30 0 0 19 11 49 Lewis et al.16 RBL 30 0 18 12 — — 5460} 5 weeks to 46(15) EH 26 0 15 11 — — 5 years 49(13) Reference . Procedure . No. of patients . Degree of haemorrhoids . Symptoms . Duration of symptoms (months)* . Follow-up . Age (years)* . . . . . . . II . III . Other . Bleeding . Prolapse . Murie et al.14 RBL 50 16 27 7 42 43 94(115)112(104)} 1 year 53(15) EH 50 16 29 5 42 45 50(12) Cheng et al.15 RBL 30 30 0 0 20 10 5460} 1 year 40 EH 30 30 0 0 19 11 49 Lewis et al.16 RBL 30 0 18 12 — — 5460} 5 weeks to 46(15) EH 26 0 15 11 — — 5 years 49(13) * Values are mean(s.d.). RBL, rubber band ligation; EH excisional haemorrhoidectomy. Open in new tab Table 1 Demographics and symptoms Reference . Procedure . No. of patients . Degree of haemorrhoids . Symptoms . Duration of symptoms (months)* . Follow-up . Age (years)* . . . . . . . II . III . Other . Bleeding . Prolapse . Murie et al.14 RBL 50 16 27 7 42 43 94(115)112(104)} 1 year 53(15) EH 50 16 29 5 42 45 50(12) Cheng et al.15 RBL 30 30 0 0 20 10 5460} 1 year 40 EH 30 30 0 0 19 11 49 Lewis et al.16 RBL 30 0 18 12 — — 5460} 5 weeks to 46(15) EH 26 0 15 11 — — 5 years 49(13) Reference . Procedure . No. of patients . Degree of haemorrhoids . Symptoms . Duration of symptoms (months)* . Follow-up . Age (years)* . . . . . . . II . III . Other . Bleeding . Prolapse . Murie et al.14 RBL 50 16 27 7 42 43 94(115)112(104)} 1 year 53(15) EH 50 16 29 5 42 45 50(12) Cheng et al.15 RBL 30 30 0 0 20 10 5460} 1 year 40 EH 30 30 0 0 19 11 49 Lewis et al.16 RBL 30 0 18 12 — — 5460} 5 weeks to 46(15) EH 26 0 15 11 — — 5 years 49(13) * Values are mean(s.d.). RBL, rubber band ligation; EH excisional haemorrhoidectomy. Open in new tab Control of symptoms and retreatment rate There was no significant difference between RBL and haemorrhoidectomy with respect to control of bleeding (two trials, 123 patients; RR 1·12 (95 per cent c.i. 0·97 to 1·29); P = 0·120) and prolapse (two trials, 109 patients; RR 1·05 (95 per cent c.i. 0·98 to 1·12); P = 0·160). However, haemorrhoidectomy achieved a better overall cure rate for haemorrhoidal disease (three trials, random effects, 202 patients; RR 1·68 (95 per cent c.i. 1·00 to 2·83); P = 0·050) at the end of the trial period (Fig. 2) Formal assessment revealed significant heterogeneity between the studies (I2 = 90·5 per cent; P < 0·001). Analysing the treatment success based on the grading of haemorrhoids revealed the superiority of haemorrhoidectomy over RBL for grade III haemorrhoids (prolapse that needs manual reduction) (two trials, 116 patients; RR 1·23 (95 per cent c.i. 1·04 to 1·45); P = 0·010). However, no significant difference was noted for grade II haemorrhoids (prolapse that reduces spontaneously on cessation of straining) (one trial, 32 patients; RR 1·07 (95 per cent c.i. 0·94 to 1·21); P = 0·320). The present study also confirmed a significant difference in the retreatment rate favouring haemorrhoidectomy (three trials, 202 patients; RR 0·20 (95 per cent c.i. 0·09 to 0·40); P < 0·001). Patients undergoing surgery have an 80 per cent less chance of recurrence of haemorrhoidal symptoms than those having RBL (Fig. 3). Fig. 2 Open in new tabDownload slide Overall cure rate. Relative risk values are shown with 95 per cent confidence intervals. RBL, rubber band ligation. EH, excisional haemorrhoidectomy. Test for heterogeneity: χ2 = 21·08, 2 d.f., P < 0·001, I2 = 90·5 per cent. Test for overall effect: Z = 1·98, P = 0·050 Fig. 3 Open in new tabDownload slide Re-treatment rate. Relative risk values are shown with 95 per cent confidence intervals. RBL, rubber band ligation; EH, excisional haemorrhoidectomy. Test for heterogeneity: χ2 = 1·86, 2 d.f., P = 0·390, I2 = 0 per cent. Test for overall effect: Z = 4·42, P < 0·001 Postoperative pain Analysis revealed significant heterogeneity among the included studies for postoperative pain (I2 = 98·6 per cent, P < 0·001). The fixed-effect model demonstrated that significantly more patients undergoing haemorrhoidectomy experienced postoperative pain (three trials, 212 patients; RR 1·94 (95 per cent c.i. 1·62 to 2·33); P < 0·001). However, the random-effects model failed to support this difference (three trials, 212 patients; RR 3·11 (95 per cent c.i. 0·26 to 37·90); P = 0·370). Complications There was no statistically significant difference in the incidence of postoperative urinary retention, postoperative haemorrhage and anal stenosis. Although surgery was associated with an overall greater individual complication rate, this difference did not reach statistical significance (Table 2). Although the delayed complication rate was statistically significantly different between the two interventions (P = 0·03), this did not apply to the early complication rate. Table 2 Complications Complication . Total no. of patients treated . No. of patients with complications . Relative risk . P . . . . RBL . EH . RBL . EH . Urinary retention 79 77 1 5 3·70 (0·62, 22·08) 0·15 Postoperative haemorrhage 109 103 1 5 3·10 (0·63, 15·30) 0·16 Anal stenosis 73 75 0 4 4·89 (0·59, 40·85) 0·14 Acute anal fissure 49 47 3 0 0·15 (0·01, 2·81) 0·20 Faecal incontinence 30 30 0 0 — — Flatus incontinence 30 26 0 2 5·74 (0·29, 114·41) 0·25 Skin bridge across anus 43 45 0 1 2·87 (0·12, 68·58) 0·52 Low back pain 43 45 0 1 2·87 (0·12, 68·58) 0·52 Complication . Total no. of patients treated . No. of patients with complications . Relative risk . P . . . . RBL . EH . RBL . EH . Urinary retention 79 77 1 5 3·70 (0·62, 22·08) 0·15 Postoperative haemorrhage 109 103 1 5 3·10 (0·63, 15·30) 0·16 Anal stenosis 73 75 0 4 4·89 (0·59, 40·85) 0·14 Acute anal fissure 49 47 3 0 0·15 (0·01, 2·81) 0·20 Faecal incontinence 30 30 0 0 — — Flatus incontinence 30 26 0 2 5·74 (0·29, 114·41) 0·25 Skin bridge across anus 43 45 0 1 2·87 (0·12, 68·58) 0·52 Low back pain 43 45 0 1 2·87 (0·12, 68·58) 0·52 Values in parentheses are 95 per cent confidence intervals. RBL, rubber band ligation; EH, excisional haemorrhoidectomy. Open in new tab Table 2 Complications Complication . Total no. of patients treated . No. of patients with complications . Relative risk . P . . . . RBL . EH . RBL . EH . Urinary retention 79 77 1 5 3·70 (0·62, 22·08) 0·15 Postoperative haemorrhage 109 103 1 5 3·10 (0·63, 15·30) 0·16 Anal stenosis 73 75 0 4 4·89 (0·59, 40·85) 0·14 Acute anal fissure 49 47 3 0 0·15 (0·01, 2·81) 0·20 Faecal incontinence 30 30 0 0 — — Flatus incontinence 30 26 0 2 5·74 (0·29, 114·41) 0·25 Skin bridge across anus 43 45 0 1 2·87 (0·12, 68·58) 0·52 Low back pain 43 45 0 1 2·87 (0·12, 68·58) 0·52 Complication . Total no. of patients treated . No. of patients with complications . Relative risk . P . . . . RBL . EH . RBL . EH . Urinary retention 79 77 1 5 3·70 (0·62, 22·08) 0·15 Postoperative haemorrhage 109 103 1 5 3·10 (0·63, 15·30) 0·16 Anal stenosis 73 75 0 4 4·89 (0·59, 40·85) 0·14 Acute anal fissure 49 47 3 0 0·15 (0·01, 2·81) 0·20 Faecal incontinence 30 30 0 0 — — Flatus incontinence 30 26 0 2 5·74 (0·29, 114·41) 0·25 Skin bridge across anus 43 45 0 1 2·87 (0·12, 68·58) 0·52 Low back pain 43 45 0 1 2·87 (0·12, 68·58) 0·52 Values in parentheses are 95 per cent confidence intervals. RBL, rubber band ligation; EH, excisional haemorrhoidectomy. Open in new tab Duration of time off work Time off work following treatment was reported in one study14. Patients undergoing RBL had significantly fewer days off work than those undergoing haemorrhoidectomy (one trial, 68 patients; WMD 29·00 (95 per cent c.i. 21·24 to 36·76); P < 0·001) (Fig. 4). Fig. 4 Open in new tabDownload slide Time off work. *Values are mean(s.d.). Weighted mean differences (WMDs) are shown with 95 per cent confidence intervals. RBL, rubber band ligation; EH, excisional haemorrhoidectomy. Test for overall effect: Z = 7·32, P < 0·001 Patient satisfaction Overall patient satisfaction was similar in both groups (two studies, 148 patients; RR 1·02 (95 per cent c.i. 0·94 to 1·10)). Sample size and power calculation In spite of doubtful validity in the systematic review, a post hoc sample size calculation was performed using the results available on retreatment rates. Ninety-four patients in each arm were found sufficient to detect a 20 per cent reduction in retreatment for haemorrhoidectomy on a two-sided test with 5 per cent significance, considering the 41·6 per cent retreatment for the RBL group from the review result. The estimated power for the total of 101 patients in each group (all three trials) to identify the 20 per cent reduction in retreatment rate for operation compared with RBL was 83 per cent (corrected χ2 test). This calculation showed that the result from meta-analysis for the retreatment rate was adequately powered. Discussion The need to treat haemorrhoids is based primarily on the severity of symptoms, but the type of treatment is based on the traditional classification of haemorrhoids39, which may have little to do with symptom severity. A wide variety of treatments has added to this confusion. The question of best treatment remains unanswered despite most of the techniques in use having being subjected to randomized evaluation. Previous meta-analyses6 have concentrated on the outcomes of symptom relief, retreatment, complications and pain. The present analysis has also included patient satisfaction and duration of time off work. In the present study, the efficacy of haemorrhoidectomy is proved by the symptom recurrence rate of less than 20 per cent and the significantly fewer retreatments required compared with RBL. This was particularly so for grade III haemorrhoids. However, this difference between the treatments was not reflected when comparing the individual symptoms of bleeding and prolapse. Furthermore, none of the three included studies reported on the control of other haemorrhoid symptoms, including itching, urgency, mucous discharge and perianal leakage. This makes it difficult to comment on the true overall efficacy of the techniques. Safety is of paramount importance, especially when treating a benign disease such as haemorrhoids. Furthermore, complications and subsequent disability are important factors on which patients often decide whether or not to accept any treatment despite troublesome symptoms. In the present study, delayed complications appeared more frequent after haemorrhoidectomy, but this was not so for early complications. Although no study included here reported any major adverse event, such events have indeed occurred, albeit rarely, following both haemorrhoidectomy and RBL4,12,40. Patient satisfaction, quality of life and economic consequences, such as time off work, also determine the acceptability of any treatment. Two of the three included trials14,15 reported on patient satisfaction and this was similar with both methods. One study by Murie et al.14 explored this subject further by recording a patient's willingness to undergo retreatment by the same method; there was no difference between the groups. Time off work was significantly less after RBL, highlighting its economic advantage, but the continuing cost of repeated treatments needs to be considered. None of the three included studies reported on quality of life or economics. The quality of the trials in this study is problematic, but post hoc sample size calculation suggests sufficient power to permit a proper interpretation of retreatment rates. Retreatment occurred less often after haemorrhoidectomy than after RBL. In summary, the review confirms the long-term efficacy of haemorrhoidectomy, at least for grade III haemorrhoids, compared with RBL, but at the expense of more pain, more complications and more time off work. Despite these disadvantages, patient satisfaction and acceptance of the treatment is similar to those associated with RBL. It seems reasonable to adopt RBL as the procedure of choice for grade II haemorrhoids as it has results similar to those of operation but without the side-effects. Haemorrhoidectomy should be reserved for grade III haemorrhoids or recurrence after RBL. Acknowledgements The authors acknowledge the Hepato-biliary Cochrane group coordinator Mrs Dimitrinka Nikolova, Copenhagen Trial Unit, Copenhagen University Hospital, Copenhagen, for translating one of the papers. They also thank the Cochrane Colorectal Cancer Group for its encouragement and support. References 1 Johansson JF , Rimm A. 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This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Copyright © 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Conze, J; Kingsnorth, A N; Flament, J B; Simmermacher, R; Arlt, G; Langer, C; Schippers, E; Hartley, M; Schumpelick, V

doi: 10.1002/bjs.5208pmid: 16308855

Abstract Background Polymer mesh has been used to repair incisional hernias with lower recurrence rates than suture repair. A new generation of mesh has been developed with reduced polypropylene mass and increased pore size. The aim of this study was to compare standard mesh with new lightweight mesh in patients undergoing incisional hernia repair. Methods Patients were randomized to receive lightweight composite mesh, or standard polyester or polypropylene mesh. Outcomes were evaluated at 21 days, 4, 12 and 24 months from patient responses to the Short Form 36 (SF-36) and daily activity questionnaires. Complications and recurrence rates were recorded. Results A total of 165 patients were included in an intention-to-treat analysis (83 lightweight mesh, 82 standard mesh). Postoperative complication rates were similar. The overall hernia recurrence rate was 17 per cent with the lightweight mesh versus 7 per cent with the standard mesh (P = 0·052). There were no differences in SF-36 physical function scores or daily activities between 21 days and 24 months after surgery. Conclusion The use of the lightweight composite mesh for incisional hernia repair had similar outcomes to polypropylene or polyester mesh with the exception of a non-significant trend towards increased hernia recurrence. The latter may be related to technical factors with regard to the specific placement and fixation requirements of lightweight composite mesh. Introduction Incisional hernia is a complication in 11–20 per cent of patients after laparotomy1,2 and can lead to bowel strangulation, requiring emergency surgery3. In most cases elective repair is the preferred option. The rate of re-recurrence remains high4, although it has been reduced to less than 10 per cent by the use of prosthetic mesh5. The only randomized controlled trial of recurrence following repair of incisional hernia reported a recurrence rate of 23 per cent for mesh repair compared with 46 per cent for suture repair6. Complications of mesh include local wound infection7 and seroma, patient discomfort and restriction of abdominal wall mobility8,9. Standard flat mesh made from polypropylene or polyester has a tensile strength that is far greater than that required physiologically10. Reducing the amount of polypropylene by increasing pore size produces a lighter weight mesh that may improve the functional properties and diminish local complications11. Lightweight composite mesh is the result of incorporating an absorbable component into a reduced polypropylene mass12. To evaluate the potential of lightweight composite mesh, a prospective randomized multicentre trial was undertaken in patients undergoing incisional hernia repair. Patients and methods Eight surgical centres participated in the trial: four from Germany, two from the UK, one from France and one from the Netherlands. Local ethics committee approval was obtained for each surgical centre to enrol patients with an incisional hernia into a randomized trial comparing repair with lightweight composite mesh to repair using one of three standard meshes. Randomization was achieved by computer-generated random numbers in sealed envelopes with block sizes to ensure balanced recruitment within each centre. All patients gave written informed consent. Patients had to be more than 18 years old. Patients were excluded if the hernia was less than 4 cm in diameter, or acute and incarcerated, or if the hernia was not derived from a vertical midline incision. The study was observer and patient blinded, such that the study personnel performing the postoperative assessments and the patients were unaware of treatment allocation. Meshes Three meshes, two polypropylene and one polyester (Atrium™, Atrium Medical, Mijdrecht, The Netherlands; Marlex™, C.R. Bard, Inc, Murray Hill, NJ, USA; and Mersilene™, Ethicon GmbH, Norderstedt, Germany), were used for standard mesh repair. The decision to use a particular mesh was based on the standard treatment in each centre, and individual centres used the same standard mesh throughout the study. The lightweight composite mesh was constructed from multifilaments of polypropylene with additional absorbable polyglactin (Vypro™; Ethicon GmbH). Absorption of the polyglactin component usually takes up to 84 days13. Characteristics of all the meshes employed are summarized in Table 1. Table 1 Characteristics of mesh used for incisional hernia repair Treatment group . Mesh . n . Material . Area weight (g/m2) . Pore size (mm) . Thickness (mm) . Composite Vypro™ 83 Polypropylene and polyglactin (1 : 1) 25* 4–5 0·4* Standard Mersilene™ 34 Polyester 33–43 1 0·3 Atrium™ 20 Polypropylene 92 1 0·5 Marlex™ 28 Polypropylene 95 1 0·6 Treatment group . Mesh . n . Material . Area weight (g/m2) . Pore size (mm) . Thickness (mm) . Composite Vypro™ 83 Polypropylene and polyglactin (1 : 1) 25* 4–5 0·4* Standard Mersilene™ 34 Polyester 33–43 1 0·3 Atrium™ 20 Polypropylene 92 1 0·5 Marlex™ 28 Polypropylene 95 1 0·6 * Denotes remaining polypropylene mesh. Open in new tab Table 1 Characteristics of mesh used for incisional hernia repair Treatment group . Mesh . n . Material . Area weight (g/m2) . Pore size (mm) . Thickness (mm) . Composite Vypro™ 83 Polypropylene and polyglactin (1 : 1) 25* 4–5 0·4* Standard Mersilene™ 34 Polyester 33–43 1 0·3 Atrium™ 20 Polypropylene 92 1 0·5 Marlex™ 28 Polypropylene 95 1 0·6 Treatment group . Mesh . n . Material . Area weight (g/m2) . Pore size (mm) . Thickness (mm) . Composite Vypro™ 83 Polypropylene and polyglactin (1 : 1) 25* 4–5 0·4* Standard Mersilene™ 34 Polyester 33–43 1 0·3 Atrium™ 20 Polypropylene 92 1 0·5 Marlex™ 28 Polypropylene 95 1 0·6 * Denotes remaining polypropylene mesh. Open in new tab Baseline characteristics Details of patient demography, medical history and occupation were recorded. Before surgery, all patients completed Short Form 36 (SF-36) and daily activity questionnaires. Operative details The type, size and dimensions of the hernia defect were recorded, in addition to operating time and type of anaesthesia. The mesh was implanted using the modified preperitoneal sublay procedure described by Rives et al.14. The different layers of the abdominal wall were reconstructed with mesh placed behind the rectus muscle. The posterior rectus sheath and the peritoneum were closed to prevent direct contact between mesh and intestine. The mesh was sized to give an overlap of at least 5 cm in all directions from the aponeurotic edges. Fixation of the mesh was performed according to each centre's standard procedure; some used absorbable and others non-absorbable sutures, employing interrupted or continuous suture techniques. The anterior fascia of the rectus sheath was then closed to reconstruct the linea alba. Drainage and wound closure was performed according to each centre's standard procedure. Clinical follow-up Patients attended for clinical follow-up at 21 days, 4, 12 and 24 months after surgery. At each visit, a SF-36 and daily activity questionnaire was completed. Times for return to normal activities and work were recorded. Wound assessments were completed to determine the presence of wound infection, seroma, haematoma, chronic wound pain and recurrence. Statistical analysis Owing to lower than expected patient recruitment, the power of the study was reduced to 80 per cent, requiring 126 patients. Consequently, enrolment was stopped once sufficient patients had been recruited for testing with reduced power. The primary endpoint was the SF-36 physical function score at 21 days after surgery. Before testing for any treatment difference, the standard mesh group was tested for homogeneity with regard to the three polypropylene and polyester meshes. If there was no evidence of a significant difference (P < 0·050) between results from the standard meshes, homogeneity was assumed and the standard mesh results were combined. Analysis of variance was used to examine the effect of treatment, centre, pretreatment score, age and sex. The analysis was based on an intention-to-treat population that included all randomized patients who had incisional hernia repair within the study. For the primary analysis, patients with 21-day data were included. For physical function scores and daily activity questionnaire variables at 4, 12 and 24 months, patients with missing data for an assessment were analysed using the last valid observation carried forward. Times for return to work and normal activities were analysed using survival techniques (Kaplan–Meier plots). For wound complications, a χ2 test that allowed for centre differences was used (Cochran–Mantel–Haenszel test) to determine any treatment differences. Other data were not analysed statistically but were summarized as mean(s.d.) (range) values. Results Baseline Between June 1999 and December 2000, 171 patients agreed to take part in the study. A total of 165 patients met the criteria for analysis: 83 received the lightweight composite mesh and 82 a standard mesh. Some 136 patients (80·5 per cent) completed the study after a follow-up of 2 years (Fig. 1). Twelve patients (7 per cent) withdrew consent, ten (6 per cent) were lost to follow-up, one patient in the composite mesh group died from pulmonary embolism 4 days after surgery, and ten (6 per cent) withdrew for other reasons (five from each group). In each group there were two patients who did not wish to attend as they were in good health, and three who were in hospital or care for other reasons. Fig. 1 Open in new tabDownload slide Trial profile Patient and hernia characteristics in the treatment groups were similar at trial entry (Table 2), although a greater proportion of men had standard mesh repair (56 versus 47 per cent for lightweight mesh). Baseline SF-36 dimension scores were comparable, although emotional problems scored higher in the standard mesh group. Table 2 Patient and incisional hernia characteristics . Lightweight composite mesh (n = 83) . Standard mesh (n = 82) . Mean(s.d.) age (years) 58·2(12·7) 57·7(11·7) Sex  M 39 (47) 46 (56)  F 44 (53) 36 (44) Mean(s.d.) BMI (kg/m2) 30·1(5·1) 29·3(4·9) Type of defect  Primary 48 (58) 45 (55)  Recurrent 35 (42) 37 (45) Below arcuate line  Yes 48 (58) 42 (51)  No 35 (42) 40 (49) Mean(s.d.) hernia size (cm)  Vertical 13·6(7·8) 13·3(6·6)  Horizontal 7·6(3·8) 6·4(3·8) . Lightweight composite mesh (n = 83) . Standard mesh (n = 82) . Mean(s.d.) age (years) 58·2(12·7) 57·7(11·7) Sex  M 39 (47) 46 (56)  F 44 (53) 36 (44) Mean(s.d.) BMI (kg/m2) 30·1(5·1) 29·3(4·9) Type of defect  Primary 48 (58) 45 (55)  Recurrent 35 (42) 37 (45) Below arcuate line  Yes 48 (58) 42 (51)  No 35 (42) 40 (49) Mean(s.d.) hernia size (cm)  Vertical 13·6(7·8) 13·3(6·6)  Horizontal 7·6(3·8) 6·4(3·8) Values in parentheses are percentages unless indicated otherwise. BMI, body mass index. Open in new tab Table 2 Patient and incisional hernia characteristics . Lightweight composite mesh (n = 83) . Standard mesh (n = 82) . Mean(s.d.) age (years) 58·2(12·7) 57·7(11·7) Sex  M 39 (47) 46 (56)  F 44 (53) 36 (44) Mean(s.d.) BMI (kg/m2) 30·1(5·1) 29·3(4·9) Type of defect  Primary 48 (58) 45 (55)  Recurrent 35 (42) 37 (45) Below arcuate line  Yes 48 (58) 42 (51)  No 35 (42) 40 (49) Mean(s.d.) hernia size (cm)  Vertical 13·6(7·8) 13·3(6·6)  Horizontal 7·6(3·8) 6·4(3·8) . Lightweight composite mesh (n = 83) . Standard mesh (n = 82) . Mean(s.d.) age (years) 58·2(12·7) 57·7(11·7) Sex  M 39 (47) 46 (56)  F 44 (53) 36 (44) Mean(s.d.) BMI (kg/m2) 30·1(5·1) 29·3(4·9) Type of defect  Primary 48 (58) 45 (55)  Recurrent 35 (42) 37 (45) Below arcuate line  Yes 48 (58) 42 (51)  No 35 (42) 40 (49) Mean(s.d.) hernia size (cm)  Vertical 13·6(7·8) 13·3(6·6)  Horizontal 7·6(3·8) 6·4(3·8) Values in parentheses are percentages unless indicated otherwise. BMI, body mass index. Open in new tab Surgical details All procedures were performed under general anaesthesia. The mean(s.d.) operating time was 1·8(0·7) h for both standard and composite mesh repair. Three centres used non-absorbable sutures to fix the mesh (40 patients), and absorbable sutures were used in five centres (125 patients). There was no difference in the mean(s.d.) number of days spent in hospital after surgery (14·0(8·2) days for composite mesh versus 13·2(8·7) days for standard mesh). Short Form 36 physical function dimension Homogeneity testing across the three standard mesh repairs confirmed that there was no significant treatment effect, enabling the data to be combined for comparison with composite mesh. Some 130 patients completed the SF-36 physical function scoring at baseline and at 21 days, and were thus included in the analysis. There was no difference between the two mesh groups at day 21, with a mean value of 50·4 for composite mesh and 48·4 for standard mesh. By 4 months after surgery, physical function scores were higher than baseline and day 21 values, and remained unchanged between 4 and 24 months (Fig. 2). Fig. 2 Open in new tabDownload slide Short Form 36 (SF-36): physical function scores after incisional hernia repair with lightweight composite or standard mesh Other Short Form 36 dimension scores There were no differences in the scores of other SF-36 dimensions (physical problems, emotional problems, social functioning, mental health, energy/vitality, pain, general health perception and change in health) at any time point. Daily activities As expected, there were marked reductions in the ability to perform strenuous daily activities (stretching, arising from bed in the morning, arising from a sitting position and heavy lifting) 21 days after surgery compared with baseline. Heavy lifting was severely limited in more than 60 per cent of patients at 21 days, compared with around 40 per cent at baseline. At 4, 12 and 24 months, the number of patients without limited daily activities was largely unchanged from baseline. Improvements from baseline were observed for heavy lifting, tying laces, coughing and sneezing. Both treatment groups followed the same pattern over time. Wound complications Although fewer seromas were observed at 21 days after standard mesh repair, between 4 and 24 months there were more seromas than with the composite mesh. Overall, there was no difference in the number of seromas during the 24-month follow-up; about one-third of patients developed a seroma (Table 3). Table 3 Wound assessment after repair of incisional hernia with mesh . Composite mesh (n = 83) . Mersilene™ (n = 34) . Marlex™ (n = 20) . Atrium™ (n = 28) . Overall standard mesh (n = 82) . P* . Seroma 28 (34) 3 (9) 4 (20) 17 (61) 24 (29) 0·270 Haematoma requiring surgery 4 (5) 0 (0) 0 (0) 1 (4) 1 (1) 0·187 Minor haematoma 13 (16) 4 (12) 3 (15) 6 (21) 13 (16) 0·790 Wound infection requiring surgery 5 (6) 1 (3) 1 (5) 3 (11) 5 (6) 0·916 Minor wound infection 10 (12) 2 (6) 3 (15) 3 (11) 8 (10) 0·580 Bruising 1 (1) 0 (0) 0 (0) 1 (4) 1 (1) 0·914 Hernia recurrence 14 (17) 5 (15) 0 (0) 1 (4) 6 (7) 0·052 Neuralgia 3 (4) 0 (0) 0 (0) 5 (18) 5 (6) 0·488 . Composite mesh (n = 83) . Mersilene™ (n = 34) . Marlex™ (n = 20) . Atrium™ (n = 28) . Overall standard mesh (n = 82) . P* . Seroma 28 (34) 3 (9) 4 (20) 17 (61) 24 (29) 0·270 Haematoma requiring surgery 4 (5) 0 (0) 0 (0) 1 (4) 1 (1) 0·187 Minor haematoma 13 (16) 4 (12) 3 (15) 6 (21) 13 (16) 0·790 Wound infection requiring surgery 5 (6) 1 (3) 1 (5) 3 (11) 5 (6) 0·916 Minor wound infection 10 (12) 2 (6) 3 (15) 3 (11) 8 (10) 0·580 Bruising 1 (1) 0 (0) 0 (0) 1 (4) 1 (1) 0·914 Hernia recurrence 14 (17) 5 (15) 0 (0) 1 (4) 6 (7) 0·052 Neuralgia 3 (4) 0 (0) 0 (0) 5 (18) 5 (6) 0·488 Values in parentheses are percentages. * Composite versus standard mesh (Cochran–Mantel–Haenszel test). Open in new tab Table 3 Wound assessment after repair of incisional hernia with mesh . Composite mesh (n = 83) . Mersilene™ (n = 34) . Marlex™ (n = 20) . Atrium™ (n = 28) . Overall standard mesh (n = 82) . P* . Seroma 28 (34) 3 (9) 4 (20) 17 (61) 24 (29) 0·270 Haematoma requiring surgery 4 (5) 0 (0) 0 (0) 1 (4) 1 (1) 0·187 Minor haematoma 13 (16) 4 (12) 3 (15) 6 (21) 13 (16) 0·790 Wound infection requiring surgery 5 (6) 1 (3) 1 (5) 3 (11) 5 (6) 0·916 Minor wound infection 10 (12) 2 (6) 3 (15) 3 (11) 8 (10) 0·580 Bruising 1 (1) 0 (0) 0 (0) 1 (4) 1 (1) 0·914 Hernia recurrence 14 (17) 5 (15) 0 (0) 1 (4) 6 (7) 0·052 Neuralgia 3 (4) 0 (0) 0 (0) 5 (18) 5 (6) 0·488 . Composite mesh (n = 83) . Mersilene™ (n = 34) . Marlex™ (n = 20) . Atrium™ (n = 28) . Overall standard mesh (n = 82) . P* . Seroma 28 (34) 3 (9) 4 (20) 17 (61) 24 (29) 0·270 Haematoma requiring surgery 4 (5) 0 (0) 0 (0) 1 (4) 1 (1) 0·187 Minor haematoma 13 (16) 4 (12) 3 (15) 6 (21) 13 (16) 0·790 Wound infection requiring surgery 5 (6) 1 (3) 1 (5) 3 (11) 5 (6) 0·916 Minor wound infection 10 (12) 2 (6) 3 (15) 3 (11) 8 (10) 0·580 Bruising 1 (1) 0 (0) 0 (0) 1 (4) 1 (1) 0·914 Hernia recurrence 14 (17) 5 (15) 0 (0) 1 (4) 6 (7) 0·052 Neuralgia 3 (4) 0 (0) 0 (0) 5 (18) 5 (6) 0·488 Values in parentheses are percentages. * Composite versus standard mesh (Cochran–Mantel–Haenszel test). Open in new tab Five patients had a postoperative haematoma that required surgery (four with composite mesh versus one with standard mesh). The rates of other wound complications were similar, and no patient required mesh removal for infection (Table 3). Chronic wound pain was recorded only at 12 and 24 months. Three patients with composite mesh were affected at 24 months, and five with standard mesh (three at 12 months and two at 24 months). Recurrence Overall, 20 recurrent hernias were identified during follow-up: 14 (17 per cent) in the composite mesh group and six (7 per cent) in the standard mesh group. Time to recurrence ranged from 131 to 742 days for composite mesh and from 164 to 833 days for standard mesh. Statistical analysis indicated a non-significant difference in favour of standard mesh (P = 0·052, Cochran–Mantel–Haenszel test). Discussion The use of mesh for repair of incisional hernia has been shown to halve the rate of recurrence compared with standard suture repair6. However, reports of complications following the use of standard polypropylene mesh have ranged from minor complaints, such as discomfort and increased wound infection rate, to more serious but rare complications, such as perforation and fistula formation7. Modifications to limit foreign body material by reducing polypropylene mass and increasing pore size have led to the development of a more physiologically compatible mesh12. In experimental studies this material-reduced mesh had a significantly decreased foreign body reaction in comparison with standard mesh. Investigation of abdominal wall mobility by three-dimensional stereography revealed a pronounced restriction after incisional hernia repair with standard mesh9. This prospective randomized multicentre trial compared standard polypropylene and polyester mesh with lightweight composite mesh for incisional hernia repair. The primary endpoint was SF-36 function after 21 days. There were no treatment differences between the two groups in the SF-36 domains or daily activity questionnaire findings at 21 days, or at any of the later time points. After a decrease in SF-36 scores between baseline and 21 days after surgery, both groups showed a noticeable improvement between 21 days and 4 months. Between 4 and 24 months, the SF-36 values showed no further improvement. Noticeably, the SF-36 function scores at 4 months were above baseline and remained at this higher level for the rest of the follow-up, confirming the benefit of the operation, irrespective of type of mesh. Analogous results were published recently by Post et al.15 for Lichtenstein groin hernia repair with lightweight composite mesh. There were two shortcomings to this study. First, the textile parameters of the polyester mesh (Mersilene®) resembled those of the composite mesh. Second, most of the patients with chronic postoperative pain had one type of standard polypropylene mesh (Atrium®), which was used in only three of the study centres. A subanalysis of data from these three centres revealed that 5 of 28 patients with Atrium® mesh had chronic pain, compared with 3 of 83 patients who had lightweight mesh. Although not statistically significant, this trend was consistent with the reduction in pain observed following the use of lightweight mesh for Lichtenstein hernia repair15,16. In addition, previous studies used specific questions related to hernia repair as primary endpoints, whereas in the present study the physical function domain of the SF-36 was not sufficiently specific to detect differences in groin pain. Secondary endpoints were mesh-related complication and recurrence. About one-third of the patients had seroma formation, independent of the type of mesh implanted. Schachtrupp et al.17 have shown that there is an individual response to biomaterials. The size of seroma varied greatly, ranging from less than 1 cm3 to more than 2000 cm3. In previous reports18,19 the rate of seroma formation varied between 0 and 41 per cent, probably depending on the diagnostic effort for detection. In the present trial there was also a high rate of reoperation for haematoma. Whether this was due to ultrasonographic findings with, or without, clinical relevance cannot be differentiated retrospectively. The rate of infection after mesh repair was similar for the two types of mesh, and accords with the literature in which variations between 4 and 16 per cent have been described6,20. The infections were mostly subcutaneous and it was never necessary to remove the mesh. The overall hernia recurrence rate (12·1 per cent) in this trial was higher than that in personal series, but lower than in the other prospective randomized trial6. Although not statistically significant, the recurrence rate after lightweight composite mesh repair was higher than with standard polypropylene or polyester mesh (17 versus 7 per cent). Most recurrences occurred at the cranial edge of the wound in the midline, revealing a possible technical problem in achieving sufficient mesh coverage21–23. The surgical steps of the operation, such as suture technique and material for mesh fixation, and closure of the anterior fascia were performed according to each centre's standard procedure. Examination of the surgical details showed that in 19 of the 20 patients with recurrence absorbable sutures were used for both mesh fixation and closure of the anterior fascia. The importance of surgical technique in preventing recurrence was underlined by the fact that only three of the eight centres were responsible for all recurrences. Acknowledgements Financial support for this study was received from Ethicon GmbH and Ethicon Ltd. None of the authors had any direct or indirect financial interest in the product. References 1 Mudge M , Hughes LE. Incisional hernia: a 10 year prospective study of incidence and attitudes . Br J Surg 1985 ; 72 : 70 – 71 . Google Scholar Crossref Search ADS PubMed WorldCat 2 van 't Riet M , Steyerberg EW, Nellensteyn J, Bonjer HJ, Jeekel J. Meta-analysis of techniques for closure of midline abdominal incisions . Br J Surg 2002 ; 89 : 1350 – 1356 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Manninen MJ , Lavonius M, Perhoniemi VJ. Results of incisional hernia repair. A retrospective study of 172 unselected hernioplasties . Eur J Surg 1991 ; 157 : 29 – 31 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 4 Kingsnorth A , LeBlanc K. Hernias: inguinal and incisional . Lancet 2003 ; 362 : 1561 – 1571 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Cassar K , Munro A. Surgical treatment of incisional hernia . Br J Surg 2002 ; 89 : 534 – 545 . Google Scholar Crossref Search ADS PubMed WorldCat 6 Luijendijk RW , Hop WC, van den Tol MP, de Lange DC, Braaksma MM, IJermans JN et al. A comparison of suture repair with mesh repair for incisional hernia . 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Surg Laparosc Endosc Percutan Tech 2003 ; 13 : 16 – 19 . Google Scholar Crossref Search ADS PubMed WorldCat 19 Schippers E , Harsányi A, Thumbs A, Schneider M. Results of open preperitoneal net plasty in incisional hernia . Viszeralchirurgie 2001 ; 36 : 152 – 156 . Google Scholar Crossref Search ADS WorldCat 20 Martin-Duce A , Noguerales F, Villeta R, Hernandez P, Lozano O, Keller J et al. Modifications to Rives technique for midline incisional hernia repair . Hernia 2001 ; 5 : 70 – 72 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 21 Klinge U , Conze J, Krones CJ, Schumpelick V. Incisional hernia: open techniques . World J Surg 2005 ; 29 : 1066 – 1072 . Google Scholar Crossref Search ADS PubMed WorldCat 22 Conze J , Prescher A, Kisielinski K, Klinge U, Schumpelick V. Technical consideration for subxiphoidal incisional hernia repair . Hernia 2004 ; 9 : 84 – 87 . Google Scholar Crossref Search ADS PubMed WorldCat 23 Conze J , Prescher A, Klinge U, Saklak M, Schumpelick V. Pitfalls in retromuscular mesh repair for incisional hernia: the importance of the ‘fatty triangle’ . Hernia 2004 ; 8 : 255 – 259 . Google Scholar PubMed OpenURL Placeholder Text WorldCat Author notes The Editors have satisfied themselves that all authors have contributed significantly to this publication Copyright © 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Copyright © 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Hung, W K; Chan, C M; Ying, M; Chong, S F; Mak, K L; Yip, A W C

doi: 10.1002/bjs.5211pmid: 16308853

Abstract Background Use of blue dye alone as a marker for sentinel lymph node (SLN) biopsy is effective, but combining it with isotope marking can improve the success rate. Use of the isotope adds extra cost and there are potential radiation hazards. The two techniques were compared in a randomized trial. Methods Women with early breast cancer (less than 3 cm) and no palpable axillary nodes were recruited. Women older than 70 years with multicentric cancers or previous surgery to the breast or axilla were excluded. Patients were randomized to either blue dye alone or combined mapping for SLN biopsy. All women had a level I and II axillary dissection after the SLN biopsy. Results A total of 123 patients were recruited, of whom five were excluded from analysis. Blue dye alone was used in 57 women and 61 had combined mapping. Baseline demographic data were similar in the two cohorts. The success rate of SLN biopsy was higher with combined mapping than with blue dye alone (100 versus 86 per cent; P = 0·002). The accuracy and false-negative rate were similar (accuracy 100 per cent for combined mapping versus 98 per cent for blue dye; false-negative rate 0 versus 5 per cent). Conclusion Combined mapping was superior to blue dye alone in identification of the SLN, but accuracy and false-negative rates were similar. Introduction Sentinel lymph node (SLN) biopsy is a minimally invasive and accurate method of axillary staging in breast cancer1. Large-scale randomized controlled trials evaluating SLN biopsy are under way2,3. However, the optimal mapping technique remains controversial4. Blue dye was the first method introduced for SLN localization in breast cancer and gave good results. Giuliano et al.5 reported a 93 per cent success rate and 100 per cent accuracy with blue dye. Isotope was introduced as a tracer for SLN biopsy in 1993 by Krag et al.6. Subsequently, the combination of blue dye and isotope for SLN localization has gained widespread popularity because it gave a higher success rate than use of either tracer alone and it facilitated the learning process7,8. However, there is additional cost for isotope and this includes the cost of lymphoscintigraphy and a handheld γ detector. Furthermore, there are potential radiation hazards with the use of isotope9. Like all surgical procedures, SLN biopsy has a learning curve and the rate of SLN identification is affected by the experience of the surgeon5,10,11. The present study was designed to compare use of blue dye alone with the combined technique in the identification of SLNs and accuracy of SLN biopsy. Patients and methods Women with early breast cancer were suitable for the trial. Exclusion criteria were: palpable axillary lymph nodes, age over 70 years, tumour larger than 3 cm, multicentric tumour, previous breast or axillary surgery, and pregnancy. The women were randomized using a computer-generated table into one of two groups, with SLN biopsy done using either blue dye alone or a combination of isotope and blue dye mapping. The study protocol was approved by the hospital ethics committee and written informed consent was obtained from each patient. Patients randomized to blue dye alone received a subdermal injection of Patent Blue dye (1 ml) over the tumour after induction of anaesthesia12. Manual massage was applied for 1 min. All blue stained lymph nodes in the axilla were removed. Patients in the combined mapping group had a subdermal injection of unfiltered technetium sulphur colloid (mean particle size 500 nm) over the tumour site followed by lymphoscintigraphy. Imaging was done 2 h after injection. The surgery was performed around 4 h after isotope injection. Patent Blue dye (1 ml) was injected subdermally, as above. In addition to removal of blue-stained lymph nodes, a handheld γ probe (Navigator®; US Surgical, Norwalk, Connecticut, USA) was used to detect radioactive lymph nodes and these were removed. All SLN biopsy procedures were done or supervised by one of two senior breast surgeons. Afterwards, a level I and II axillary dissection was performed for verification of axillary node status. Intraoperative frozen-section staining with haematoxylin and eosin was performed. When this was negative, further serial sectioning was performed on paraffin blocks, and immunohistochemical (IHC) staining with CAM 5.2 and AE1/AE3 was applied. Statistical analysis Assuming the success rate differed by 20 per cent, and α and β values were 0·05 and 0·8 respectively, the required sample size for each group was estimated to be around 70 women. Data were entered prospectively into a database and analysed by the SPSS program (SPSS, Chicago, Illinois, USA). χ2 test and Student's t test were used to determine statistical significance. Results One hundred and twenty-three women were recruited. Five women were excluded from analysis, three with a final pathological diagnosis of ductal carcinoma in situ and two in whom the protocol was violated (blue dye injected around the tumour instead of subdermally). Blue dye was used in 57 procedures and 61 women had combined mapping. Baseline demographic data were comparable between the two groups (Table 1). None of the lymphoscintigraphic images showed isotope migration to the internal mammary chain. Table 1 Comparison of the two groups who underwent sentinel lymph node biopsy . Blue dye only (n = 57) . Blue dye and isotope mapping (n = 61) . P . Mean age (years) 52·5 52·6 0·918* Mean tumour size (mm) 22 19 0·092* Mean number of SLNs harvested 1·8 2·1 0·274* Node positive 25 (44) 33 (54) 0·266† Breast conservation 26 (46) 31 (51) 0·572† Mean body mass index 23·6 24·3 0·261* Location in breast 0·055†  Lateral 39 41  Medial 10 18  Central 8 2 . Blue dye only (n = 57) . Blue dye and isotope mapping (n = 61) . P . Mean age (years) 52·5 52·6 0·918* Mean tumour size (mm) 22 19 0·092* Mean number of SLNs harvested 1·8 2·1 0·274* Node positive 25 (44) 33 (54) 0·266† Breast conservation 26 (46) 31 (51) 0·572† Mean body mass index 23·6 24·3 0·261* Location in breast 0·055†  Lateral 39 41  Medial 10 18  Central 8 2 Values in parentheses are percentages. * Student's t-test; † χ-square test. Open in new tab Table 1 Comparison of the two groups who underwent sentinel lymph node biopsy . Blue dye only (n = 57) . Blue dye and isotope mapping (n = 61) . P . Mean age (years) 52·5 52·6 0·918* Mean tumour size (mm) 22 19 0·092* Mean number of SLNs harvested 1·8 2·1 0·274* Node positive 25 (44) 33 (54) 0·266† Breast conservation 26 (46) 31 (51) 0·572† Mean body mass index 23·6 24·3 0·261* Location in breast 0·055†  Lateral 39 41  Medial 10 18  Central 8 2 . Blue dye only (n = 57) . Blue dye and isotope mapping (n = 61) . P . Mean age (years) 52·5 52·6 0·918* Mean tumour size (mm) 22 19 0·092* Mean number of SLNs harvested 1·8 2·1 0·274* Node positive 25 (44) 33 (54) 0·266† Breast conservation 26 (46) 31 (51) 0·572† Mean body mass index 23·6 24·3 0·261* Location in breast 0·055†  Lateral 39 41  Medial 10 18  Central 8 2 Values in parentheses are percentages. * Student's t-test; † χ-square test. Open in new tab Blue dye alone versus combined mapping The SLN was identified successfully in all 61 women in the combined group compared with 49 (86 per cent) of 57 in the blue dye group (P = 0·002). Accuracy and false-negative rate were similar (Table 2). Table 2 Results of sentinel lymph node biopsy in the two groups . Blue dye alone (n = 57) . Blue dye and isotope mapping (n = 61) . P . Success rate 49 (86) 61 (100) 0·002* True positive 21 of 49 (43) 33 of 61 (54) True negative 27 of 49 (55) 28 of 61 (46) False negative 1 of 49 (2) 0 of 61 (0) Accuracy 48 of 49 (98) 61 of 61 (100) 0·262* False-negative rate 1 of 22 (5) 0 of 33 (0) 0·216* . Blue dye alone (n = 57) . Blue dye and isotope mapping (n = 61) . P . Success rate 49 (86) 61 (100) 0·002* True positive 21 of 49 (43) 33 of 61 (54) True negative 27 of 49 (55) 28 of 61 (46) False negative 1 of 49 (2) 0 of 61 (0) Accuracy 48 of 49 (98) 61 of 61 (100) 0·262* False-negative rate 1 of 22 (5) 0 of 33 (0) 0·216* Values in parentheses are percentages. * χ-square test. Open in new tab Table 2 Results of sentinel lymph node biopsy in the two groups . Blue dye alone (n = 57) . Blue dye and isotope mapping (n = 61) . P . Success rate 49 (86) 61 (100) 0·002* True positive 21 of 49 (43) 33 of 61 (54) True negative 27 of 49 (55) 28 of 61 (46) False negative 1 of 49 (2) 0 of 61 (0) Accuracy 48 of 49 (98) 61 of 61 (100) 0·262* False-negative rate 1 of 22 (5) 0 of 33 (0) 0·216* . Blue dye alone (n = 57) . Blue dye and isotope mapping (n = 61) . P . Success rate 49 (86) 61 (100) 0·002* True positive 21 of 49 (43) 33 of 61 (54) True negative 27 of 49 (55) 28 of 61 (46) False negative 1 of 49 (2) 0 of 61 (0) Accuracy 48 of 49 (98) 61 of 61 (100) 0·262* False-negative rate 1 of 22 (5) 0 of 33 (0) 0·216* Values in parentheses are percentages. * χ-square test. Open in new tab Frozen section There was one false positive among the 35 women with a positive SLN on frozen section. In this patient, a megakaryocyte was mistaken as a tumour cell on frozen section. Subsequent histological analysis showed negative nodes. Among the 70 women with a negative SLN on frozen section, 16 had metastasis discovered on paraffin section histology and IHC staining. The false-negative rate was 32 per cent. The false-negative rate was affected by the load of metastasis in the SLN. Three per cent of nodes containing macrometastases were missed on frozen section compared with 60 per cent of those with micrometastases. IHC staining was not used on frozen sections and so micrometastases were diagnosed solely on paraffin sections. In five patients the SLN was positive on IHC staining. Discussion In the present study, combined mapping with radioisotope and blue dye was superior to blue dye alone in the identification of SLNs in women with breast cancer. Accuracy and false-negative rates were similar with both techniques. The authors first performed SLN biopsy using the blue dye technique in 199613. Since 2000, the combination of isotope and blue dye was used routinely and there was a marked improvement in both the success rate and accuracy14. This might be explained by an increase in surgeon experience, superiority of the combined technique, or both. Therefore, this trial was designed to compare the two techniques in a randomized setting and all the SLN biopsies were performed or supervised by a senior breast surgeon with experience of over 50 procedures. The SLN identification rate of 85 per cent in the authors' initial experience (1997–1999)13 was similar to the 86 per cent in the present study using blue dye alone, suggesting that the lower identification rate was not related to the surgeon's experience but is intrinsic to the technique. The first randomized trial comparing blue dye with combined mapping was reported by Morrow et al.15. The success rate of the two techniques was the same (88 per cent for blue dye and 86 per cent for the combined technique). However, the identification rate for the combined method seemed lower than expected from results reported in the literature1. This might have been due to surgeon inexperience in the early phase of the learning curve. The result in the present study was similar to that of Meyer-Rochow et al.16, in that the combined technique gave a better identification rate, whereas the accuracy and false-negative rates were similar to those of blue dye alone. A recent study from Serbia found the same SLN identification rate, but the combined technique gave a better accuracy and fewer false negatives17. Overall, including the present trial, three of four published studies showed that isotope mapping combined with the blue dye technique was superior to blue dye alone, with either an improved rate of SLN identification or fewer false-negative results. Drawbacks of the use of isotope include the additional costs of nuclear medicine facilities and a handheld γ probe. Lymphoscintigraphy is performed after isotope injection to demonstrate drainage to the lymph node basin, but its value has been questioned18. The sentinel node can be located during surgery using a handheld γ probe and so lymphoscintigraphy could be omitted. Concern about radiation exposure is also common among operating theatre personnel, but the radiation dose is very small9 and no special precautions, such as protective shields and aprons, are needed. Precautions must be taken to minimize radiation exposure during the procedure19. Intraoperative frozen-section analysis was not sufficiently accurate as the false-negative rate was 32 per cent. Other series reported similar rates20,21. There is an intrinsic limitation to production of good-quality frozen sections because of the fat content in SLNs and the time constraint on the number of sections prepared and examined. The false-negative rate was also related to the metastatic load in the SLN22. In the present series, 60 per cent of nodes containing micrometastasis were missed by frozen-section analysis. The current standard management is to clear the axilla even if the SLN contains only micrometastasis23,24. Acknowledgements The authors thank C. K. Chung for his generous contribution to this research project. References 1 Noguchi M . Sentinel lymph node biopsy and breast cancer . Br J Surg 2002 ; 89 : 21 – 34 . Google Scholar OpenURL Placeholder Text WorldCat 2 Krag D . Current status of sentinel lymph node surgery for breast cancer . J Natl Cancer Inst 1999 ; 91 : 302 – 303 . Google Scholar OpenURL Placeholder Text WorldCat 3 Clarke D , Khonji NI, Mansel RE. Sentinel node biopsy in breast cancer: ALMANAC trial . World J Surg 2001 ; 25 : 819 – 822 . Google Scholar OpenURL Placeholder Text WorldCat 4 Tuttle TM , Zogakis TG, Dunst CM, Zera RT, Singletary SE. A review of technical aspects of sentinel lymph node identification for breast cancer . J Am Coll Surg 2002 ; 195 : 261 – 268 . Google Scholar OpenURL Placeholder Text WorldCat 5 Giuliano AE , Jones RC, Brennan M, Statman R. Sentinel lymphadenectomy in breast cancer . J Clin Oncol 1997 ; 15 : 2345 – 2350 . Google Scholar OpenURL Placeholder Text WorldCat 6 Krag DN , Weaver DL, Alex JC, Fairbank JT. Surgical resection and radiolocalization of the sentinel lymph node in breast cancer using gamma probe . Surg Oncol 1993 ; 2 : 335 – 340 . Google Scholar OpenURL Placeholder Text WorldCat 7 Cody HS , Fey J, Akhurst T, Fazzari M, Mazumdar M, Yueng H et al. Complementarity of blue dye and isotope in sentinel node localization for breast cancer: univariate and multivariate analysis of 966 procedures . Ann Surg Oncol 2001 ; 8 : 13 – 19 . Google Scholar OpenURL Placeholder Text WorldCat 8 Hung WK , Lau Y, Chan MCM, Yip AWC. Role of radioisotope in sentinel node biopsy in breast cancer: a discussion paper . JHK Coll Radiol 2001 ; 4 : 37 – 40 . Google Scholar OpenURL Placeholder Text WorldCat 9 Stratmann SL , McCarty TM, Kuhn JA. Radiation safety with breast sentinel node biopsy . Am J Surg 1999 ; 178 : 454 – 457 . Google Scholar OpenURL Placeholder Text WorldCat 10 Giuliano AE , Kirgan DM, Guenther JM, Morton DL. Lymphatic mapping and sentinel lymphadenectomy for breast cancer . Ann Surg 1994 ; 220 : 391 – 401 . Google Scholar OpenURL Placeholder Text WorldCat 11 Hung WK , Chan MC, Mak KL, Chong SF, Lau Y, Ho CM et al. Non-sentinel node metastases in breast cancer patients with metastatic sentinel nodes . ANZ J Surg 2005 ; 75 : 27 – 31 . Google Scholar OpenURL Placeholder Text WorldCat 12 Borgstein PJ , Meijer S, Pjipers RJ. Intradermal blue dye to identify sentinel lymph-node in breast cancer . Lancet 1997 ; 349 : 1668 – 1669 . Google Scholar OpenURL Placeholder Text WorldCat 13 Chung CK , Hung WK, Chan CM, Lau Y, Mak KL, Yip AWC. Early experience of sentinel lymph node biopsy in breast cancer with blue dye technique . Ann Coll Surg Hong Kong 2001 ; 5 : 142 – 145 . Google Scholar OpenURL Placeholder Text WorldCat 14 Hung WK , Chan CM, Chong SF, Mak KL, Lau Y, Yip AWC. Sentinel node biopsy in breast cancer: report of 50 cases using combined isotope and blue dye mapping . Ann Coll Surg Hong Kong 2002 ; 6 : 53 – 57 . Google Scholar OpenURL Placeholder Text WorldCat 15 Morrow M , Rademaker AW, Bethke KP, Talamonti MS, Dawes LG, Clauson J et al. Learning sentinel node biopsy: results of a prospective randomized trial of two techniques . Surgery 1999 ; 126 : 714 – 720 . Google Scholar OpenURL Placeholder Text WorldCat 16 Meyer-Rochow GY , Martin RC, Harman CR. Sentinel node biopsy in breast cancer: validation study and comparison of blue dye alone with triple modality localization . ANZ J Surg 2003 ; 73 : 815 – 818 . Google Scholar OpenURL Placeholder Text WorldCat 17 Radovanovic Z , Golubovic A, Plzak A, Stojiljkovic B, Radovanovic D. Blue dye versus combined blue dye-radioactive tracer technique in detection of sentinel lymph node in breast cancer . Eur J Surg Oncol 2004 ; 30 : 913 – 917 . Google Scholar OpenURL Placeholder Text WorldCat 18 Upponi SS , McIntosh SA, Wishart GC, Balan KK, Purushotham AD. Sentinel lymph node biopsy in breast cancer—is lymphoscintigraphy really necessary? Eur J Surg Oncol 2002 ; 28 : 479 – 480 . Google Scholar OpenURL Placeholder Text WorldCat 19 Kollias J , Gill PG, Chatterton B, Raymond W, Collins PJ. Sentinel node biopsy in breast cancer: recommendations for surgeons, pathologists, nuclear physicians and radiologists in Australia and New Zealand . Aust N Z J Surg 2000 ; 70 : 132 – 136 . Google Scholar OpenURL Placeholder Text WorldCat 20 Holck S , Galatius H, Engel U, Wagner F, Hoffmann J. False-negative frozen section of sentinel node biopsy for breast cancer . Breast 2004 ; 13 : 42 – 48 . Google Scholar OpenURL Placeholder Text WorldCat 21 Chao C , Wong SL, Ackermann D, Simpson D, Carter MB, Brown CM et al. Utility of intraoperative frozen section analysis of sentinel lymph nodes in breast cancer . Am J Surg 2001 ; 182 : 609 – 615 . Google Scholar OpenURL Placeholder Text WorldCat 22 Turner RR , Hansen NM, Stern SL, Giuliano AE. Intraoperative examination of the sentinel lymph node for breast carcinoma staging . Am J Clin Pathol 1999 ; 112 : 627 – 634 . Google Scholar OpenURL Placeholder Text WorldCat 23 Morrow M . Is axillary dissection necessary after positive sentinel node biopsy? Yes! Ann Surg Oncol 2001 ; 8 ( Suppl ): S74 – S76 . Google Scholar OpenURL Placeholder Text WorldCat 24 Noguchi M . Therapeutic relevance of breast cancer micrometastases in sentinel lymph nodes . Br J Surg 2002 ; 89 : 1505 – 1515 . Google Scholar OpenURL Placeholder Text WorldCat Copyright © 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Copyright © 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

El Sakka, K; Gambhir, R P S; Halawa, M; Chong, P; Rashid, H

doi: 10.1002/bjs.5125pmid: 16078297

Abstract Background The aim of the study was to determine the prevalence of malignant disease in patients with critical leg ischaemia (CLI). Methods Data for all patients with CLI presenting to a tertiary vascular unit over an 18-month interval were collected prospectively. Patients with clinical, laboratory or radiological features suggestive of malignancy were evaluated further. Results Of 192 patients admitted with CLI, 22 (11·5 per cent) were found to have an associated malignancy; ten had lung cancer. Fifteen were anaemic on presentation. The prevalence of occult malignancy in patients with acute leg ischaemia was 16 per cent (ten of 62) compared with 9·2 per cent (12 of 130) in those with chronic CLI. Eleven of 22 of patients with CLI and malignancy died within 6 months, compared with 35 (20·6 per cent) of 170 patients with no evidence of malignancy. Conclusion A high prevalence of occult cancer was found in patients presenting with CLI; this was associated with a significantly increased mortality rate at 6 months. Introduction Cancer is the second most common cause of late death in patients with peripheral vascular disease1. Hypercoagulability is associated with cancer and represents a complex imbalance of coagulation and fibrinolysis. The association between malignancy and venous thrombosis has been well documented ever since its first elucidation by Trousseau in 18682. Between 5 and 15 per cent of patients with various carcinomas, such as lung, breast and pancreas cancers, develop deep vein thrombosis (DVT); 23 per cent of patients with idiopathic DVT have underlying malignancy when investigated3. What is not so well recognized, however, is the rate of malignant disease in patients with arterial disease. These patients share some common risk factors, yet the presence of malignancy is probably underdiagnosed and underreported. The aim of this 18-month observational study was to assess the prevalence of malignant disease in patients presenting with critical leg ischaemia (CLI). Patients and methods Between January 2002 and June 2003, all patients with CLI who presented to a tertiary vascular unit were included in this observational study. Data were collected prospectively. CLI was defined, according to the TransAtlantic Inter-Society Consensus4, as chronic ischaemic rest pain, ulcers or gangrene attributable to objectively proven arterial occlusive disease. Acute leg ischaemia (ALI) was defined as a sudden decrease or worsening in limb perfusion causing a potential threat to extremity viability4. Iatrogenic and traumatic leg ischaemia were excluded. All patients underwent routine blood tests and evaluation of the peripheral circulation using Doppler waveform analysis and duplex ultrasonography. Digital subtraction arteriography and magnetic resonance angiography were performed as indicated clinically. Evaluation of cardiac status, including echocardiography and 24-h electrocardiography, was performed in selected patients. Any patient with features of occult malignancy was investigated further. The χ2 test was used for statistical analysis. Results Over the 18 months of the study, 192 patients were admitted to hospital with CLI. Their median age was 74 (range 62–90) years and there were 96 men and 96 women. Sixty-two patients (32·3 per cent) presented with ALI. A total of 49 patients had one or more of the possible signs or symptoms of occult malignancy (Table 1) and were investigated further. Malignant disease was confirmed in 22 patients (11·5 per cent). Five patients had been treated for malignant disease in the past, one of whom was diagnosed when investigated for leg ischaemia. Fifteen new cases were discovered based on the presence of markers of occult malignancy. Two new cancers were diagnosed on post-mortem examination. There were only two patients with concurrent venous and arterial thrombosis associated with malignancy. Table 1 Markers for occult malignancy and number with malignant disease in 192 patients admitted with critical leg ischaemia Clinical or biochemical feature . No. of patients with malignancy . Unexplained weight loss 7 Anaemia 15 Abnormal finding on chest radiography 9 Increased plasma fibrinogen level 10 Clinical ascites or pleural effusion 2 Generalized lymphadenopathy 1 Leg ischaemia in a patient on warfarin 5 Clinical or biochemical feature . No. of patients with malignancy . Unexplained weight loss 7 Anaemia 15 Abnormal finding on chest radiography 9 Increased plasma fibrinogen level 10 Clinical ascites or pleural effusion 2 Generalized lymphadenopathy 1 Leg ischaemia in a patient on warfarin 5 Open in new tab Table 1 Markers for occult malignancy and number with malignant disease in 192 patients admitted with critical leg ischaemia Clinical or biochemical feature . No. of patients with malignancy . Unexplained weight loss 7 Anaemia 15 Abnormal finding on chest radiography 9 Increased plasma fibrinogen level 10 Clinical ascites or pleural effusion 2 Generalized lymphadenopathy 1 Leg ischaemia in a patient on warfarin 5 Clinical or biochemical feature . No. of patients with malignancy . Unexplained weight loss 7 Anaemia 15 Abnormal finding on chest radiography 9 Increased plasma fibrinogen level 10 Clinical ascites or pleural effusion 2 Generalized lymphadenopathy 1 Leg ischaemia in a patient on warfarin 5 Open in new tab There was a wide range of malignancies, including lung cancer (ten patients), haematological malignancy (three), gastrointestinal or hepatobiliary malignancy (three), spinal malignancy (two), prostate cancer (two), renal cancer (one) and metastases of unknown origin (one). Routine blood test results were compared between patients with and those without malignant disease (Table 2). Plasma fibrinogen levels were available for 165 patients (85·9 per cent). Of the 22 patients with malignancy, ten had a raised fibrinogen level; 15 had anaemia at presentation and more than half had increased γ-glutamyl transferase levels and a low lymphocyte count. Seven patients with all of the above abnormalities were dead within 1–6 months. Table 2 Laboratory results in patients with critical leg ischaemia according to whether or not malignant disease was identified Laboratory test . No malignant disease (n = 170) . Malignant disease (n = 22) . Anaemia 68 (40·0) 15 (68) Reduced lymphocyte count 56 (32·9) 12 (55) Raised alkaline phosphatase 37 (21·8) 8 (36) Raised γ-glutamyl transferase 37 (21·8) 11 (50) Raised fibrinogen 77 of 143 (53·8) 10 (45) Laboratory test . No malignant disease (n = 170) . Malignant disease (n = 22) . Anaemia 68 (40·0) 15 (68) Reduced lymphocyte count 56 (32·9) 12 (55) Raised alkaline phosphatase 37 (21·8) 8 (36) Raised γ-glutamyl transferase 37 (21·8) 11 (50) Raised fibrinogen 77 of 143 (53·8) 10 (45) Values in parentheses are percentages. Open in new tab Table 2 Laboratory results in patients with critical leg ischaemia according to whether or not malignant disease was identified Laboratory test . No malignant disease (n = 170) . Malignant disease (n = 22) . Anaemia 68 (40·0) 15 (68) Reduced lymphocyte count 56 (32·9) 12 (55) Raised alkaline phosphatase 37 (21·8) 8 (36) Raised γ-glutamyl transferase 37 (21·8) 11 (50) Raised fibrinogen 77 of 143 (53·8) 10 (45) Laboratory test . No malignant disease (n = 170) . Malignant disease (n = 22) . Anaemia 68 (40·0) 15 (68) Reduced lymphocyte count 56 (32·9) 12 (55) Raised alkaline phosphatase 37 (21·8) 8 (36) Raised γ-glutamyl transferase 37 (21·8) 11 (50) Raised fibrinogen 77 of 143 (53·8) 10 (45) Values in parentheses are percentages. Open in new tab Of the 22 patients with malignancy, two were managed with thrombolysis and angioplasty, four with angioplasty alone, one with surgical bypass and 11 with anticoagulation alone. Four patients with ALI were managed with thromboembolectomy. Histopathological examination of the tissue retrieved at thromboembolectomy from the four patients revealed no malignant cells. The clinical course of two patients with CLI and malignancy was complicated by recurrent thrombosis. One presented with acute arm ischaemia, had successful thrombolysis, but reoccluded and required thromboembolectomy. A week later, while still on anticoagulation, the patient developed ALI requiring embolectomy. This patient died within 1 month of presentation. A second patient underwent successful embolectomy for ALI and was discharged on aspirin and clopidogrel. This patient re-presented within 2 weeks after chemotherapy for lung cancer with rethrombosis and was subsequently anticoagulated. Eleven of the 22 patients with CLI and malignancy died within 6 months, compared with 35 (20·6 per cent) of 170 patients without malignant disease (P = 0·002). On subgroup analysis, patients who presented with ALI had a higher prevalence of occult malignancy (ten (16 per cent) of 62) than patients with chronic ischaemia (12 (9·2 per cent) of 130), but this difference was not statistically significant (P = 0·165). Discussion The main causes of death in patients with peripheral vascular occlusive disease are coronary arterial disease (40–60 per cent), malignancy (7–23 per cent) and cerebrovascular disease (2–15 per cent)5. The association between coronary, cerebrovascular and peripheral vascular disease is well documented. However, the association between peripheral vascular disease and malignancy is less well recognized and probably underreported, in spite of shared risk factors. Critical ischaemia is also associated with a prothrombotic state, with raised levels of plasma fibrinogen, cross-linked fibrin degradation products and von Willebrand factor antigen—a state that persists even after the resolution of the critical ischaemia6. Hypercoagulability in cancer has been known since 1865 and represents a complex imbalance of coagulation and fibrinolysis7. Both local and systemic activation of the coagulation cascade have been well documented in cancer, as are the roles of transmembrane protein tissue factors and other tumour-derived activators of coagulation, and inhibitors of fibrinolysis8. In patients with venous thromboembolism, non-invasive screening detects a relatively high incidence of occult cancer and the search for thrombophilia is important in patients without known cancer9. It is estimated that 5–15 per cent of patients with cancer develop venous thrombosis (Trousseau's syndrome)10. Surprisingly, there were only two patients with venous thrombosis in the present series. Both also had arterial thrombosis and malignancy, and died within 2 months of presentation. The association of arterial thrombosis and malignancy has received less attention. Naschitz et al.11 performed a retrospective analysis of 300 patients with intermittent claudication and found that 5 per cent had associated neoplastic disease. In the present study, the rate was 11·5 per cent in patients with CLI. Ten had lung cancer, which is known for its paraneoplastic manifestations such as arterial thrombosis, non-bacterial thrombotic endocarditis and recurrent venous migratory thrombophlebitis. Beauchamp et al.12 found lung cancer in 3·2 per cent of 676 patients undergoing surgery for peripheral vascular disease and suggested that chest radiography and sputum cytology should be performed in all patients. In the present series, 5·2 per cent of patients with CLI had lung cancer. There have also been reports of acute arterial occlusion occurring in patients with lung cancer soon after initiation of chemotherapy, representing either a manifestation of hypercoagulability or a vascular side-effect of platinum-based chemotherapy13. In the present study, one patient also had recurrent thrombosis after chemotherapy and had to be anticoagulated. The presence and stage of malignancy certainly influenced the treatment. Although aggressive tumour management and vascular reconstruction may be attempted, the prognosis for long-term survival is poor; in this series, half of the patients had died within 6 months. At times a palliative procedure may be more appropriate than a major reconstruction. Firm recommendations for management cannot be made from the small number of patients in this study; however, major surgical reconstruction should be avoided if possible, owing to the poor life expectancy of this group and the possibility that their hypercoagulable state might compromise bypass patency. Revascularization using thromboembolectomy or angioplasty offers palliative treatment. The use of warfarin anticoagulation should be encouraged in successfully treated patients to reduce the risk of recurrent ischaemia. It may be advantageous to involve a palliative care team in the management of these patients. Excellent analgesia, comfort measures and good pastoral care are all vital14. Not all of the patients with CLI in this series were investigated fully for occult malignancy; only the 49 with suggestive features were evaluated further. Hence, the true prevalence of cancer in these patients could be higher. One patient who underwent a major amputation following a failed vascular reconstruction presented 6 months later to the local hospital with a metastatic spinal tumour. This study raises the question of whether all patients with CLI would benefit from routine detailed investigation. It has shown that a wide variety of malignancies are associated with CLI, and hence any attempt to screen for malignancy would involve multiple investigations, although this cannot be recommended on the basis of the present study. However, as lung cancer is the commonest malignancy associated with CLI, routine chest radiography is justified as part of the vascular workup. References 1 Nehler MR , Krupski WC. Cardiac complications and screening. In Vascular Surgery , Rutherford RB (ed.), vol. 1 (5th edn). WB Saunders : Philadelphia , 2000 ; 626 – 646 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 2 Trousseau A . Phlegmasia Alba Dolens. In Clinique Medicale de l'Hotel-Dieu de Paris , vol. 3. New Sydenham Society : London , 1868 ; 695 – 727 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 3 Monreal M , Lafoz E, Casals A, Inaraja L, Montserrat E, Callejas JM et al. Occult cancer in patients with deep vein thrombosis—a systematic approach . Cancer 1991 ; 67 : 541 – 545 . Google Scholar OpenURL Placeholder Text WorldCat 4 TransAtlantic Inter-Society Consensus (TASC) working group . Management of peripheral arterial disease (PAD). Recommendations 45 and 73 . Eur J Vasc Endovasc Surg 2000 ; 19 : S115 – S243 . OpenURL Placeholder Text WorldCat 5 Bergan JJ , Wilson SE, Wolf G, Deupree RH. Unexpected, late cardiovascular effects of surgery for peripheral artery disease. Veterans Affairs Cooperative Study 199 . Arch Surg 1992 ; 127 : 1119 – 1123 . Google Scholar OpenURL Placeholder Text WorldCat 6 Woodburn KR , Rumley A, Lowe GD, Pollock JG. 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Google Scholar OpenURL Placeholder Text WorldCat 11 Naschitz JE , Yeshurun D, Abrahamson J. Arterial occlusive disease in occult cancer . Am Heart J 1992 ; 124 : 738 – 745 . Google Scholar OpenURL Placeholder Text WorldCat 12 Beauchamp G , Lassonde J, Laurendeau F, Leveille A. Lung cancer and peripheral vascular surgery . Can J Surg 1983 ; 26 : 472 – 474 . Google Scholar OpenURL Placeholder Text WorldCat 13 Mathews J , Goel R, Evans WK, Shamji F, Stewart DJ. Arterial occlusion in patients with peripheral vascular occlusive disease treated with platinum-based regimens for lung cancer . Cancer Chemother Pharmacol 1997 ; 40 : 19 – 22 . Google Scholar OpenURL Placeholder Text WorldCat 14 Campbell WB . Non-intervention and palliative care in vascular patients . Br J Surg 2000 ; 87 : 1601 – 1602 . Google Scholar OpenURL Placeholder Text WorldCat Copyright © 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Copyright © 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Blazeby, J M; Metcalfe, C; Nicklin, J; Barham, C P; Donovan, J; Alderson, D

doi: 10.1002/bjs.5175pmid: 16252311

Abstract Background Evidence suggests that baseline quality of life (QOL) scores are independently prognostic for survival in patients with cancer, but the role of QOL data in predicting short-term outcome after surgery is uncertain. This study assessed the association between QOL scores and short-term outcomes after surgery for oesophageal and gastric cancer. Methods Consecutive patients selected for oesophagectomy or total gastrectomy between November 2000 and May 2003 completed the European Organization for Research and Treatment of Cancer's quality of life questionnaire, QLQ-C30. Multivariable regression models, adjusting for known clinical risk factors, were used to investigate relationships between QOL scores, major morbidity, hospital stay and survival status at 6 months. Results Of 130 patients, 121 completed the questionnaire (response rate 93·1 per cent). There were 29 major complications (24·0 per cent) and 22 patients (18·2 per cent) died within 6 months of operation. QOL scores were not associated with major morbidity but were significantly related to survival status at 6 months after adjusting for known clinical risk factors. A worse fatigue score of 10 points (scale 0–100) corresponded to an increase in the odds of death within 6 months of surgery of 37·4 (95 per cent confidence interval (c.i.) 12·4 to 67·8) per cent (P = 0·002). Pretreatment social function scores were moderately associated with hospital stay (P = 0·021); a reduction in social function by 10 points corresponded to an increase in hospital stay of 0·93 (95 per cent c.i. 0·12 to 1·74) days. Conclusion QOL scores supplement standard staging procedures for oesophageal and gastric cancer by providing prognostic information, but they do not contribute to perioperative risk assessment. Introduction Major surgery for oesophageal and gastric cancer offers a prospect of cure, but perioperative risks are high: about 40 per cent of patients experience complications1,2. Although morbidity is common, the in-hospital death rate has been falling over the past two decades, reflecting improved patient selection, case-volume effects and provision of intensive care services1,3–5. Despite these factors, between 30 and 40 per cent of patients selected for resection die from recurrent disease within 1 year, and before death never regain the quality of life (QOL) experienced before surgery5–7. Preoperative identification of patients likely to suffer major morbidity or to die within months would enable them to be fully informed of the possible consequences of major surgery and allow consideration of other treatment options. Hospital death may be predicted by means of objective preoperative criteria including the physiological component of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and tests of cardiorespiratory function, and by using clinicians' impressions of general health status2,7. Assessment of general health may also be obtained using questionnaires completed by patients, such as QOL questionnaires8,9. Although QOL questionnaires are not designed specifically as risk assessment tools, they contain questions related to cardiorespiratory function, performance status, symptoms and psychosocial issues. Recent evidence has suggested that self-report QOL questionnaires may provide useful summary measures of co-morbid health status within the context of cancer stage and are therefore valuable in predicting outcomes such as surgical morbidity10. There is also accumulating evidence that measures of self-reported QOL are valuable prognostic indicators of survival after treatment for cancer10–13. A pooled analysis of prognostic factors in patients with locally advanced or metastatic oesophagogastric cancer undergoing chemotherapy found that those with better physical, role and global QOL scores before treatment had a longer survival9. Better baseline physical function scores were also found to be independently prognostic in patients with oesophageal cancer undergoing surgery, radiotherapy and palliative endoscopic treatment8,10. The aim of the present study was to examine whether pretreatment QOL scores were predictive of short-term outcome after planned surgery for oesophageal or gastric cancer, including major morbidity and survival status at 6 months. Patients and methods Between November 2000 and September 2003, all patients selected at the upper gastrointestinal multidisciplinary team meeting to undergo oesophagectomy or total gastrectomy were invited to participate in this prospective cohort study. Oesophagectomy was offered to fit patients with oesophageal squamous cell cancer or adenocarcinoma, including those with Siewert type I and II junctional tumours with either T1–2 N0 M0 or T3 N0–1 M0 disease who had completed neoadjuvant treatment without evidence of disease progression14. Total gastrectomy alone was offered to patients who had Siewert type III junctional tumours at the stages given above. Patients were eligible if they were able to understand or read English, were not confused and provided written informed consent. The study was approved by the United Bristol Hospitals Ethical Committee. Four upper gastrointestinal surgeons, or trainees under their supervision, performed all operations. Two-phase (abdomen and right chest) oesophagectomy and two-field (abdomen and mediastinum) lymphadenectomy or D2 total gastrectomy was performed. Clinical and demographic information, including age, sex, marital status, cohabitation, employment details, American Society of Anesthesiologists (ASA) grade, pathological stage, morbidity and in-hospital mortality, was recorded prospectively. In-hospital mortality was defined as death as an inpatient. A major complication was defined as the need for reoperation, readmission to the high-dependency or intensive care unit, readmission to hospital within 30 days of operation, death within 30 days of surgery or later if the patient failed to leave hospital, or surgery without proceeding to resection because of unexpected metastatic disease. Survival status 6 months after surgery was recorded for all patients. All patients selected for surgery were contacted by telephone by one of two trained research nurses and asked to participate in the study. Consenting patients were interviewed when attending the hospital and asked to complete the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 questionnaire in the 4 weeks before surgery8,15,16. Questionnaires were checked for missing items, and responses were obtained before the end of the interview to reduce the number of missing data. All QOL scores were linearly transformed to a score from 0 to 100; missing items were handled according to the developers' recommendations17. For multi-item function scales, higher scores are interpreted as a higher level of functioning. For single items, a higher score reflects more symptoms. Statistical analysis Multivariable regression models were used to investigate whether QOL scores improved the prediction of short-term surgical outcome beyond that achieved by established prognostic factors. Adjustments were made for patient age, sex, ASA grade and tumour stage. Additional possible prognostic factors examined included disease site, neoadjuvant treatment and whether the patient lived alone. Logistic regression models were used to assess the association between baseline QOL score and the presence of major morbidity, and survival status at 6 months. The association between hospital stay and QOL score was assessed using ordinary least squares regression, with significance tests based on a robust estimate of the standard errors and confidence intervals (c.i.) calculated using the bootstrap method18. A nominal significance level of 1 per cent was used throughout. Results Of 130 new patients selected for oesophagectomy or total gastrectomy within the time frame of the study, 121 consented to participate (response rate 93·1 per cent). Clinical and sociodemographic details of the responders and non-responders were similar (data not shown). Clinical, demographic and treatment variables for the 121 responders are shown in Table 1. Twenty-nine patients (24·0 per cent) had major complications, resulting in nine in-hospital deaths (following reoperation for anastomotic leak, four; secondary to respiratory failure, two; postoperative stroke, one; severe infection with Clostridium difficile, one; and major upper gastrointestinal bleed, one). Mean hospital stay was 22 (range 4–89) days. Six months after treatment, 22 patients had died (nine in-hospital deaths and 13 from disease recurrence). Table 1 Clinical, sociodemographic and treatment factors . No. of patients (n = 121) . Male sex 88 (72·7) Mean (range) age (years) 64 (35–84) Operation  Oesophagectomy 88 (72·7)  Total gastrectomy 33 (27·3) Received neoadjuvant treatment 69 (57·0) ASA grade  I or II 101 (83·5)  III 20 (16·5) Cohabitation  Living alone 20 (16·5)  Living with adults 101 (83·5) Major complications 29 (24·0)  Readmission within 30 days 4 (3·3)  Reoperation 12 (9·9)  Intensive care respiratory support 20 (16·5)  Open and close laparotomy 6 (5·0)  Major wound infection 4 (3·3) Minor complications 24 (19·8)  Chest infection 20 (16·5)  Wound infection 1 (0·8)  Diarrhoea 2 (1·7)  Intra-abdominal collection, no intervention 2 (1·7) Tumour stage19  I 15 (12·4)  II 42 (34·7)  III 47 (38·8)  IV 17 (14·0) In-hospital mortality 9 (7·4) . No. of patients (n = 121) . Male sex 88 (72·7) Mean (range) age (years) 64 (35–84) Operation  Oesophagectomy 88 (72·7)  Total gastrectomy 33 (27·3) Received neoadjuvant treatment 69 (57·0) ASA grade  I or II 101 (83·5)  III 20 (16·5) Cohabitation  Living alone 20 (16·5)  Living with adults 101 (83·5) Major complications 29 (24·0)  Readmission within 30 days 4 (3·3)  Reoperation 12 (9·9)  Intensive care respiratory support 20 (16·5)  Open and close laparotomy 6 (5·0)  Major wound infection 4 (3·3) Minor complications 24 (19·8)  Chest infection 20 (16·5)  Wound infection 1 (0·8)  Diarrhoea 2 (1·7)  Intra-abdominal collection, no intervention 2 (1·7) Tumour stage19  I 15 (12·4)  II 42 (34·7)  III 47 (38·8)  IV 17 (14·0) In-hospital mortality 9 (7·4) Values in parentheses are percentages unless indicated otherwise. ASA, American Society of Anesthesiologists. Open in new tab Table 1 Clinical, sociodemographic and treatment factors . No. of patients (n = 121) . Male sex 88 (72·7) Mean (range) age (years) 64 (35–84) Operation  Oesophagectomy 88 (72·7)  Total gastrectomy 33 (27·3) Received neoadjuvant treatment 69 (57·0) ASA grade  I or II 101 (83·5)  III 20 (16·5) Cohabitation  Living alone 20 (16·5)  Living with adults 101 (83·5) Major complications 29 (24·0)  Readmission within 30 days 4 (3·3)  Reoperation 12 (9·9)  Intensive care respiratory support 20 (16·5)  Open and close laparotomy 6 (5·0)  Major wound infection 4 (3·3) Minor complications 24 (19·8)  Chest infection 20 (16·5)  Wound infection 1 (0·8)  Diarrhoea 2 (1·7)  Intra-abdominal collection, no intervention 2 (1·7) Tumour stage19  I 15 (12·4)  II 42 (34·7)  III 47 (38·8)  IV 17 (14·0) In-hospital mortality 9 (7·4) . No. of patients (n = 121) . Male sex 88 (72·7) Mean (range) age (years) 64 (35–84) Operation  Oesophagectomy 88 (72·7)  Total gastrectomy 33 (27·3) Received neoadjuvant treatment 69 (57·0) ASA grade  I or II 101 (83·5)  III 20 (16·5) Cohabitation  Living alone 20 (16·5)  Living with adults 101 (83·5) Major complications 29 (24·0)  Readmission within 30 days 4 (3·3)  Reoperation 12 (9·9)  Intensive care respiratory support 20 (16·5)  Open and close laparotomy 6 (5·0)  Major wound infection 4 (3·3) Minor complications 24 (19·8)  Chest infection 20 (16·5)  Wound infection 1 (0·8)  Diarrhoea 2 (1·7)  Intra-abdominal collection, no intervention 2 (1·7) Tumour stage19  I 15 (12·4)  II 42 (34·7)  III 47 (38·8)  IV 17 (14·0) In-hospital mortality 9 (7·4) Values in parentheses are percentages unless indicated otherwise. ASA, American Society of Anesthesiologists. Open in new tab Mean baseline functional QOL scores were higher (indicating better function) and symptom scores generally lower (fewer symptoms) in patients who did not subsequently experience major morbidity than in those who developed serious complications (Table 2). Following adjustment for age and sex, or for age, sex, tumour stage and ASA grade, no significant associations between baseline QOL scores and major morbidity were found; results from the latter analyses are therefore shown in Table 2. Mean baseline functional aspects of QOL were also higher (indicating better function) and symptom scores lower (indicating fewer symptoms) in patients who were alive at 6 months, compared with those who died within 6 months (Table 3). Whether adjusting for age and sex, or for age, sex, tumour stage and ASA grade, logistic regression analysis indicated strong evidence of an association between pretreatment fatigue levels and death within 6 months of operation, with the fully adjusted analysis presented in Table 3. For a 10-point increase in fatigue score, the likelihood of death within 6 months of surgery was increased by 37·4 (95 per cent c.i. 12·4 to 67·8) per cent (P = 0·002). In addition, there was modest evidence that pretreatment cognitive (P = 0·012) and role (P = 0·027) function were both associated with death within 6 months of operation. Further adjustment for disease site, neoadjuvant treatment or living alone did not affect the findings. Table 2 Association between baseline quality of life scores and major morbidity in patients with cancer selected for oesophagectomy or gastrectomy . Mean baseline QOL score . . . . Major morbidity (n = 29) . No morbidity (n = 92) . Adjusted odds ratio* . P§ . Functional scales†  Physical 79 86 0·86 (0·69, 1·08) 0·204  Role 69 75 0·97 (0·84, 1·11) 0·625  Social 72 73 1·02 (0·87, 1·19) 0·801  Emotional 70 73 0·93 (0·78, 1·11) 0·400  Cognitive 80 82 0·94 (0·79, 1·13) 0·530  Overall QOL 62 69 0·94 (0·77, 1·13) 0·495 Symptom scales‡  Fatigue 38 27 1·14 (0·97, 1·36) 0·118  Nausea and vomiting 14 12 0·99 (0·81, 1·21) 0·930  Pain 22 16 1·05 (0·88, 1·26) 0·556  Dyspnoea 18 9 1·16 (0·96, 1·42) 0·128  Diarrhoea 8 6 1·13 (0·88, 1·46) 0·332  Constipation 14 17 0·87 (0·72, 1·06) 0·169  Sleep problems 29 24 1·04 (0·91, 1·18) 0·584  Loss of appetite 17 24 0·92 (0·80, 1·07) 0·300  Financial problems 18 13 1·07 (0·91, 1·26) 0·400 . Mean baseline QOL score . . . . Major morbidity (n = 29) . No morbidity (n = 92) . Adjusted odds ratio* . P§ . Functional scales†  Physical 79 86 0·86 (0·69, 1·08) 0·204  Role 69 75 0·97 (0·84, 1·11) 0·625  Social 72 73 1·02 (0·87, 1·19) 0·801  Emotional 70 73 0·93 (0·78, 1·11) 0·400  Cognitive 80 82 0·94 (0·79, 1·13) 0·530  Overall QOL 62 69 0·94 (0·77, 1·13) 0·495 Symptom scales‡  Fatigue 38 27 1·14 (0·97, 1·36) 0·118  Nausea and vomiting 14 12 0·99 (0·81, 1·21) 0·930  Pain 22 16 1·05 (0·88, 1·26) 0·556  Dyspnoea 18 9 1·16 (0·96, 1·42) 0·128  Diarrhoea 8 6 1·13 (0·88, 1·46) 0·332  Constipation 14 17 0·87 (0·72, 1·06) 0·169  Sleep problems 29 24 1·04 (0·91, 1·18) 0·584  Loss of appetite 17 24 0·92 (0·80, 1·07) 0·300  Financial problems 18 13 1·07 (0·91, 1·26) 0·400 Values in parentheses are 95 per cent confidence intervals. * Adjusted for age, sex, tumour stage and American Society of Anesthesiologists grade; † a high score is equivalent to better function; ‡ a high score is equivalent to more symptoms. QOL, quality of life. § Wald test. Open in new tab Table 2 Association between baseline quality of life scores and major morbidity in patients with cancer selected for oesophagectomy or gastrectomy . Mean baseline QOL score . . . . Major morbidity (n = 29) . No morbidity (n = 92) . Adjusted odds ratio* . P§ . Functional scales†  Physical 79 86 0·86 (0·69, 1·08) 0·204  Role 69 75 0·97 (0·84, 1·11) 0·625  Social 72 73 1·02 (0·87, 1·19) 0·801  Emotional 70 73 0·93 (0·78, 1·11) 0·400  Cognitive 80 82 0·94 (0·79, 1·13) 0·530  Overall QOL 62 69 0·94 (0·77, 1·13) 0·495 Symptom scales‡  Fatigue 38 27 1·14 (0·97, 1·36) 0·118  Nausea and vomiting 14 12 0·99 (0·81, 1·21) 0·930  Pain 22 16 1·05 (0·88, 1·26) 0·556  Dyspnoea 18 9 1·16 (0·96, 1·42) 0·128  Diarrhoea 8 6 1·13 (0·88, 1·46) 0·332  Constipation 14 17 0·87 (0·72, 1·06) 0·169  Sleep problems 29 24 1·04 (0·91, 1·18) 0·584  Loss of appetite 17 24 0·92 (0·80, 1·07) 0·300  Financial problems 18 13 1·07 (0·91, 1·26) 0·400 . Mean baseline QOL score . . . . Major morbidity (n = 29) . No morbidity (n = 92) . Adjusted odds ratio* . P§ . Functional scales†  Physical 79 86 0·86 (0·69, 1·08) 0·204  Role 69 75 0·97 (0·84, 1·11) 0·625  Social 72 73 1·02 (0·87, 1·19) 0·801  Emotional 70 73 0·93 (0·78, 1·11) 0·400  Cognitive 80 82 0·94 (0·79, 1·13) 0·530  Overall QOL 62 69 0·94 (0·77, 1·13) 0·495 Symptom scales‡  Fatigue 38 27 1·14 (0·97, 1·36) 0·118  Nausea and vomiting 14 12 0·99 (0·81, 1·21) 0·930  Pain 22 16 1·05 (0·88, 1·26) 0·556  Dyspnoea 18 9 1·16 (0·96, 1·42) 0·128  Diarrhoea 8 6 1·13 (0·88, 1·46) 0·332  Constipation 14 17 0·87 (0·72, 1·06) 0·169  Sleep problems 29 24 1·04 (0·91, 1·18) 0·584  Loss of appetite 17 24 0·92 (0·80, 1·07) 0·300  Financial problems 18 13 1·07 (0·91, 1·26) 0·400 Values in parentheses are 95 per cent confidence intervals. * Adjusted for age, sex, tumour stage and American Society of Anesthesiologists grade; † a high score is equivalent to better function; ‡ a high score is equivalent to more symptoms. QOL, quality of life. § Wald test. Open in new tab Table 3 Association between quality of life scores and survival status 6 months after oesophagectomy or gastrectomy . Mean baseline QOL score . . . . Dead at 6 months (n = 22) . Alive at 6 months (n = 99) . Adjusted odds ratio* . P§ . Functional scales†  Physical 76 86 0·79 (0·61, 1·00) 0·054  Role 60 76 0·84 (0·72, 0·98) 0·027  Social 65 75 0·89 (0·75, 1·05) 0·171  Emotional 68 73 0·83 (0·67, 1·01) 0·067  Cognitive 72 84 0·77 (0·63, 0·94) 0·012  Overall QOL 58 70 0·83 (0·67, 1·04) 0·101 Symptom scales‡  Fatigue 46 26 1·37 (1·12, 1·68) 0·002  Nausea and vomiting 20 10 1·19 (0·97, 1·46) 0·090  Pain 25 16 1·18 (0·97, 1·44) 0·095  Dyspnoea 15 10 1·07 (0·86, 1·33) 0·531  Diarrhoea 8 6 1·14 (0·85, 1·54) 0·374  Constipation 26 14 1·20 (1·00, 1·46) 0·056  Sleep problems 33 24 1·12 (0·97, 1·29) 0·120  Loss of appetite 29 21 1·11 (0·96, 1·30) 0·156  Financial problems 20 13 1·09 (0·91, 1·30) 0·338 . Mean baseline QOL score . . . . Dead at 6 months (n = 22) . Alive at 6 months (n = 99) . Adjusted odds ratio* . P§ . Functional scales†  Physical 76 86 0·79 (0·61, 1·00) 0·054  Role 60 76 0·84 (0·72, 0·98) 0·027  Social 65 75 0·89 (0·75, 1·05) 0·171  Emotional 68 73 0·83 (0·67, 1·01) 0·067  Cognitive 72 84 0·77 (0·63, 0·94) 0·012  Overall QOL 58 70 0·83 (0·67, 1·04) 0·101 Symptom scales‡  Fatigue 46 26 1·37 (1·12, 1·68) 0·002  Nausea and vomiting 20 10 1·19 (0·97, 1·46) 0·090  Pain 25 16 1·18 (0·97, 1·44) 0·095  Dyspnoea 15 10 1·07 (0·86, 1·33) 0·531  Diarrhoea 8 6 1·14 (0·85, 1·54) 0·374  Constipation 26 14 1·20 (1·00, 1·46) 0·056  Sleep problems 33 24 1·12 (0·97, 1·29) 0·120  Loss of appetite 29 21 1·11 (0·96, 1·30) 0·156  Financial problems 20 13 1·09 (0·91, 1·30) 0·338 Values in parentheses are 95 per cent confidence intervals. * Adjusted for age, sex, tumour stage and American Society of Anesthesiologists grade; † a high score is equivalent to better function; ‡ a high score is equivalent to more symptoms. QOL, quality of life. § Wald test. Open in new tab Table 3 Association between quality of life scores and survival status 6 months after oesophagectomy or gastrectomy . Mean baseline QOL score . . . . Dead at 6 months (n = 22) . Alive at 6 months (n = 99) . Adjusted odds ratio* . P§ . Functional scales†  Physical 76 86 0·79 (0·61, 1·00) 0·054  Role 60 76 0·84 (0·72, 0·98) 0·027  Social 65 75 0·89 (0·75, 1·05) 0·171  Emotional 68 73 0·83 (0·67, 1·01) 0·067  Cognitive 72 84 0·77 (0·63, 0·94) 0·012  Overall QOL 58 70 0·83 (0·67, 1·04) 0·101 Symptom scales‡  Fatigue 46 26 1·37 (1·12, 1·68) 0·002  Nausea and vomiting 20 10 1·19 (0·97, 1·46) 0·090  Pain 25 16 1·18 (0·97, 1·44) 0·095  Dyspnoea 15 10 1·07 (0·86, 1·33) 0·531  Diarrhoea 8 6 1·14 (0·85, 1·54) 0·374  Constipation 26 14 1·20 (1·00, 1·46) 0·056  Sleep problems 33 24 1·12 (0·97, 1·29) 0·120  Loss of appetite 29 21 1·11 (0·96, 1·30) 0·156  Financial problems 20 13 1·09 (0·91, 1·30) 0·338 . Mean baseline QOL score . . . . Dead at 6 months (n = 22) . Alive at 6 months (n = 99) . Adjusted odds ratio* . P§ . Functional scales†  Physical 76 86 0·79 (0·61, 1·00) 0·054  Role 60 76 0·84 (0·72, 0·98) 0·027  Social 65 75 0·89 (0·75, 1·05) 0·171  Emotional 68 73 0·83 (0·67, 1·01) 0·067  Cognitive 72 84 0·77 (0·63, 0·94) 0·012  Overall QOL 58 70 0·83 (0·67, 1·04) 0·101 Symptom scales‡  Fatigue 46 26 1·37 (1·12, 1·68) 0·002  Nausea and vomiting 20 10 1·19 (0·97, 1·46) 0·090  Pain 25 16 1·18 (0·97, 1·44) 0·095  Dyspnoea 15 10 1·07 (0·86, 1·33) 0·531  Diarrhoea 8 6 1·14 (0·85, 1·54) 0·374  Constipation 26 14 1·20 (1·00, 1·46) 0·056  Sleep problems 33 24 1·12 (0·97, 1·29) 0·120  Loss of appetite 29 21 1·11 (0·96, 1·30) 0·156  Financial problems 20 13 1·09 (0·91, 1·30) 0·338 Values in parentheses are 95 per cent confidence intervals. * Adjusted for age, sex, tumour stage and American Society of Anesthesiologists grade; † a high score is equivalent to better function; ‡ a high score is equivalent to more symptoms. QOL, quality of life. § Wald test. Open in new tab Multivariable analyses of baseline QOL scores and hospital stay found only a modest association between pretreatment social function scores and hospital stay (P = 0·021). After adjustment for age, sex, tumour stage and ASA grade, a 10-point reduction in social function corresponded to an increase in hospital stay of 0·93 (95 per cent c.i. 0·12 to 1·74) days. Discussion This prospective study has provided evidence to support an association between pretreatment measures of QOL and survival status 6 months after surgery, but no evidence that QOL scores can be used to predict surgical morbidity. Poorer pretreatment scores for fatigue, cognitive function and role function were associated with an increased likelihood of death within 6 months of surgery. The adjusted analysis demonstrated that these associations existed over and above what could be explained by known prognostic factors. The study suggested, therefore, that incorporation of self-reported measures of QOL using the EORTC QLQ-C30 into clinical decision-making may help to identify patients who will not experience long-term survival after surgery, and may aid in making the decision to decline operative treatment. The EORTC QLQ-C30 questionnaire, however, does not provide a sufficient measure of co-morbidity to be used as a tool for operative risk assessment. A similar study in patients undergoing colorectal resection did identify an association between pretreatment QOL scores (using the Medical Outcomes Survey Short Form 36 (SF-36) and Functional Assessment of Cancer Therapy (FACT) colorectal scale) and morbidity10. More gastrointestinal symptoms before surgery and poorer social function were both associated with an increased risk of surgical morbidity. These differences from the present study might be related to use of the SF-36 (a generic measure of self-reported health), which could be more sensitive to health issues related to co-morbidity than the EORTC QLQ-C30. Although interesting, the strength of the associations was modest and a larger study, adjusting for more clinical risk variables, is needed to confirm these findings. A second study using the SF-36 in patients undergoing coronary artery bypass graft surgery found that the summary score for the physical component was an independent risk factor for hospital death20. QOL scores have been shown to be independent predictors of survival after treatment for upper gastrointestinal cancer11–13. Although the present study had a similar finding, it has provided more meaningful information for decision-making because baseline QOL scores may be used to identify individuals who die before any benefit of surgery is apparent. All studies used the same QOL measure (EORTC QLQ-C30), but in patients undergoing different treatments. The results show some consistency and several prognostic QOL variables are emerging. Within a cohort of patients undergoing chemotherapy, global QOL and role function were prognostic indicators9, although this study did not include the symptom scales or items in the EORTC QLQ-C30. In a group of patients undergoing a variety of treatments for oesophageal cancer, physical function was found to predict survival11, a finding that was supported by a study of similar size in patients undergoing primary radiotherapy13. In the present study, less fatigue and better cognitive function predicted survival status at 6 months. Fatigue is frequently linked to physical function and, although physical function showed an association with survival in univariable analysis, statistical significance was not demonstrated after adjusting for known prognostic factors. The associations found in this study do not establish a causative relationship between baseline QOL score and outcome, although patients with unrecognized micrometastatic disease before surgery may feel more tired (and report this in terms of high fatigue scores and low cognitive function) before metastatic disease is apparent clinically or radiologically. This hypothesis is supported by publications demonstrating the prognostic value of QOL scores in patients with advanced breast cancer but not in those with non-metastatic disease21,22. Although this makes clinical sense, in the present study patients who died within 6 months of surgery comprised both patients who died from recurrent disease and those who died in-hospital from complications. Clinical interpretation of the findings is therefore difficult, although patients could be advised that QOL measures may identify individuals who are likely to die before seeing any benefit of surgery. This study raises the question of the necessity and practicality of using self-report measures of QOL to help identify patients who will not benefit from surgical resection. An increase in the preoperative fatigue score of 10 points (range 0–100) was associated with a 37·4 per cent increase in the risk of death 6 months after surgery. At present, surgeons are unfamiliar with the clinical significance of QOL scores, although this should gradually change as more surgical departments use self-report QOL questionnaires to evaluate treatment. A 10-point change in one of the QLQ-C30 fatigue questions (for example, ‘Were you tired?’) represents a change in response from ‘not at all’ to ‘a little’, or from ‘quite a bit’ to ‘very much’. In general, surgeons do not appreciate the clinical significance of this type of change in response to a single question. Further work by surgeons in the use of health-related QOL questionnaires is therefore recommended before they can be used to influence surgical decision-making for patients with cancer of the oesophagus or gastric cardia. Acknowledgements The contribution of J.M.B. to this work was supported by a Medical Research Council Clinician Scientist Award. References 1 Hulscher JB , van Sandick JW, de Boer AG, Wijnhoven BP, Tijssen JG, Fockens P et al. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus . N Engl J Med 2002 ; 347 : 1662 – 1669 . Google Scholar OpenURL Placeholder Text WorldCat 2 McCulloch P , Ward J, Tekkis PP. Mortality and morbidity in gastro-oesphageal cancer surgery: initial results of ASCOT multicentre prospective cohort study . BMJ 2003 ; 327 : 1192 – 1197 . Google Scholar OpenURL Placeholder Text WorldCat 3 Cuschieri A , Fayers P, Fielding J, Craven J, Bancewicz J, Joypaul V et al. Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer. Preliminary results of the MRC randomised controlled surgical trial. The Surgical Cooperative Group . Lancet 1996 ; 347 : 995 – 999 . Google Scholar OpenURL Placeholder Text WorldCat 4 Sano T , Sasako M, Yamamoto S, Nashimoto A, Kurita A, Hiratsuka M et al. Gastric cancer surgery: morbidity and mortality results from a prospective randomized controlled trial comparing D2 and extended para-aortic lymphadenectomy—Japan Clinical Oncology Group study 9501 . J Clin Oncol 2004 ; 22 : 2767 – 2773 . Google Scholar OpenURL Placeholder Text WorldCat 5 Jamieson GG , Mathew G, Ludemann R, Wayman J, Myers JC, Devitt PG. Postoperative mortality following oesophagectomy and problems in reporting its rate . Br J Surg 2004 ; 91 : 943 – 947 . Google Scholar OpenURL Placeholder Text WorldCat 6 Blazeby JM , Farndon JR, Donovan J, Alderson D. A prospective longitudinal study examining the quality of life of patients with esophageal cancer . Cancer 2000 ; 88 : 1781 – 1787 . Google Scholar OpenURL Placeholder Text WorldCat 7 Bartels H , Stein HJ, Siewert JR. Preoperative risk analysis and postoperative mortality of oesophagectomy for resectable oesophageal cancer . Br J Surg 1998 ; 85 : 840 – 844 . Google Scholar OpenURL Placeholder Text WorldCat 8 Aaronson NK , Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ et al. The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology . J Natl Cancer Inst 1993 ; 85 : 365 – 376 . Google Scholar OpenURL Placeholder Text WorldCat 9 Cella DF , Tulsky DS, Gray G, Sarafian B, Linn E, Bonomi A et al. The Functional Assessment of Cancer Therapy Scale: development and validation of the general measure . J Clin Oncol 1993 ; 11 : 570 – 579 . Google Scholar OpenURL Placeholder Text WorldCat 10 Anthony T , Hynan LS, Rosen D, Kim L, Nwariaku F, Jones C et al. The association of pretreatment health-related quality of life with surgical complications for patients undergoing open surgical resection for colorectal cancer . Ann Surg 2003 ; 238 : 690 – 696 . Google Scholar OpenURL Placeholder Text WorldCat 11 Blazeby JM , Brookes ST, Alderson D. The prognostic value of quality of life scores during treatment for oesophageal cancer . Gut 2001 ; 49 : 227 – 230 . Google Scholar OpenURL Placeholder Text WorldCat 12 Chau I , Norman AR, Cunningham D, Waters JS, Oates J, Ross PJ. Multivariate prognostic factor analysis in locally advanced and metastatic esophago-gastric cancer—pooled analysis from three multicenter, randomized, controlled trials using individual patient data . J Clin Oncol 2004 ; 22 : 2395 – 2403 . Google Scholar OpenURL Placeholder Text WorldCat 13 Fang FM , Tsai WL, Chiu HC, Kuo WR, Hsiung VY. Quality of life as a survival predictor for esophageal squamous cell carcinoma treated with radiotherapy . Int J Radiat Oncol Biol Phys 2004 ; 58 : 1394 – 1404 . Google Scholar OpenURL Placeholder Text WorldCat 14 Siewert JR , Stein HJ. Classification of adenocarcinoma of the oesophagogastric junction . Br J Surg 1998 ; 85 : 1457 – 1459 . Google Scholar OpenURL Placeholder Text WorldCat 15 Blazeby JM , Conroy T, Bottomley A, Vickery C, Arraras J, Sezer O et al. Clinical and psychometric validation of a questionnaire module, the EORTC QLQ-STO 22, to assess quality of life in patients with gastric cancer . Eur J Cancer 2004 ; 40 : 2260 – 2268 . Google Scholar OpenURL Placeholder Text WorldCat 16 Blazeby JM , Conroy T, Hammerlid E, Fayers P, Sezer O, Koller M et al. Clinical and psychometric validation of an EORTC questionnaire module, the EORTC QLQ-OES18, to assess quality of life in patients with oesophageal cancer . Eur J Cancer 2003 ; 39 : 1384 – 1394 . Google Scholar OpenURL Placeholder Text WorldCat 17 Fayers P , Aaronson NK, Bjordal K, Groenvold M, Curran D, Bottomley A. EORTC QLQ-C30 Scoring Manual (3rd edn). European Organization for Research and Treatment of Cancer : Brussels , 2001 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 18 Kirkwood BR , Sterne JAC. Essential Medical Statistics (2nd edn). Blackwell Science : Oxford , 2003 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 19 Sobin LH , Wittekind C. UICC. TNM Classification of Malignant Tumours (5th edn). Wiley-Liss : New York , 1997 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 20 Rumsfeld JS , MaWhinney S, McCarthy M, Shroyer AL, VillaNeuva CB, O'Brien M et al. Health-related quality of life as a predictor of mortality following coronary artery bypass graft surgery. Participants of the Department of Veterans Affairs Cooperative Study Group on Processes, Structures, and Outcomes of Care in Cardiac Surgery . JAMA 1999 ; 281 : 1298 – 1303 . Google Scholar OpenURL Placeholder Text WorldCat 21 Coates AS , Hurny C, Peterson HF, Bernhard J, Castiglione Gertsch M, Gelber RD et al. Quality-of-life scores predict outcome in metastatic but not early breast cancer. International Breast Cancer Study Group . J Clin Oncol 2000 ; 18 : 3768 – 3774 . Google Scholar OpenURL Placeholder Text WorldCat 22 Efficace F , Therasse P, Piccart MJ, Coens C, van Steen K, Welnicka Jaskiewicz M et al. Health-related quality of life parameters as prognostic factors in a nonmetastatic breast cancer population: an international multicenter study . J Clin Oncol 2004 ; 22 : 3381 – 3388 . Google Scholar OpenURL Placeholder Text WorldCat Copyright © 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Copyright © 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Hellman, P; Hennings, J; Åkerström, G; Skogseid, B

doi: 10.1002/bjs.5149pmid: 16231278

Abstract Background Pancreatic tumours are common in patients with multiple endocrine neoplasia type 1 (MEN1), and close surveillance is needed to detect pancreatic lesions at an early stage. Conventional radiology is inefficient in verifying the small tumours indicated by biochemical screening. During the past decade, endoscopic ultrasonography (EUS) has evolved as a sensitive method for the detection of small pancreatic lesions. Methods EUS was evaluated in 25 patients with MEN1, two of whom had symptoms due to hormonal secretion. Twenty-two patients had biochemical signs of pancreatic tumours, and in five patients lesions were located by either computed tomography (two) or transabdominal ultrasonography (three). Results EUS visualized pancreatic tumours in the five patients in whom lesions were detected by the other methods and in a further nine patients. Eight of these 14 patients had surgery, and tumours were confirmed histopathologically. No lesion was detected in any of the 11 patients with no tumour detected by EUS. Conclusion EUS is a more sensitive technique for the detection and localization of potentially malignant lesions in patients with MEN1 than computed tomography or transabdominal ultrasonography. Introduction Multiple endocrine neoplasia type 1 (MEN1) is characterized clinically by tumours arising in the anterior pituitary, parathyroid, pancreas or duodenum, with varying frequency among gene carriers. It is also associated with an increased prevalence of adrenal, thymic or bronchial tumours1. Pancreaticoduodenal tumours represent the second most common classical lesion in MEN1, being detected in 30–75 per cent of patients. These patients are prone to premature death, usually as a result of the development of pancreatic tumours1–3. About half of the patients already have malignant pancreatic tumours when clinical symptoms develop, and non-functional tumours may precede the symptomatic phase by about a decade1. Close surveillance is therefore mandatory to identify pancreaticoduodenal tumours at an early stage. Early surgery has been advocated previously, even in asymptomatic patients with only a biochemical diagnosis of pancreaticoduodenal tumour and negative results for radiological localization procedures15. The authors' biochemical screening programme comprises analysis of a comprehensive panel of hormonal markers for pancreatic tumour diagnosis4. Routine radiological investigation of MEN1 carriers includes triple-phase computed tomography (CT) and transabdominal ultrasonography. Other radiological methods such as magnetic resonance imaging (MRI) and somatostatin receptor scintigraphy (SRS) have been used in selected patients. However, conventional radiological methods are inefficient in detecting endocrine pancreatic tumours in patients with MEN1, as usually only larger tumours are visible5. Use of 5-hydroxytryptophan positron emission tomography (5-HTP PET) has not yet been evaluated6. Endoscopic ultrasonography (EUS) has been reported to be the most sensitive method for visualization of neuroendocrine tumours of the pancreas7. It was able to detect tumours smaller than those identified by CT, angiography or octreoscan in patients with MEN1 in one study8, and in combination with octreoscan allowed detection of 93 per cent of tumours in other series7,9. In the present study, EUS was used to to evaluate 25 consecutive patients with MEN1 and varying biochemical evidence of pancreatic tumours. Patients and methods Between October 1999 and December 2003, 25 consecutive patients (17 females) with known MEN1 and a mean age of 48 (range 15–73) years underwent EUS for presumed pancreaticoduodenal tumours. All patients had the diagnosis of MEN1 confirmed by detection of a MEN1 gene mutation and/or unequivocal biochemical and radiological signs of MEN1-associated endocrine tumours. The patients belonged to 19 different families. Twenty-three had previously been operated on for primary hyperparathyroidism and ten for pituitary tumours. Eleven patients had previously had surgery for pancreatic tumours; two had been operated on twice. Nine underwent left-sided pancreatic resections of varying extent, one with concomitant duodenotomy and resection of a duodenal gastrinoma. One patient had a Whipple pancreaticoduodenectomy for a tumour in the pancreatic head. Histopathological examination of the resected pancreatic specimens revealed endocrine pancreatic tumours (one to four per patient); all were positive for pancreatic polypeptide (PP) and chromogranin A, in addition to other hormones in different combinations. At the time of the present investigation, two patients had excess gastrin production and were classified as having Zollinger–Ellison syndrome. No patient had distant metastasis or histopathological evidence of regional lymph node metastasis at the time of the first operation. All patients had repeated biochemical screening4 using standard immunoassays, and underwent transabdominal ultrasonography and abdominal CT using triple-phase protocols that enabled contrast enhancement of venous and arterial vessels. Contrast enhancement was also used more recently during transabdominal ultrasonography, although data acquired by this method are not presented separately. SRS and MRI were used in selected patients and 5-HTP PET6 was performed in 16 patients. The 25 patients underwent a total of 34 EUS examinations. A Pentax endoscope (Pentax Corporation, Tokyo, Japan) equipped with a radial scanner (FG-32A) (Fig. 1) and Hitachi E525 ultrasound equipment (Hitachi Medical Corporation, Tokyo, Japan) were used10. The endoscope had 60° oblique forward-viewing optics and a curved linear array transducer in front of the lens. The frequency could be switched from 5 to 7·5 MHz, and a water-filled balloon surrounding the transducer could be used to enhance visualization. The equipment allowed storing and printing of still ultrasound images as well as video recording of entire examinations. Fig. 1 Open in new tabDownload slide Radial scanner at the end of a Pentax FG-32A endoscope Of the 11 patients who had undergone surgery previously, four were operated on again after EUS, with extended resection of the pancreatic body. A further four patients underwent 80–85 per cent pancreatic body and tail resection at least to the portal vein as a primary procedure. This included exploration of the entire pancreas and bimanual palpation combined with intraoperative ultrasonography. Duodenotomy and careful palpation of the intestinal wall was included in patients with a raised serum gastrin level. Results All but three of the 25 patients had endocrine pancreatic tumours diagnosed biochemically11. In two, the predominant biochemical feature was a 10–17-fold increase in gastrin production, accompanied by symptoms typical of Zollinger–Ellison syndrome. Most had non-functional pancreatic tumours with predominant PP secretion in combination with increased levels of other peptides. Two patients had markedly increased proinsulin levels without hypoglycaemic symptoms, and one patient a two times raised level of vasoactive intestinal polypeptide. Meal tests with measurement of PP and gastrin levels demonstrated a pathological response in 21 patients, including four patients with normal basal values. Transabdominal ultrasonography without contrast enhancement revealed pancreatic tumours in three of the 25 patients; in two, more than one tumour was visualized. All tumours were located in the body or tail of the pancreas. Triple-phase CT visualized tumours confined to the body and tail in two patients. In no patient were pancreatic tumours detected by either transabdominal ultrasonography or CT. 5-HTP PET revealed the presence of pancreatic tumours in six of 16 patients; in two patients this corresponded to the tumour location identified by CT. EUS visualized a total of 22 tumours in 14 patients; the lesions ranged from 4 to 22 (mean 10) mm in diameter (Fig. 2). Three tumours were detected in one patient, two tumours in six individuals, and a single tumour in seven patients. Seven of these 14 patients had previously undergone surgery and all new lesions were located within the pancreatic remnant. In the remaining patients the predominant location was the pancreatic body and tail. In five patients EUS was the only method that located the tumour; in other patients tumours were also visualized by transabdominal ultrasonography (three patients), CT (two) or 5-HTP PET (six). Fig. 2 Open in new tabDownload slide Pancreatic tumour visualized by endoscopic ultrasonography. The 11 × 20-mm tumour (delineated in white and demonstrated by the large arrow) was later resected and verified histopathologically. The small arrow indicates the portal vein Eight patients underwent surgery after EUS. No tumours of the pancreatic head were found. Levels of biochemical markers normalized after operation in five of the eight patients, although the serum chromogranin A level remained high in three, possibly owing to coexisting parathyroid (one) or pituitary (two) disease. The meal test was normalized in four patients. Preoperative EUS results corresponded to operative findings in all patients (no false positives). Intraoperative ultrasonography detected all tumours visualized by EUS, as well as a further five pancreatic tumours that were confirmed by histopathological examination. The latter investigation revealed the presence of a further five tumours, giving a total of ten tumours in these eight patients that were not detected by EUS. These eight operated patients had 13 tumours previously known from EUS, yielding a False-negative rate or 43·4%. The tumours missed by EUS ranged in size from 2 to 6 (mean 3·2) mm. Intraoperative palpation and ultrasonography followed by histopathological examination detected peripancreatic lymph node metastases in three patients and liver metastases in one. None of these patients had pancreatic tumours larger than 15 mm. Discussion Life-long cancer prevention with preserved endocrine and exocrine pancreatic function is the aim in pancreatic management of patients with MEN1. To achieve early detection, patients are followed by means of an annual screening programme. The Uppsala policy is to operate before symptoms develop in patients with biochemically recognized tumours, defined by raised levels of basal and/or meal-stimulated markers, although indications for primary pancreatic surgery in MEN1 vary between referral centres. The authors' current aim is to locate the tumours by EUS before operation, and to remove all lesions visualized by intraoperative ultrasonography. The present results support the use of EUS in the screening of patients with MEN1. Recurrent disease is common in MEN1, but is difficult to manage and indications for reoperation are controversial. In the absence of evidence-based guidelines, the authors' policy has been to embark on such major surgery only if levels of two markers are rising in combination with a visualized lesion of at least 1 cm. However, EUS has emerged recently as a sensitive tool for tumour localization that can support the decision to reoperate, and patients with inconclusive biochemical markers but evidence of a growing lesion on EUS are considered for reoperation. The preferred procedure is 80–85 per cent distal resection, in combination with intraoperative ultrasonographically guided enucleation, in order to avoid total pancreatectomy with endocrine and exocrine insufficiency. In the early development of pancreatic lesions, measurement of serum PP concentration has proved useful in the detection of non-functional tumours, although false positives occur1. Some ‘false-positive’ results actually indicate the presence of small tumours that cannot be visualized by imaging, leading to extensive and repeated biochemical testing and early operation. It is currently not known whether this is of benefit to the patient11. Nevertheless, several small series of patients have been followed for more than 10 years in this way and have shown no sign of malignant disease. Whether this policy affects survival remains to be proven. Conventional radiological localization methods such as CT, transabdominal ultrasonography, MRI and SRS have been disappointing for the detection of pancreatic tumours in MEN14,12, whereas EUS has proved useful for small neuroendocrine pancreatic tumours7,8,13. EUS can visualize small lesions with a lower limit of resolution of approximately 5 mm, allowing earlier localization of pancreatic tumours8,13. Three of the present patients with pancreatic tumours smaller than 15 mm had liver and peripancreatic lymph node metastases detected during operation. In a previous study it was found that biochemical signs of pancreatic tumours in the absence of tumour localization by CT, SRS or transabdominal ultrasonography were indicative of no metastases, whereas metastatic disease was found in 26 per cent of patients with tumours imaged by these methods before operation14. It is noteworthy that the number of pancreatic tumours determined by microscopic examination often exceeds the number detected either before or during operation. In the present series most pancreatic tumours were localized before surgery by EUS alone. Ten additional tumours were found at intraoperative ultrasonography or final histopathological examination, reflecting the general underestimation of tumours in patients with MEN1. All operations involved resection of the pancreatic body and tail alone, so information on microscopic tumours was available only for this part of the pancreas. Assuming that all patients, including those not having surgery, actually had pancreatic tumours, the success rate of EUS was 56 per cent (14 of 25 patients). It was 64 per cent (14 of 22) when biochemical signs were taken as the standard, and approximately 50 per cent for histopathologically verified tumours. However, allowing for the fact that EUS is not expected to detect tumours smaller than 5 mm, the success rate increased to 76·5 per cent (13 out of 17 tumours larger than 0·5 mm were found by EUS). The other localization procedures were considerably less efficient. It should be noted that histopathological evidence of smaller undetected tumours was present in all resected specimens. Nevertheless, all imaging findings were confirmed at operation and histopathologically. EUS with a sector-scanning linear array is a difficult methodology with a considerable learning curve. The investigations in this series were performed by one experienced examiner. Other authors have reported similar results using mechanical radial scanners8. It has been claimed that the pancreatic tail is more difficult to examine by EUS, owing to its deviation from the stomach in this region8. However, this may apply only to mechanical radial EUS, as examination of the pancreatic tail was not found to be difficult in this study. More troublesome may be the thorough investigation of the uncinate process and especially submucosal duodenal gastrinomas. However, simultaneous examination of the adrenals is easily performed, and may be of value in patients with MEN1, who are known to have a higher prevalence of adrenal tumours. Newly developing techniques including contrast-enhanced transabdominal ultrasonography and 5-HTP PET may prove useful in the future in the early detection of pancreatic tumours in patients with MEN1, but require further evaluation. Of the currently available methods, EUS has the highest sensitivity for localization of pancreatic tumours in MEN1 and should be included in the routine annual screening programme of MEN1 gene carriers. Acknowledgements The authors acknowledge the staff of the Endoscopic Unit, Department of Surgery, University Hospital Uppsala, for support during the course of the study. References 1 Skogseid B , Rastad J, Åkerström G. Pancreatic endocrine tumors in multiple endocrine neoplasia type 1. In: Surgical Endocrinology , Doherty GM, Skogseid B (eds). Lippincott, Williams & Wilkins : Philadelphia , 2001 ; 511 – 525 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 2 Dean PG , van Heerden JA, Farley DR, Thompson GB, Grant CS, Harmsen WS et al. Are patients with multiple endocrine neoplasia type I prone to premature death? World J Surg 2000 ; 24 : 1437 – 1441 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Doherty GM , Olson JA, Frisella MM, Lairmore TC, Wells SA, Norton JA. Lethality of multiple endocrine neoplasia type I . World J Surg 1998 ; 22 : 581 – 586 . Google Scholar Crossref Search ADS PubMed WorldCat 4 Akerstrom G , Hessman O, Skogseid B. Timing and extent of surgery in symptomatic and asymptomatic neuroendocrine tumors of the pancreas in MEN 1 . Langenbecks Arch Surg 2002 ; 386 : 558 – 569 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Yim JH , Siegel BA, DeBenedetti MK, Norton JA, Lairmore TC, Doherty GM. Prospective study of the utility of somatostatin-receptor scintigraphy in the evaluation of patients with multiple endocrine neoplasia type 1 . Surgery 1998 ; 124 : 1037 – 1042 . Google Scholar Crossref Search ADS PubMed WorldCat 6 Orlefors H , Sundin A, Ahlstrom H, Bjurling P, Bergstrom M, Lilja A et al. Positron emission tomography with 5-hydroxytryptophan in neuroendocrine tumors . 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Google Scholar Crossref Search ADS PubMed WorldCat 10 Vilmann P , Hancke S. Endoscopic ultrasound scanning of the upper gastrointestinal tract using a curved linear array transducer: ‘the linear anatomy’ . Gastrointest Endosc Clin N Am 1995 ; 5 : 507 – 521 . Google Scholar Crossref Search ADS PubMed WorldCat 11 Doherty GM . Multiple endocrine neoplasia type 1: duodenopancreatic tumors . Surg Oncol 2003 ; 12 : 135 – 143 . Google Scholar Crossref Search ADS PubMed WorldCat 12 Owen NJ , Sohaib SA, Peppercorn PD, Monson JP, Grossman AB, Besser GM et al. MRI of pancreatic neuroendocrine tumours . Br J Radiol 2001 ; 74 : 968 – 973 . Google Scholar Crossref Search ADS PubMed WorldCat 13 Thompson NW , Czako PF, Fritts LL, Bude R, Bansal R, Nostrant TT et al. Role of endoscopic ultrasonography in the localization of insulinomas and gastrinomas . Surgery 1994 ; 116 : 1131 – 1138 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 14 Skogseid B , Oberg K, Akerstrom G, Eriksson B, Westlin JE, Janson ET et al. Limited tumor involvement found at multiple endocrine neoplasia type I pancreatic exploration: can it be predicted by preoperative tumor localization? World J Surg 1998 ; 22 : 673 – 677 ; discussion 667–668. Google Scholar Crossref Search ADS PubMed WorldCat 15 Skogseid B , Oberg K, Eriksson B et al. Surgery for asymptomatic pancreatic lesion in multiple endocrine neoplasia type I . World J Surg 1996 ; 20 : 872 – 876 . Google Scholar Crossref Search ADS PubMed WorldCat Copyright © 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Copyright © 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Andersen, I S; Rijkhoff, N J M; Vukovic, A; Buntzen, S; Djurhuus, J C; Laurberg, S

doi: 10.1002/bjs.4987pmid: 16273528

Abstract Background Control of defaecation and continence may be lost in patients with spinal cord injury. Electrical stimulation of sacral nerve roots to promote defaecation simultaneously activates both the rectum and the external anal sphincter (EAS), and may actually obstruct defaecation. The aim of this study was to investigate whether the EAS could be blocked selectively by selective stimulation of the ventral sacral nerve roots, and whether activation of the rectum without activation of the EAS could be obtained by stimulation of the ventral sacral nerve roots. Methods Selective electrical stimulation was performed using anodal blocking, a tripolar cuff electrode and monophasic rectangular current pulses applied to the sacral nerve roots in nine Göttingen minipigs. Results Simultaneous responses in the rectum and the anal canal were observed in five animals, whereas only anal responses were noted in four. Variations in cross-sectional area and an increase in rectal pressure seemed to facilitate defaecation. Without blocking, the increase in anal canal pressure was 16–45 cmH2O. With blocking, this increase was abolished in seven and reduced to 3–6 cmH2O in two animals. Conclusion Selective activation of the rectum is possible using an anodal block of somatic motor fibres. This technique holds promise in further development of electro-defaecation. Introduction Defaecation is the result of simultaneous relaxation of the internal anal sphincter and the striated muscle in the external anal sphincter (EAS) in combination with contraction of the smooth musculature of the rectum. Following spinal cord injury (SCI) control and coordination of these activities may be lost, leading to intractable constipation associated with episodic impaction and overflow incontinence1–3. Treatment of this is difficult and often involves use of stool softeners, suppositories and/or digital stimulation. Other treatments, including the use of an enema continence catheter and construction of a colostomy3–5, may cause psychosocial duress and ultimately lead to physical and psychological dependence on others. An alternative method of initiating bowel emptying is use of electrical stimulation. The Finetech–Brindley sacral root stimulator6–8 was developed to obtain bladder emptying in patients with SCI. Because the parasympathetic and somatic nerve fibres that innervate the distal colon, rectum and anal sphincters are located in the same sacral spinal roots as the fibres that innervate the lower urinary tract (S2–S4), stimulation in this location might also induce defaecation2,7,9–14. However, sacral nerve stimulation alone initiates defaecation in only a small proportion of patients, and the remaining patients need to use additional medication or manual evacuation14,15. Stimulation elicits a contraction in both the rectal smooth muscles and the EAS. Defaecation occurs only in the short period after stimulation when rectal pressure is higher than anal canal pressure12. Efficiency of defaecation in patients with SCI might improve if the rectal smooth muscles could be activated without simultaneous contraction of the EAS. The parasympathetic nerve fibres that innervate the rectum have a smaller diameter than the somatic nerve fibres that innervate the EAS16,17. Because large-diameter fibres need a smaller stimulus for activation than smaller fibres, activation of the small fibres also results in activation of the large fibres16,18. However, a selective block of the large fibres is possible because they need a smaller stimulus to be blocked than smaller fibres19,20. Selective activation can be obtained by a combination of cathodal excitation of both large- and small-diameter fibres, and anodal blocking, distal to the excitation point, of the propagation of the induced action potential in the large fibres21. Anodal block takes advantage of the fact that nerve fibres close to an anode are locally hyperpolarized by the anodal current. If the membrane is hyperpolarized adequately, action potentials cannot pass the hyperpolarized zone and are abolished6,19–21. The objectives of the present study were to investigate whether sacral nerve stimulation of the EAS could be blocked selectively by selective stimulation of the ventral sacral nerve roots, and whether activation of rectal smooth muscles without activation of the EAS could be achieved by selective stimulation of the ventral sacral nerve roots (S2–S3). Effects of stimulation were monitored by multilevel impedance planimetry. Methods Impedance planimetry and experimental probe design Impedance planimetry allows simultaneous measurement of intraluminal pressure and estimation of luminal cross-sectional area (CSA)22,23. The CSA is determined from the impedance of fluid inside a balloon using two excitation electrodes supplied with an alternating current and two detection electrodes for measuring the impedance between them22. A probe with more than one pair of detection electrodes allows CSA to be determined at several levels simultaneously. The probe used in the present study had five pairs of detection electrodes (Fig. 1). The probe and electrodes were covered with a flaccid bag that could be filled with an electrically conducting fluid. Anal canal pressure was measured using a small bag (volume 4 ml) placed distal to the rectal bag. Anal and rectal pressures were measured using a low-compliance system with external transducers (Baxter, Chicago, Illinois, USA). Before each experiment calibration of CSA and pressure was performed. Fig. 1 Open in new tabDownload slide Schematic diagram of the probe and impedance planimetry system. The probe includes two excitation electrodes (E) and five pairs of detection electrodes (D1–D5) covered with a rectal bag. Pressure was measured in both bags. A/D, analogue-digital The probe was found to have a coefficient of variation of up to 13 per cent24. To minimize the risk of misattributing in vivo changes caused by variations within the measuring system, an event was defined as a CSA deviation of 15 per cent from baseline within a period of 30 s. This is acceptable, as the purpose of the probe is to investigate significant, simultaneous, short-term changes from baseline CSA at multiple positions24. Surgical procedures Acute experiments were performed on nine mature female Göttingen minipigs (Ellegaard Göttingen Minipigs, Dalmose, Denmark), 10–13 months old and weighing 19·5–28 kg. The pigs were deprived of solid food from the night before examination but had free access to water. All procedures were carried out in accordance with Danish law relating to the care and use of laboratory animals. The pigs were preanaesthetized by intramuscular injection of ketalar 10 mg/kg (Ketaminol®; Veterinaria, Zurich, Switzerland) and midazolam 0·5 mg/kg (Dumex Pharma, Oslo, Norway). Anaesthesia was induced with intravenous α-chloralose 62·5 mg per kg bodyweight (Aarhus University Hospital, Aarhus, Denmark) and maintained with intravenous α-chloralose 50 mg per kg per h. The pigs were intubated and ventilated with a 2 : 1 (v/v) mixture of nitrous oxide and oxygen (Servo 900; Siemens Elema-Schönander, Solna, Sweden) and kept well hydrated throughout the experiment by intravenous administration of Ringer's lactate. An intra-arterial route for continuous monitoring of blood pressure was established. Arterial blood samples were sampled every hour to check for normal blood gas levels. The pigs were placed in the prone position on a thermal mattress to ensure a constant body temperature of 38 °C. Oesophageal temperature was monitored with a Cardiomed-CM-4008 device (Cardiomed, Oslo, Norway). Electrocardiograms were performed continuously using the same equipment. A laminectomy was performed between S1 and S4. The extradural sacral nerves (S2–S3) were identified by test stimulation using a hook electrode. The dura was opened and the intradural sacral roots exposed. The roots were separated into dorsal and ventral parts by tracing the nerves back to their origin at the spinal cord. Identification and confirmation of the ventral root was made by stimulation of the nerve with the probe inserted in the rectum and registration of the response to electrical stimulation using a hook electrode. The pigs were killed with an overdose of intravenous pentobarbital. Nerve stimulation The ventral sacral nerve roots were stimulated using ‘split-cylinder’ tripolar cuff electrodes (cathode flanked by two anodes). These consisted of three circular stainless steel foil contacts 0·5 mm wide embedded in a tubular insulating sheath of silicone rubber (inner diameter 1 mm, contact spacing 3 mm)25. The electrodes were connected to a custom-made computer-controlled stimulator. Monophasic pulses were used for excitation and blocking. The cuff electrodes were placed on the S2 nerve root in seven experiments and at the S3 root in two. However, in one of the nine experiments the S2 and S3 ventral nerve roots were placed together in one cuff because rectal and sphincter responses could be elicited from separate ipsilateral roots (sphincter responses in S2 and rectal responses in the S3). In addition, sphincter and rectal responses could be elicited from each side in one experiment, and separate cuffs were placed on the S2 root and the contralateral S3 root. In all experiments, square pulses of two different durations were applied: short-duration pulses (100–200 µs) that cannot and long pulses (400–600 µs) that can produce anodal blocking21. The duration of the long pulses was set to the minimum needed to obtain anodal blocking. To analyse the effect of pulse duration on the anodal block, the pulse duration was varied while the cathodal current was kept constant at 1·8 mA. Data analysis Anal canal and rectal pressures, and changes in these variables, are presented as median (range). Statistical analysis was not used because of the small numbers. Results After 30 min of equilibration, the median resting pressure in the anal canal was 20 (range 16–54) cmH2O (n = 9) at a rectal distension pressure of 5 cmH2O. The arterial blood pressure ranged between 80/58 and 176/120 mmHg. Anorectal responses to short-duration rectangular pulses Fig. 2a shows a typical example of the response to short-duration pulses. The response was characterized by a relatively fast increase in anal canal pressure followed by a plateau phase and a relatively fast decrease when stimulation ceased. In this example the anal response was accompanied by rectal responses that started almost immediately after the stimulation had ceased. Rectal pressure also increased on stimulation. The threshold for activation of the EAS varied from 0·02 to 0·15 mA. Full recruitment was obtained between 0·10 and 0·75 mA. The median maximum pressure increase to unilateral stimulation of the S2 or S3 ventral nerve roots with trains of pulses 100 or 200 µs wide at 20–25 Hz was 25 (range 16–45) cmH2O. Fig. 2 Open in new tabDownload slide a Anal canal and rectal pressure responses and b cross-sectional area responses in the rectum to unilateral stimulation of an S2 ventral sacral nerve root in one pig. D1–5, detection electrodes 1–5. Stimulation parameters: pulse duration 100 µs, frequency 20 Hz, amplitude 0·95 mA Rectal responses were obtained in only five of the nine pigs. In these five pigs the threshold for activation was 0·4 mA in four and 0·3 mA in one pig. The CSA changes in response to stimulation varied from pig to pig. In four experiments the result was very similar to that shown in Fig. 2b; there was a reduction in CSA at detection electrode 1 concomitant with an increase in CSA at detection electrodes 2–5. In the remaining experiment a decline in CSA was measured at all five detection electrodes. The median maximum rectal pressure increase to stimulation at 20–25 Hz was 10 (range 7–26) cmH2O. In four pigs the rectal response to stimulation started during the stimulation period and continued for approximately 20 s after stimulation had ceased; in the remaining pig the rectal response started almost at the end of the stimulation train and continued for approximately 40 s. In four pigs, rectal responses were not achieved although all nerves were stimulated using different stimulation parameters. Anorectal responses to long-duration rectangular pulses When the stimulation amplitude was increased beyond the level for maximum anal canal pressure (median 25, range 16–45 cmH2O) using long-duration pulses (400–600 µs), the anal canal pressure response to stimulation was progressively suppressed to almost zero. Anodal blocking was achieved in all nine pigs. Fig. 3 shows a typical anal canal pressure response to stimulation of an S2 ventral sacral nerve root with a pulse duration of 600 µs and increasing current above the threshold for blocking. A maximum pressure plateau was reached at 0·7 mA, at which all motor fibres were activated. As the amplitude was increased, the anal pressure response gradually decreased until the maximum pressure reduction was reached. The anal canal pressure response as a function of the stimulus current in five animals is shown in Fig. 4. Using a pulse duration of 400–600 µs the anal pressure response to stimulation increased initially with increasing current (Fig. 4). Initially a steep increase in the anal canal pressure response was registered until all motor fibres were activated and a maximum pressure plateau was reached. Thereafter the response gradually decreased until the maximum pressure reduction was achieved. Fig. 3 Open in new tabDownload slide Pressure response in the anal canal to stimulation of an S2 ventral sacral root with increasing pulse amplitude. Stimulation parameters: pulse duration 600 µs, frequency 25 Hz. Dashed vertical lines denote start and end of stimulation Fig. 4 Open in new tabDownload slide Pressure response in the anal canal (deviation above baseline pressure) to unilateral stimulation of S2 or S3 as a function of pulse amplitude in five animals. Stimulation parameters: pulse duration 400 or 600 µs, frequency 25 Hz When stimulation was performed with long-duration pulses an anal canal pressure increase was observed in only two of the experiments. The anal canal pressure increase was 23 and 19 cmH2O in the absence of anodal blocking in these two experiments, and 3 and 6 cmH2O respectively with blocking. The anal canal pressure increase to stimulation was completely suppressed in seven animals. The effect of pulse duration on the anodal block is shown in Fig. 5, in which the maximum anal canal pressure response is plotted as a function of pulse duration for one pig. Below 150 µs no blocking effect was observed. With increasing pulse duration, the pressure response gradually decreased and above 400 µs the maximum pressure reduction was obtained. Fig. 5 Open in new tabDownload slide Pressure response in the anal canal to stimulation of a nerve root as a function of pulse duration in one pig. Stimulation parameters: 1·8 mA and 25 Hz Using rectangular pulses of duration above 400 µs, the threshold to rectal activation was between 0·3 and 0·4 mA. In two of the five pigs that had rectal responses, no responses could be elicited when the amplitude was increased above 0·8 mA. The rectal CSA responses varied. In four experiments the response to stimulation was a reduction in CSA at detection electrode 1 and an increase at detection electrodes 2–5, and in one experiment a reduction in CSA was detected at all five electrodes, similar to responses when short-duration pulses were applied. In contrast to the response to short-duration pulses, the CSA responses to long pulses began simultaneously with the onset of stimulation in four of the five pigs and during stimulation in the remaining animal. The responses to stimulation continued for 10–60 s after the stimulation had ceased. In pigs in which a rectal response was present when anodal blocking was obtained, the median rectal pressure increase to stimulation was 15 (range 11·5–20) cmH2O. Discussion The results of the present study show the feasibility of selectively activating the rectum by electrical stimulation of the relevant ventral sacral nerve roots without simultaneous activation of the EAS. Monophasic rectangular pulses were used for stimulation. In chronic implants, however, monophasic pulses may induce neural damage and electrode contact corrosion owing to a net transfer of charge at each contact. With a chronic implant a secondary reversed pulse must be added to reduce the net charge applied. Although biphasic pulses were not used in this study, such pulses have shown to be as effective as monophasic pulses in producing anodal blocking26. A pressure increase in the anal canal was observed in only two experiments when blocking was achieved using long-duration pulses, and in these the pressure increase was considerably reduced to 3 and 6 cmH2O. In comparison, the increase observed without blocking ranged from 16 to 45 cmH2O. Similar techniques have been used in monkey6 and dog21 experiments on the urinary bladder. These have shown an average reduction in intraurethral sphincter pressure response to 76 per cent16 and 80 per cent21 of that seen with stimulation without blocking. In the present study the average percentage reduction was 95 per cent. The difference might be explained by differences between studies in manipulation of the sacral nerve during insertion of the cuff electrodes, muscles investigated and types of electrodes used16,20. More nerve manipulation seems to be associated with higher thresholds, a higher minimum current for maximal suppression, and a decrease in the degree of suppression of sphincter activation16,17. This may partly explain the difference in current needed to obtain maximal suppression of EAS pressure between animals (Fig. 4). In the present study, an initial anal canal pressure increase occurred as the cathodal current exceeded the excitation threshold for the thickest α-motor neurones, at a current of approximately 0·045 mA. As more motor units were activated the pressure increased to a maximum. However, as the current was further increased the anodal current exceeded the blocking threshold for the largest α-motor neurones and the anal pressure response decreased to a minimum in all experiments as more α-motor neurones were blocked, confirming previous findings17,21. Moreover, the excitation threshold for the rectal response was between 0·3 and 0·4 mA and, in contrast to the responses in the EAS, the rectal response persisted as the current was increased further, again confirming other studies19,21. Anodal blocking also depends on pulse duration. It takes time for an action potential to propagate from the excitation point near the cathode to the hyperpolarized zone. Therefore the hyperpolarizing stimulus must at least be maintained until the action potential has reached this zone, and this requires sufficient pulse duration17. Examination of the relationship between changes in anal canal pressure response and pulse duration at a fixed current amplitude showed that there was no blocking effect below 150 µs. This is in agreement with results in monkey6 and dog21. An increasing number of motor neurones were blocked as the pulse duration was increased and the maximum pressure reduction was obtained above 450 µs, as shown previously16,21. In monkeys maximum blocking was achieved with pulse durations of 500 µs and 1 ms6, and in a human study above 600 µs17. The differences in pulse duration needed to obtain maximum anal canal pressure reduction can probably be explained by differences in propagation velocity of action potentials in different species. The propagation velocity in motor fibres in humans is 40 per cent lower than that in cat and dog27. The changes in rectal CSA observed during and/or after stimulation confirm previous results24. In four pigs it was possible to achieve anodal blocking of the EAS alone, and rectal activation could not be obtained. Failure to obtain a rectal response might have been a consequence of excessive manipulation of the nerves during the preparation. Alternatively, it is possible that the motor fibres innervating the rectum in these pigs were present in a ventral sacral nerve root other than that innervating the EAS. The stimulator used in the present study was not able to drive more than two electrodes simultaneously. In humans, bowel management was improved in patients with SCI who received a Brindley stimulator for electromicturition2,12,14,15. However, only a few such patients defaecated using the stimulator alone. The Brindley stimulator causes a rise in rectal pressure and contraction in the EAS. EAS contraction ceases after stimulation; however, the rectum continues to contract for a short time and higher rectal pressures might initiate defaecation12. However, in most patients this period was too short to induce defaecation. Using the same technique as that employed in the present study, Rijkhoff et al.21 have shown that it is possible to eliminate contraction in the EAS as well as the external urethral sphincter concomitant with selective activation of the detrusor muscle. Future studies might be able to improve the technique such that both micturition and defaecation can be facilitated. 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This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Copyright © 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.