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Biomedical subjects

A W Majeed

Publications and source records attributed to A W Majeed.

At least 19 recordsLinked to original sources
PubMed2000

Hepatic resection for colorectal liver metastases: A cost-effectiveness analysis.

OBJECTIVE: To analyze the cost-effectiveness of resection for liver metastases compared with standard nonsurgical cytotoxic treatment. SUMMARY BACKGROUND DATA: The efficacy of hepatic resection for metastases from colorectal cancer has been debated, despite reported 5-year survival rates of 20% to 40%. Resection is confined to specialized centers and is not widely available, perhaps because of lack of appropriate expertise, resources, or awareness of its efficacy. The cost-effectiveness of resection is important from the perspective of managed care in the United States and for the commissioning of health services in the United Kingdom. METHODS: A simple decision-based model was developed to evaluate the marginal costs and health benefits of hepatic resection. Estimates of resectability for liver metastases were taken from UK-reported case series data. The results of 100 hepatic resections conducted in Sheffield from 1997 to 1999 were used for the cost calculation of liver resection. Survival data from published series of resections were compiled to estimate the incremental cost per life-year gained (LYG) because of the short period of follow-up in the Sheffield series. RESULTS: Hepatic resection for colorectal liver metastases provides an estimated marginal benefit of 1.6 life-years (undiscounted) at a marginal cost of 6,742 pound sterling++. If 17% of patients have only palliative resections, the overall cost per LYG is approximately 5,236 pound sterling (5,985 pound sterling with discounted benefits). If potential benefits are extended to include 20-year survival rates, these figures fall to approximately 1,821 pound sterling (2,793 pound sterling with discounted benefits). Further univariate sensitivity analysis of key model parameters showed the cost per LYG to be consistently less than 15,000 pound sterling. CONCLUSION: In this model, hepatic resection appears highly cost-effective compared with nonsurgical treatments for colorectal-related liver metastases.

Analysis of Variance↗
PubMed1999

Common duct diameter as an independent predictor of choledocholithiasis: is it useful?

We have evaluated the value of ultrasonographic measurement of common duct diameter in isolation from other predictors of choledocholithiasis. A cohort of 223 patients who did not have a history of jaundice or pancreatitis and had normal liver function tests underwent pre-operative ultrasound of the common hepatic duct and then had elective (open) cholecystectomy with operative cholangiography. One hundred and ninety-one (86%) of all patients had a normal (< or = 5 mm) common duct and of these only 12 (6%) had common duct calculi. Of the 32 patients who had a common duct diameter greater than 5 mm on pre-operative ultrasonography, 12 (37.5%) patients had ductal calculi. A pre-operatively dilated duct on ultrasonography has a high chance of containing stones and should be considered as a strong indication for pre-operative bile duct imaging or operative cholangiography.

Adult↗
PubMed1999

The preoperatively normal bile duct does not dilate after cholecystectomy: results of a five year study.

BACKGROUND: The common hepatic duct (CHD) is commonly believed to dilate after cholecystectomy but previous studies have either not measured CHD diameter preoperatively or the follow up period is short. AIMS: To measure CHD diameter before and after cholecystectomy. METHODS: Patients undergoing (open) cholecystectomy and operative cholangiography had ultrasonographic measurement of CHD diameter before, and three and six months, and one and five years after cholecystectomy. The normal duct diameter was considered to be 5 mm or less, with an observer error of +/-1 mm. RESULTS: Fifty nine patients with normal diameter ducts were studied. The majority (more than 95%) of patients did not have a dilatation of the CHD beyond 6 mm after cholecystectomy. The CHD appeared to increase as well as decrease with an overall trend towards a minor increase at five years. This was not statistically significant if the margin of error of 1 mm was taken into account. CONCLUSION: A preoperatively normal CHD does not dilate after cholecystectomy and may require further investigation in symptomatic patients.

Adult↗
PubMed1998

A randomized, prospective, blinded comparison of postoperative pain, metabolic response, and perceived health after laparoscopic and small incision cholecystectomy.

BACKGROUND: We have previously shown that in a randomized comparison of laparoscopic (LC) versus small incision (SC) cholecystectomy, postoperative hospital stay is comparable. This randomized prospective study compares the postoperative pain, analgesic and antiemetic consumption, perceived health, and metabolic and respiratory responses after these two procedures. METHODS: Two hundred patients were recruited; postoperative stay, pain scores, analgesic and antiemetic consumption were recorded. Nottingham Health Profile questionnaires were completed by a subgroup of 100 patients, and the metabolic and respiratory responses were also compared in a further subgroup of 20 patients. RESULTS: Pain scores in both groups were low. LC, however, was associated with lower postoperative pain scores and analgesic requirements compared with SC, but the antiemetic requirements were greater after LC. The duration of hospital stay and the perceived health after operation were the same in both groups, and both procedures were associated with a similar reduction of respiratory function. Twenty-four hours after operation the inflammatory (C-reactive protein, CRP) response to LC (22 +/- 20 mg/L) was significantly lower than after SC (68 +/- 30 mg/L), but the neuroendocrine (cortisol) response was similar (LC, 475 +/- 335 nmol/L, compared with SC, 710 +/- 410 nmol/L). Independent of the technique used, the duration of postoperative hospital stay correlated significantly with the magnitude of both the 24-hour postoperative cortisol and CRP responses (cortisol: rs = 0.678, p < 0.001; CRP: rs = 0.566, p = 0.011). CONCLUSIONS: LC appears to be associated with less tissue destruction and pain than SC, but this did not confer any advantage in the degree of postoperative respiratory impairment, length of hospital stay, or postoperative perceived health. The neuroendocrine component of the metabolic response evoked by each procedure was similar and had a significant correlation to patient's postoperative hospital stay. This finding may explain the similar postoperative recovery after LC and SC.

Adult↗
PubMed1998

A requiem for the cholecystokinin provocation test?

BACKGROUND: The cholecystokinin provocation test (CCKPT) has been claimed to predict a better symptomatic result after cholecystectomy in patients with acalculous biliary pain. AIMS: To examine the predictive value of the CCKPT for symptom relief after cholecystectomy in both CCKPT positive and negative patients. PATIENTS AND METHODS: Fifty eight patients with acalculous biliary pain underwent CCKPT with serial ultrasound gall bladder volumetry. CCKPT positive patients were offered cholecystectomy; negative patients were reassessed and were offered a cholecystectomy if symptoms persisted. Six months after cholecystectomy, the CCKPT was repeated. RESULTS: Of 32 CCKPT positive patients, 27 underwent cholecystectomy and of these, 18 (67%) became symptom-free. Postoperatively, 20 of 25 patients converted to CCKPT negative but five remained CCKPT positive and were symptomatic. Of the 26 CCKPT negative patients, nine became symptom-free without cholecystectomy; six of 14 (42.8%) patients undergoing cholecystectomy became asymptomatic and remained CCKPT negative. Cholecystectomy seemed to reduce symptoms in both groups, but there was no significant difference in the symptomatic outcome between preoperative CCKPT positive and negative patients. CONCLUSIONS: In this study, cholecystokinin provocation testing did not predict symptomatic benefit from cholecystectomy and we suggest it should no longer be used in the evaluation of patients with acalculous biliary pain.

Adolescent↗
PubMed1998

Is it necessary to catheterise the bladder before laparoscopy?

Fifty patients had residual urine measured by catheterisation immediately before laparoscopic cholecystectomy. The median amount of urine in the bladder was 100 ml (range 5-500 ml). This urine volume does not distend the bladder enough to risk inadvertant perforation during insertion of a subumbilical port. Urinary bladder catheterisation is unnecessary before laparoscopy especially if the bladder is impalpable.

Adult↗
PubMed1997

Chemical ablation of the gallbladder.

BACKGROUND: Chemical ablation of the gallbladder might avoid the need for surgery in elderly, unfit patients. This study examined the efficacy of various chemicals in destroying gallbladder mucosa. METHODS: Ninety-five per cent ethanol, 3 per cent sodium tetradecyl sulphate (STD), trifluoroacetic acid (TFA) 2 mol/l, tetracycline 50 mg/ml, 30 and 50 per cent phenol, and a mucosal exfoliant solution (compound ethylene diamine tetra-acetic acid) were tested for gallbladder ablation in rabbits. Histology was obtained 8 weeks after exposure to these chemicals. RESULTS: Thirty per cent phenol, tetracycline, TFA and ethanol when used as single agents were moderately effective in causing complete gallbladder mucosal obliteration, 50 per cent phenol caused a macroscopic burn of the entire gallbladder. The mucosal exfoliant solution and STD on their own did not cause mucosal destruction but had significantly enhanced efficacy when combined with 95 per cent ethanol, allowing reliable mucosal destruction with a 5-min contact duration. CONCLUSION: Ninety-five per cent ethanol and STD after pretreatment with a mucosal exfoliant solution may be the combination of choice for in situ gallbladder mucosal ablation.

Animals↗
PubMed1997

Gallstone removal with a modified cholecystoscope: an alternative to cholecystectomy in the high-risk patient.

BACKGROUND: Symptomatic gallstones in patients who are at high risk from or who wish to avoid anesthesia may be difficult to treat, especially if the gallstones are unsuitable for oral dissolution or lithotripsy. We describe our experience with a minimally invasive surgical method of gallstone extraction under thoracic epidural or intercostal anesthesia. STUDY DESIGN: Eight-one patients who were either at high risk from or did not wish to undergo general anesthesia or those who wished to conserve their gallbladder underwent percutaneous cholecystolithotomy with a modified cholecystoscope. Of these patients, 63 (78 percent) were in American Society of Anesthesiology grades III and IV and 28 (35 percent) had thick-walled, diseased gallbladders. RESULTS: Gallstones were completely cleared in 66 (81 percent) patients and complete symptom relief was obtained in more than 95 percent of these patients. There were no deaths or serious complications. CONCLUSIONS: Percutaneous cholecystolithotomy under regional anesthesia is an effective means of gallstone treatment in selected high-risk patients.

Adult↗
PubMed1996

Randomised, prospective, single-blind comparison of laparoscopic versus small-incision cholecystectomy.

BACKGROUND: We report a prospective randomised comparison between laparoscopic and small-incision cholecystectomy in 200 patients which was designed to eliminate bias for or against either technique. METHODS: Patients were randomised in the operating theatre and anaesthetic technique and pain-control methods were standardised. Four experienced surgeons did both types of procedure. Identical wound dressings were applied in both groups so that carers could be kept blind to the type of operation. FINDINGS: There was no significant difference between the groups for age, sex, body mass index, and American Society of Anaesthesiologists grade. Laparoscopic cholecystectomy took significantly longer than small-incision cholecystectomy (median 65 [range 27-140] min vs 40 [18-142] min, p<0.001). The operating time included operative cholangiography which was attempted in all patients. We found no significant difference between the groups for hospital stay (postoperative nights in hospital, median 3-0 [1-17] nights for laparoscopic vs 3-0 [1-14] nights for small-incision, p=0.74), time back to work for employed persons (median 5-0 weeks vs 4.0 weeks; p=0.39), and time to full activity (median 3-0 weeks vs 3.0 weeks; p=0.15). INTERPRETATION: Laparoscopic cholecystectomy takes longer to do than small-incision cholecystectomy and does not have any significant advantages in terms of hospital stay or postoperative recovery.

Analgesia, Patient-Controlled↗