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K K Madhavan

Publications and source records attributed to K K Madhavan.

At least 19 recordsLinked to original sources
PubMed2006

Palliation for suspected unresectable hilar cholangiocarcinoma.

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

Aged↗
PubMed2006

Predicting survival in patients with hepatocellular carcinoma: a UK perspective.

BACKGROUND AND AIMS: Hepatocellular carcinoma (HCC) is a cancer of rising incidence in the UK. The aim of this study was to compare the Okuda, Cancer of the Liver Italian Program (CLIP), and Barcelona Clinic Liver Cancer (BCLC) classifications as predictors of survival in UK patients with HCC. METHODS: Data were analysed from a prospective database maintained in a specialist hepatobiliary unit from 1998 to 2003. Each system was assessed for its discriminatory power, monotonicity of gradient, and independent contribution to prediction of mortality status based on a multivariate model. RESULTS: One hundred and two patients (77 males, 25 females) were identified with a median age of 65 (range, 14-87) years. The overall median survival time was 13 months and the one- and five-year survival rates were 52.9% (95% CI: 43.2%, 62.6%) and 35.3% (95% CI: 26.0%, 44.6%), respectively. All three classification systems had the capacity to differentiate between patient survival times across different stages. The Okuda system was superior in overall discriminatory power and in strength of monotonicity. The BCLC system, however, made the highest independent contribution of all three systems in predicting survival in the Cox regression model. CONCLUSIONS: All three classification systems were effective in predicting survival for patients with HCC in a UK population.

Adolescent↗
PubMed2006

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

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

Aged↗
PubMed2006

Refining the role of laparoscopy and laparoscopic ultrasound in the staging of presumed pancreatic head and ampullary tumours.

Laparoscopy and laparoscopic ultrasound have been validated previously as staging tools for pancreatic cancer. The aim of this study was to identify if assessment of vascular involvement with abdominal computed tomography (CT) would allow refinement of the selection criteria for laparoscopy and laparoscopic ultrasound (LUS). The details of patients staged with LUS and abdominal CT were obtained from the unit's pancreatic cancer database. A CT grade (O, A-F) of vascular involvement was recorded by a single radiologist. Of 152 patients, who underwent a LUS, 56 (37%) had unresectable disease. Three of 26 (12%) patients with CT grade O, 27 of 88 (31%) patients with CT grade A to D, 17 of 29 (59%) patients with CT grade E and all nine patients with CT grade F were found to have unresectable disease. In all, 24% of patients with tumours <3 cm were found to have unresectable disease. In those patients with tumours considered unresectable, local vascular involvement was found in 56% of patients and vascular involvement with metastatic disease in 17%, while 20% of patients had liver metastases alone and 5% had isolated peritoneal metastases. The remaining patient was deemed unfit for resection. Selective use of laparoscopic ultrasound is indicated in the staging of periampullary tumours with CT grades A to D.

Adult↗
PubMed2006

Early specialist repair of biliary injury.

BACKGROUND: Considerable debate surrounds the timing of repair of injury to the common bile duct following cholecystectomy. In the absence of sepsis or significant peritoneal soiling, repair within the first week may be optimal. This study compared the outcome of early (within the first 2 weeks) and delayed (between 2 weeks and 6 months) repair. METHODS: Data on all patients referred with biliary injuries were recorded prospectively. In the absence of sepsis or significant peritoneal soiling, repair was considered within 2 weeks. RESULTS: Between November 1988 and November 2003, 123 patients were referred with injury to the biliary tree. Repair of the injury had been attempted in 55 patients (44.7 per cent) before referral. Of the 68 patients with no previous repair, nine were managed without surgery and 59 required subsequent surgical reconstruction of the ductal injury. Within the first 2 weeks after injury, 22 patients underwent primary biliary repair and three had revision of a failed biliary repair. Between 2 weeks and 6 months, a further 22 injuries were repaired. Successful repair was possible in 22 of 25 early repairs compared with 20 of 22 delayed repairs (P = 0.615). The overall operative mortality rate for patients undergoing repair was 4 per cent (two of 47 patients). CONCLUSION: A successful outcome was achieved in a high proportion of patients (42 of 47) when repair of the bile duct injury was undertaken in a unit experienced in the management of biliary injury. In selected patients, early repair within the first 2 weeks resulted in a similar outcome to that of delayed repair.

Adolescent↗
PubMed2006

Association between early systemic inflammatory response, severity of multiorgan dysfunction and death in acute pancreatitis.

BACKGROUND: Mortality in patients with acute pancreatitis is associated with the number of failing organs and the severity and reversibility of organ dysfunction. The aim of this study was to assess the significance of early systemic inflammatory response syndrome (SIRS) in the development of multiorgan dysfunction syndrome (MODS) and death from acute pancreatitis. METHODS: Data for all patients with a diagnosis of acute pancreatitis between January 2000 and December 2004 were reviewed. Serum C-reactive protein (CRP), Acute Physiology And Chronic Health Evaluation (APACHE) II scores and presence of SIRS were recorded on admission and at 48 h. Marshall organ dysfunction scores were calculated during the first week of presentation. Presence of SIRS and raised serum CRP levels on admission and at 48 h were correlated with the cumulative organ dysfunction scores in the first week. RESULTS: A total of 759 patients with acute pancreatitis were identified, of whom 45 (5.9 per cent) died during the index admission. SIRS was identified in 162 patients on admission and was persistent in 138 at 48 h. The median (range) cumulative Marshall score in patients with persistent SIRS was significantly higher than that in patients in whom SIRS resolved and in those with no SIRS (4 (0-12), 3 (0-7) and 0 (0-9) respectively; P < 0.001). Thirty-five patients (25.4 per cent) with persistent SIRS died from acute pancreatitis, compared with six patients (8 per cent) with transient SIRS and four (0.7 per cent) without SIRS (P < 0.001). No correlation was observed between CRP level on admission and Marshall score (P = 0.810); however, there was a close correlation between CRP level at 48 h and Marshall score (P < 0.001). CONCLUSION: Persistent SIRS is associated with MODS and death in patients with acute pancreatitis and is an early indicator of the likely severity of acute pancreatitis.

APACHE↗
PubMed2004

Presentation, treatment and outcome in patients with ampullary tumours.

BACKGROUND: Ampullary tumours are relatively rare, and few large single-centre reports provide information on their treatment and outcome. The aim of this study was to analyse outcome and determine predictors of survival for patients with ampullary tumours treated in a specialist centre. METHODS: Over an 11-year period, 561 patients were treated for periampullary tumours, 88 of whom had a histologically proven ampullary neoplasm. Prospectively gathered data were analysed to assess predictors of survival. RESULTS: The overall resection rate was 92 per cent; there were no postoperative deaths. Median survival was 45.8 months for patients with resectable tumours and 8.0 months for those with irresectable disease (P < 0.001). On univariate analysis, age less than 70 years (P = 0.015) and a bilirubin level of 75 micromol/l or less (P = 0.012) favoured long-term survival. Among 70 patients who underwent cancer resection, factors associated with significantly worse long-term survival on univariate analysis included poorly differentiated tumour (P < 0.001), positive nodes (P < 0.001), perineural invasion (P = 0.001) and invasion of the pancreas (P = 0.018). Multivariate analysis identified positive nodes and bilirubin concentration as independent predictors of survival. CONCLUSION: An aggressive surgical approach to ampullary tumours is justified by the low proportion of benign lesions, the absence of postoperative mortality and improved long-term survival.

Adult↗
PubMed2004

The extent of resection influences outcome following hepatectomy for colorectal liver metastases.

BACKGROUND: The acceptable indications for liver resection in patients with colorectal metastases have increased significantly in the last decade. It is thus becoming more difficult to ascertain the limitations for selection as the boundaries have been greatly extended. This has resulted in not only more extensive resections, but more atypical and bilobar resections. The aim of this study was to compare the outcome of patients undergoing different extent of liver resection in a specialist unit. METHODS: All patients undergoing liver resection for colorectal metastases at the Royal Infirmary of Edinburgh between October 1988 and April 2001 were reviewed. Patients were allocated into one of three groups: standard group, extended group, and segmental group. Patient information was collected from a prospectively completed database. RESULTS: One hundred and thirty-seven patients had liver resections for colorectal metastases during the study period. There were 69 standard hepatectomies, 41 extended resections and 27 segmental resections. CEA level was significantly lower in the segmental group(p = 0.012). There was a significant difference between the groups in terms of median operating time (p < 0.0001, Kruskal-Wallis test), operative blood loss (p = 0.006, Kruskal-Wallis test) and post-operative stay ( p = 0.036, Kruskal-Wallis test). Major post-operative complications were similar between standard and extended resections but less following segmental resection (p = 0.050. Predicted median survival was 51 months following standard resection, 23 months following extended resection and 59 months after segmental resection ( p = 0.037, log rank test), however, there was no difference between the three groups for actual 5-year survival (p = 0.662, Pearson chi-square test). CONCLUSION: Morbidity and mortality rates were comparable with other previous studies as was overall survival, although survival in patients undergoing extended resections was reduced. There was an acceptable level of morbidity and mortality for all three groups. Patients undergoing segmental resection had fewer complications, shorter length of stay, and the longest median survival suggesting adequate oncological clearance. Segmental resection has a role for favourably placed tumour deposits if oncological clearance can be ensured. Extended liver resections have a role for selected patients with bilobar colorectal metastases or large solitary deposits close to the hepatic vein confluence.

Adult↗
PubMed2003

Postchemoembolisation syndrome--tumour necrosis or hepatocyte injury?

Transarterial chemoembolisation of liver tumours is typically followed by elevated body temperature and liver transaminase enzymes. This has often been considered to indicate successful embolisation. The present study questions whether this syndrome reflects damage to tumour cells or to the normal hepatic tissue. The responses to 256 embolisations undertaken in 145 patients subdivided into those with hepatocyte-derived (primary hepatocellular carcinoma) and nonhepatocyte-derived tumours (secondary metastases) were analysed to assess the relative effects of tumour necrosis and damage to normal hepatocytes in each group. Cytolysis, measured by elevated alanine aminotransferase, was detected in 85% of patients, and there was no difference in the abnormalities in liver function tests measured between the two groups. Furthermore, cytolysis was associated with a higher rate of postprocedure symptoms and side effects, and elevated temperature was associated with a worse survival on univariate analysis. Multivariate analysis demonstrated that there was no benefit in terms of survival from having elevated temperature or cytolysis following embolisation. Cytolysis after chemoembolisation is probably due to damage to normal hepatocytes. Temperature changes may reflect tumour necrosis or necrosis of the healthy tissue. There is no evidence that either a postchemoembolisation fever or cytolysis is associated with an enhanced tumour response or improved long-term survival in patients with primary or secondary liver cancer.

Adult↗
PubMed2003

Incidence of benign pathology in patients undergoing hepatic resection for suspected malignancy.

BACKGROUND: Confirming the presence of hepatic or proximal bile duct malignancy pre-operatively remains difficult and some patients may undergo surgical resection for suspected malignant lesions which subsequently turn out to be benign. The aim of this study was to establish whether improvements in pre-operative staging might better identify this patient population. METHODS: Analysis of a prospectively collected database, which has been maintained in our unit since 1988. RESULTS: Of 250 consecutive patients undergoing hepatic resection for presumed malignancy, 18 (7.2%) were shown to have benign pathology. These "false positive" rates were 4 out of 160 (2.5%) resections for colorectal metastases, 4 out of 49 (8.2%) resections for other solid hepatobiliary tumours and 10 out of 41 (24.4%) resections for hilar cholangiocarcinoma. Four of the 18 patients (22%) developed post-operative complications but there was no postoperative mortality. CONCLUSION: Although hepatic resection remains a potentially curative procedure for patients with tumours involving the liver parenchyma or proximal bile ducts, pre-operative confirmation of malignancy remains difficult. Despite appropriate investigation a subset of patients with benign disease will still be subjected to major hepatic resection which should be undertaken in a specialist unit.

Adult↗
PubMed2002

Outcome of necrosectomy in acute pancreatitis: the case for continued vigilance.

BACKGROUND: Surgery for pancreatic necrosis complicating acute severe pancreatitis carries a high risk of mortality and may be influenced by a range of variables including patterns of referral, case selection and quality of care. METHODS: An observational study of a consecutive series of 54 patients undergoing pancreatic necrosectomy in a specialist Hepatobiliary unit over an 8-year study period. Principal outcomes were organ dysfunction and physiological derangement in relation to surgery, microbial colonization of necrosis and relation to outcome, re-operation rates, requirement for peri-operative nutritional support, trends in mortality and survival analysis. RESULTS: Necrosectomy was associated with statistically significant deterioration in immediate postoperative organ dysfunction scores (ANOVA P < 0.01). Infected necrosis was present in 36 (68%). Fungal colonization of necrosis was present in 5 (9%). Mortality in this subgroup was 80% (4 deaths). There was no association between bacterial colonization of necrosis and death in this study (P = 0.77; Fisher exact test; relative risk 0.9,95% confidence interval 0.54-1.54). Twenty patients (37%) required further surgical intervention with an average of 1.5 surgical procedures per patient. Twenty-three patients (43%) died. Patient survival to discharge was best predicted by admission APACHE-II score with relative risk of death increasing 14% for each unit increase in APACHE-II score at admission. CONCLUSIONS: The results of the present study illustrate that there is no place for complacency in the surgical management of patients with severe acute pancreatitis. A clinical governance approach would promote pre-defined protocols between admitting hospitals and tertiary referral centres. Future research should target new interventions in patients with high admission APACHE-II scores in whom prognosis is particularly poor and explore the role of infection of necrotic tissue.

APACHE↗
PubMed2000

Selective alteration of agonist-mediated contraction in hepatic arteries isolated from patients with cirrhosis.

BACKGROUND & AIMS: Impaired pressor function in cirrhosis may be specific to certain agonists and vascular territories. This investigation determined whether responses to arginine vasopressin (AVP) and 5-hydroxytryptamine (5-HT) were impaired in hepatic arteries from cirrhotic patients. METHODS: Cumulative concentration-response curves were produced for AVP (10(-11) to 3 x 10(-6) mol/L), 5-HT (10(-9) to 3 x 10(-5) mol/L), and potassium chloride (2.5 -120 mmol/L) in hepatic arteries from liver donors (noncirrhotic) and recipients (cirrhotic). The receptor stimulated by AVP was identified using a V(1)-receptor antagonist (d[CH(2)](5)Tyr[Me]AVP) and a selective V(2)-receptor agonist (desmopressin [DDAVP]). RESULTS: Cirrhotic patients had a high heart rate (98 +/- 4 beats/min) and cardiac output (9.87 +/- 0.51 L/min) but low peripheral vascular resistance (711 +/- 35 dyn. s/cm(5)). None of the arteries had a functional endothelium. Maximal contraction (but not sensitivity) to AVP was smaller (P = 0.0002) in hepatic arteries from recipients (34.03% +/- 3.42% KCl) than donors (60.69% +/- 5.56% KCl). 5-HT-mediated contraction was enhanced in recipient hepatic arteries (88.81% +/- 5.43% KCl vs. 71.63% +/- 4. 46% KCl; P = 0.01), but sensitivities were similar (P = 0.20). KCl-mediated contractions were similar (P = 0.87) in both groups. Arteries did not respond to DDAVP, but d(CH(2))(5)Tyr(Me)AVP produced a concentration-dependent rightward shift in the response to AVP. CONCLUSIONS: These results demonstrate a selective impairment of V(1) receptor-mediated contraction in denuded hepatic arteries from cirrhotic patients, suggesting an abnormality within the vascular smooth muscle.

Arginine Vasopressin↗
PubMed2000

Combined hepatic artery and segmental portal vein occlusion in antiphospholipid syndrome.

Antiphospholipid syndrome can have various clinical presentations, two of the most common being arterial and venous thrombosis. It is, however, unusual for them to occur in combination. We report here a case of combined hepatic artery and segmental portal venous occlusion in a 32-year-old patient who was shown to have a lupus anticoagulant. There have been no previous reports of thrombosis occurring simultaneously in the coeliac axis and the portal vein. Computerised tomography, Doppler ultrasound scanning and selective visceral angiography were used to demonstrate the anatomical lesions. The patient was treated medically with unfractionated heparin leading to a favourable clinical outcome. The diagnosis and management of this case is discussed with reference to the current literature on visceral thrombosis and antiphospholipid antibody syndrome.

Adult↗
PubMed1999

Training opportunities in liver transplantation surgery.

BACKGROUND: Liver transplantation surgery is carried out in only a few selected centres in the UK. This study was performed with a view to identifying potential training opportunities available for the general and specialist higher surgical trainee, and also to assess the outcome following liver transplant surgery according to the grade of the surgeon performing the procedure. METHODS: Data on 111 liver transplants with caval preservation undertaken consecutively in a single unit during a 32-month period were collected and analysed. The transplant procedures were grouped into those performed by consultants and those performed by supervised trainees. Survival was estimated by the Kaplan-Meier method. The Cox regression model was used to examine the influence of grade of the surgeon on survival. chi2 and independent sample t tests were used to identify significant preoperative, intraoperative and postoperative variables. RESULTS: Trainees carried out 34 recipient hepatectomies (31 per cent), 47 implant procedures (42 per cent) and all 143 retrieval operations. The mean time taken by a supervised trainee to carry out a recipient hepatectomy and implantation was 183 and 44 min compared with 165 and 46 min for a consultant (P = 0. 22 and P = 0.44 respectively). The mean intraoperative red cell requirement was 8 units for both consultants and trainees (P = 0.85). The overall patient survival rate was 88 per cent at 3 years and the grade of the surgeon made no difference to survival or the occurrence of complications (P > 0.05). CONCLUSION: The outcome following liver transplantation with caval preservation did not differ according to the grade of the surgeon performing the procedure. Extensive training opportunities are available to learn hepatobiliary and vascular surgical techniques in liver transplantation surgery.

General Surgery↗
PubMed1999

Supervised surgical trainees can perform pancreatic resections safely.

With the recent changes in surgical training and sub-specialisation, the role of surgical trainees in more advanced surgical procedures has come into question. In order to examine this further, we analysed the early outcome of patients in a single surgical unit undergoing pancreatic resections, with regard to the grade of the surgeon performing the operation. Between January 1994 and May 1996, data were collected prospectively on all the patients undergoing pancreatic resections with regards to the grade of the surgeon performing the procedure and the early outcome following the operation. Sixty-two patients underwent pancreatic resections for both benign and malignant diseases. Overall, 19 operations (31%) were performed by trainees under supervision, 14 of the 40 pancreatico-duodenectomies (35%) and 5 of the 19 left partial pancreatectomies (26%). All 3 total pancreatectomies were carried out by consultants. In the 43 patients operated upon by the consultants, there were 8 anastomotic leaks (19%) and 1 death. In the 19 patients operated upon by the supervised trainees, there were only 2 anastomotic leaks (11%) and no deaths. This series has demonstrated that in a unit with a major interest and large workload in pancreatic surgery, there appears to be no difference between a consultant and a supervised trainee in the early outcome following pancreatic resections.

General Surgery↗
PubMed1999

Role of the surgical trainee in upper gastrointestinal resectional surgery.

The 'New Deal' set out by the Department of Health in 1991, together with the introduction of specialist 6-year training grades by Calman in 1993, has resulted in a decrease in available training time for surgeons in the UK. There is also an emerging belief that surgical procedures performed by trainees might compromise patient outcome. This study examines the level of trainee experience in a specialist gastrointestinal unit and whether operation by a trainee surgeon adversely affects patient outcome. All patients in the University Department of Surgery, Royal Infirmary, Edinburgh, undergoing oesophagogastric, hepatic or pancreatic resection between January 1994 and December 1996 were entered into the study. The early clinical outcome (in-hospital mortality and morbidity, considered in three groups: anastomotic leak, other technique-related complications and non-technique-related complications) was evaluated with regard to the grade of surgeon (consultant or trainee) performing the operation. Of the 222 patients undergoing major upper gastrointestinal resection during the study period, 100 (45%) were operated on by trainees. Trainees were assisted and closely supervised by consultants in all but six resections. There was no major difference in mortality rate (consultant, 4.1% vs trainee, 5%), incidence of non-technique-related complications (consultant, 6.7% vs trainee, 7.1%), anastomotic leaks (consultant, 10.7% vs trainee, 5%) or technique-related complications (consultant, 18.9% vs trainee, 15%) between the two grades of surgeon. In a specialist unit, the early clinical outcome of patients undergoing major upper gastrointestinal resection by supervised trainees is no worse than in those operated on by consultants. Participation of trainees in such complex procedures enhances surgical training and does not jeopardise patient care.

Adolescent↗