Publications by authors named "Altaf Awan"

19 Publications

  • Page 1 of 1

The first international Delphi consensus statement on Laparoscopic Gastrointestinal surgery.

Int J Surg 2022 Jul 13;104:106766. Epub 2022 Jul 13.

Imperial College London, UK.

Background: Laparoscopic surgery has almost replaced open surgery in many areas of Gastro-Intestinal (GI) surgery. There is currently no published expert consensus statement on the principles of laparoscopic GI surgery. This may have affected the training of new surgeons. This exercise aimed to achieve an expert consensus on important principles of laparoscopic GI surgery.

Methods: A committee of 38 international experts in laparoscopic GI surgery proposed and voted on 149 statements in two rounds following a strict modified Delphi protocol.

Results: A consensus was achieved on 133 statements after two rounds of voting. All experts agreed on tailoring the first port site to the patient, whereas 84.2% advised avoiding the umbilical area for pneumoperitoneum in patients who had a prior midline laparotomy. Moreover, 86.8% agreed on closing all 15 mm ports irrespective of the patient's body mass index. There was a 100% consensus on using cartridges of appropriate height for stapling, checking the doughnuts after using circular staplers, and keeping the vibrating blade of the ultrasonic energy device in view and away from vascular structures. An 84.2% advised avoiding drain insertion through a ≥10 mm port site as it increases the risk of port-site hernia. There was 94.7% consensus on adding laparoscopic retrieval bags to the operating count and ensuring any surgical specimen left inside for later removal is added to the operating count.

Conclusion: Thirty-eight experts achieved a consensus on 133 statements concerning various aspects of laparoscopic GI Surgery. Increased awareness of these could facilitate training and improve patient outcomes.
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http://dx.doi.org/10.1016/j.ijsu.2022.106766DOI Listing
July 2022

Solve study: a study to capture global variations in practices concerning laparoscopic cholecystectomy.

Surg Endosc 2022 Jun 9. Epub 2022 Jun 9.

South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK.

Background: There is a lack of published data on variations in practices concerning laparoscopic cholecystectomy. The purpose of this study was to capture variations in practices on a range of preoperative, perioperative, and postoperative aspects of this procedure.

Methods: A 45-item electronic survey was designed to capture global variations in practices concerning laparoscopic cholecystectomy, and disseminated through professional surgical and training organisations and social media.

Results: 638 surgeons from 70 countries completed the survey. Pre-operatively only 5.6% routinely perform an endoscopy to rule out peptic ulcer disease. In the presence of preoperatively diagnosed common bile duct (CBD) stones, 85.4% (n = 545) of the surgeons would recommend an Endoscopic Retrograde Cholangio-Pancreatography (ERCP) before surgery, while only 10.8% (n = 69) of the surgeons would perform a CBD exploration with cholecystectomy. In patients presenting with gallstone pancreatitis, 61.2% (n = 389) of the surgeons perform cholecystectomy during the same admission once pancreatitis has settled down. Approximately, 57% (n = 363) would always administer prophylactic antibiotics and 70% (n = 444) do not routinely use pharmacological DVT prophylaxis preoperatively. Open juxta umbilical is the preferred method of pneumoperitoneum for most patients used by 64.6% of surgeons (n = 410) but in patients with advanced obesity (BMI > 35 kg/m, only 42% (n = 268) would use this technique and only 32% (n = 203) would use this technique if the patient has had a previous laparotomy. Most surgeons (57.7%; n = 369) prefer blunt ports. Liga clips and Hem-o-loks® were used by 66% (n = 419) and 30% (n = 186) surgeons respectively for controlling cystic duct and (n = 477) 75% and (n = 125) 20% respectively for controlling cystic artery. Almost all (97.4%) surgeons felt it was important or very important to remove stones from Hartmann's pouch if the surgeon is unable to perform a total cholecystectomy.

Conclusions: This study highlights significant variations in practices concerning various aspects of laparoscopic cholecystectomy.
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http://dx.doi.org/10.1007/s00464-022-09367-8DOI Listing
June 2022

Complicated Severe Acute Pancreatitis: Open and Laparoscopic Infracolic Approach.

J Gastrointest Surg 2022 May 17. Epub 2022 May 17.

Department of Pancreaticobiliary, Advanced Laparoscopic and Robotic Surgery, University Hospitals of Derby & Burton, Uttoxeter Road, Derby, DE22 3NE, UK.

Introduction: The heterogeneous nature of severe acute pancreatitis (SAP) renders decisions related to complications challenging. Central solid collections at the root of the mesentery are difficult to access with traditional techniques. Here we describe a case series of laparoscopic infracolic necrosectomy (ICN) and open or laparoscopic infracolic necrosectomy with Roux-en Y cystjejunostomy (ICN-RYCJ) for the management of complicated SAP.

Materials And Methods: A retrospective analysis of a prospectively maintained database identified all patients treated with infracolic necrosectomy or drainage of pancreatic collections for complicated SAP between 2012 and 2021 inclusive at a single institution.

Results: Forty patients were identified (median age 53 years)-ICN group 9 patients (median time to intervention-22 days) and ICN-RYCJ group 31 patients (median time to intervention-99 days). Two patients in ICN group underwent interval fistula-tract jejunostomy. Thirty-one patients had laparoscopic surgery and 9 patients underwent an open approach. Four patients required intervention post-operatively. Nineteen patients were discharged from follow-up at two years.

Conclusion: Infracolic approach with selective Roux-en Y cystjejunostomy, as a single or staged intervention, is an effective and safe operative option to add to the armamentarium of the pancreatic surgeon when dealing with complicated SAP not amenable to drainage/debridement by traditional techniques.
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http://dx.doi.org/10.1007/s11605-022-05350-9DOI Listing
May 2022

Laparoscopic Management of Obstructing Blood Clot at Jejuno-jejunal Anastomosis Post Laparoscopic Roux-en-Y Gastric Bypass.

Obes Surg 2022 07 29;32(7):2488-2489. Epub 2022 Apr 29.

East Midlands Bariatric and Metabolic Surgery Institute, University Hospitals of Derby & Burton, Uttoxeter Road, Derby, DE22 3NE, UK.

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http://dx.doi.org/10.1007/s11695-022-06081-1DOI Listing
July 2022

Laparoscopic Cholecystectomy Versus Percutaneous Cholecystostomy: Suitability of APACHE-II Score, ASA Grade, and Tokyo Guidelines 18 Grade as Predictors of Outcome in Patients With Acute Cholecystitis.

Surg Laparosc Endosc Percutan Tech 2022 Jun 1;32(3):342-349. Epub 2022 Jun 1.

Department of Pancreaticobiliary and Advanced Laparoscopic Surgery.

Introduction: Intervention options in acute cholecystitis (AC) include drainage (percutaneous/endoscopic) or surgery. Several scoring systems have been used to risk stratify acute surgical patients, but few have been validated. This study investigated the suitability of Acute Physiology and Chronic Health Evaluation II (APACHE-II) score, American Society of Anesthesiologist (ASA) grade, and Tokyo Guidelines 2018 (TG18) grade as predictors of outcome and assess laparoscopic cholecystectomy versus percutaneous cholecystostomy (PC) as treatment options in patients with AC.

Materials And Methods: Retrospective data was collected from patients that underwent acute inpatient cholecystectomy (index admission), urgent interval cholecystectomy (2 to 4 wk) and PC between 2016 and 2018. Data included baseline demographics, co-morbidities, ASA grade, APACHE-II score, TG18 grade, morbidity, and mortality. A P-value of <0.05 was statistically significant. Area under the receiver operating characteristic curve was calculated to compare accuracy of APACHE-II, ASA and TG18 in predicting morbidity.

Results: A total of 344 consecutive patients (266 cholecystectomies and 84 PC) were included in the study. Significant difference in co-morbidities [median Charlson Co-Morbidity Index (CCI) 1 surgery and 4 cholecystostomy (PC) (P<0.05)], median APACHE-II score (3 surgery and 9 PC), median TG18 grade (1 surgery and 2 PC) and mortality rate [0% surgery and 7% cholecystostomy (PC)]. TG18 grade alone predicted postoperative/postprocedure morbidity (receiver operating characteristic; AUC=0.884; 95% confidence interval: 0.845-0.923; odds ratio: 4.38, 96% confidence interval, P<0.05).

Discussion: Utilization of the TG18 grade have shown to be more accurate in risk stratifying and predicting outcomes in patients with AC and therefore may appropriately guide biliary intervention.PC can be utilized in a select group of septic and co-morbid patients (myocardial infarction <6 weeks, chest infection and acute cerebrovascular accident) unable to withstand surgical intervention or in those with complex biliary disease (Mirizzi Syndrome). In a proportion, PC drains sepsis to improve critical state of the patient enough to consider an interval cholecystectomy with satisfactory outcomes.
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http://dx.doi.org/10.1097/SLE.0000000000001048DOI Listing
June 2022

Laparoscopic Management of Jejuno-jejunal Intussusception Post Laparoscopic Roux-en-Y Gastric Bypass in a Pregnant Patient.

Obes Surg 2021 12 1;31(12):5504-5505. Epub 2021 Sep 1.

East Midlands Bariatric and Metabolic Surgery Institute, University Hospitals of Derby and Burton, Uttoxeter Road, Derby, DE22 3NE, UK.

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http://dx.doi.org/10.1007/s11695-021-05689-zDOI Listing
December 2021

30-Day Morbidity and Mortality of Bariatric Surgery During the COVID-19 Pandemic: a Multinational Cohort Study of 7704 Patients from 42 Countries.

Obes Surg 2021 10 30;31(10):4272-4288. Epub 2021 Jul 30.

Bariatric Unit, South Tyneside and Sunderland NHS Trust, Sunderland, UK.

Background: There are data on the safety of cancer surgery and the efficacy of preventive strategies on the prevention of postoperative symptomatic COVID-19 in these patients. But there is little such data for any elective surgery. The main objectives of this study were to examine the safety of bariatric surgery (BS) during the coronavirus disease 2019 (COVID-19) pandemic and to determine the efficacy of perioperative COVID-19 protective strategies on postoperative symptomatic COVID-19 rates.

Methods: We conducted an international cohort study to determine all-cause and COVID-19-specific 30-day morbidity and mortality of BS performed between 01/05/2020 and 31/10/2020.

Results: Four hundred ninety-nine surgeons from 185 centres in 42 countries provided data on 7704 patients. Elective primary BS (n = 7084) was associated with a 30-day morbidity of 6.76% (n = 479) and a 30-day mortality of 0.14% (n = 10). Emergency BS, revisional BS, insulin-treated type 2 diabetes, and untreated obstructive sleep apnoea were associated with increased complications on multivariable analysis. Forty-three patients developed symptomatic COVID-19 postoperatively, with a higher risk in non-whites. Preoperative self-isolation, preoperative testing for SARS-CoV-2, and surgery in institutions not concurrently treating COVID-19 patients did not reduce the incidence of postoperative COVID-19. Postoperative symptomatic COVID-19 was more likely if the surgery was performed during a COVID-19 peak in that country.

Conclusions: BS can be performed safely during the COVID-19 pandemic with appropriate perioperative protocols. There was no relationship between preoperative testing for COVID-19 and self-isolation with symptomatic postoperative COVID-19. The risk of postoperative COVID-19 risk was greater in non-whites or if BS was performed during a local peak.
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http://dx.doi.org/10.1007/s11695-021-05493-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8323543PMC
October 2021

SARS-CoV-2 infection in acute pancreatitis increases disease severity and 30-day mortality: COVID PAN collaborative study.

Gut 2021 06 5;70(6):1061-1069. Epub 2021 Feb 5.

Auckland City Hospital, Auckland, New Zealand.

Objective: There is emerging evidence that the pancreas may be a target organ of SARS-CoV-2 infection. This aim of this study was to investigate the outcome of patients with acute pancreatitis (AP) and coexistent SARS-CoV-2 infection.

Design: A prospective international multicentre cohort study including consecutive patients admitted with AP during the current pandemic was undertaken. Primary outcome measure was severity of AP. Secondary outcome measures were aetiology of AP, intensive care unit (ICU) admission, length of hospital stay, local complications, acute respiratory distress syndrome (ARDS), persistent organ failure and 30-day mortality. Multilevel logistic regression was used to compare the two groups.

Results: 1777 patients with AP were included during the study period from 1 March to 23 July 2020. 149 patients (8.3%) had concomitant SARS-CoV-2 infection. Overall, SARS-CoV-2-positive patients were older male patients and more likely to develop severe AP and ARDS (p<0.001). Unadjusted analysis showed that SARS-CoV-2-positive patients with AP were more likely to require ICU admission (OR 5.21, p<0.001), local complications (OR 2.91, p<0.001), persistent organ failure (OR 7.32, p<0.001), prolonged hospital stay (OR 1.89, p<0.001) and a higher 30-day mortality (OR 6.56, p<0.001). Adjusted analysis showed length of stay (OR 1.32, p<0.001), persistent organ failure (OR 2.77, p<0.003) and 30-day mortality (OR 2.41, p<0.04) were significantly higher in SARS-CoV-2 co-infection.

Conclusion: Patients with AP and coexistent SARS-CoV-2 infection are at increased risk of severe AP, worse clinical outcomes, prolonged length of hospital stay and high 30-day mortality.
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http://dx.doi.org/10.1136/gutjnl-2020-323364DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7871229PMC
June 2021

Index Admission Emergency Laparoscopic Cholecystectomy and Common Bile Duct Exploration: Results From a Specialist Center in the United Kingdom.

Surg Laparosc Endosc Percutan Tech 2019 Apr;29(2):113-116

Department of Surgery, Royal Derby Hospital, Uttoxeter Road, Derby, UK.

Background: The incidence of common bile duct (CBD) stones is between 10% to 18% in people undergoing cholecystectomy for gallstones. Laparoscopic exploration of the CBD is now becoming routine practice in the elective setting, however its safety and efficacy in emergencies is poorly understood.

Methods: We analyzed our results for index emergency admission laparoscopic cholecystectomy within a specialist center in the United Kingdom. Data from all emergency cholecystectomies in our unit, between 2011 to 2016 were collected and analyzed retrospectively.

Results: In total, 494 patients underwent emergency laparoscopic cholecystectomy; 53 (10.7%) patients underwent common bile duct exploration (CBDE), with 1 conversion and 1 bile leak. Indications for CBDE were based on preoperative imaging (41 cases, 81%) or intra-operative cholangiogram (44 cases, 83%) findings.

Conclusions: Index admission laparoscopic cholecystectomy and concomitant CBDE is safe and should be the gold standard treatment for patients presenting with acute biliary complications, reducing readmissions and the need for a 2-stage procedure.
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http://dx.doi.org/10.1097/SLE.0000000000000602DOI Listing
April 2019

Mid-Term Remission of Type 2 Diabetes Mellitus After Laparoscopic Roux En-Y Gastric Bypass.

World J Surg 2016 Nov;40(11):2719-2725

The East-Midlands Bariatric & Metabolic Institute (EMBMI), Royal Derby Hospital, Derby Teaching Hospitals NHS Foundation Trust, Uttoxeter Road, Derby, DE22 3NE, UK.

Background: Laparoscopic Roux en-Y gastric bypass (LRYGB) is an established therapeutic modality for type 2 diabetes mellitus (T2DM). However, there is paucity of data on the outcomes of LRYGB on T2DM beyond 2 years. This study aimed to examine the medium-term effects of LRYGB on T2DM and determine the predictors of T2DM resolution.

Methods: Prospective data were collected for all consecutive LRYGB performed from September 2009 to November 2010. The American Diabetes Association guidelines were used to define complete (CR) or partial (PR) remission of diabetes. Diabetes status was considered improved when there was >50 % reduction in the dose of medications or when glycaemic control was achieved after stopping insulin. The effects of baseline characteristics, diabetes data and weight loss data at 4 years on T2DM remission were studied.

Results: Forty-six patients with T2DM underwent LRYGB with mean ± SD age and body mass index (BMI) of 48.6 ± 9.6 years and 50.4 ± 6.5 kg/m, respectively. Median (IQR, interquartile range) duration of T2DM preoperatively was 60 (36-126) months. Median (IQR) follow-up was 52 (50-57) months. T2DM remission was achieved in 64 % of patients (44 % CR, 20 % PR), and a further 28 % of patients had improvement in their diabetes status. Multivariate analyses demonstrated significant excess weight loss (EWL) [P = 0.008] and lower BMI [P = 0.04] at 4 years to be the only independent predictors of T2DM medium-term outcomes.

Conclusion: The medium-term effects of LRYGB on T2DM remission/improvement were maintained in 92 % of patients. EWL and lower BMI at 4 years were independent predictors of T2DM remission.
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http://dx.doi.org/10.1007/s00268-016-3609-8DOI Listing
November 2016

Torsion of epiploic appendix presenting as acute pancreatitis.

JRSM Open 2014 Dec 5;5(12):2054270414543398. Epub 2014 Dec 5.

Department of General Surgery, Royal Derby Hospital, Derby, UK.

Epiploic appendagitis is a little-diagnosed condition capable of mimicking various pathologies. Here, we present a case presenting as acute pancreatitis.
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http://dx.doi.org/10.1177/2054270414543398DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4271775PMC
December 2014

Are we meeting the British Society of Gastroenterology guidelines for cholecystectomy post-gallstone pancreatitis?

ANZ J Surg 2016 Dec 25;86(12):1024-1027. Epub 2014 Aug 25.

Department of Hepatobiliary Surgery, Royal Derby Hospital, Derby, UK.

Background: The aim of this study was to audit the current management of patients suffering with gallstone pancreatitis (GSP) at a university teaching hospital for compliance with the British Society of Gastroenterology (BSG) guidelines regarding cholecystectomy post-GSP.

Methods: Data were collected on all patients identified via the hospital coding department that presented with GSP between January 2011 and November 2013. Patients with alcoholic pancreatitis were excluded. The primary outcome was the length of time in days from diagnosis of GSP to cholecystectomy. Secondary outcomes included readmission with gallstone-related disease prior to definitive management and admitting speciality.

Results: One hundred and fifty-eight patients were identified with a presentation of GSP during the study period. Thirty-nine patients were treated conservatively. One hundred and six patients underwent laparoscopic cholecystectomy a median (interquartile range) interval of 33.5 days (64 days) post-admission. Patients with a severe attack as classified by the Glasgow severity score (n = 16) waited a median of 79.5 days (71.5) for cholecystectomy. Only 32% (n = 34) of patients with mild disease underwent cholecystectomy during the index admission or within 2 weeks. When grouped by admitting speciality, patients admitted initially under hepatobiliary surgery waited significantly fewer days for definitive treatment compared with other specialities (P < 0.0001). Twenty-one patients (19.8%) re-presented with gallstone-related pathology prior to undergoing cholecystectomy.

Conclusions: Only 32.1% were treated as per BSG guidelines. About 19.8% (n = 21) of the patients suffered further morbidity as a result of a delayed operation and there is a clear difference between admitting speciality and the median time to operation.
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http://dx.doi.org/10.1111/ans.12827DOI Listing
December 2016

Laparoscopic adjustable gastric band erosion and migration into the proximal jejunum.

Surg Obes Relat Dis 2014 Mar-Apr;10(2):e19-21. Epub 2013 Jun 19.

Department of Upper GI and Bariatric Surgery, Royal Derby Hospital, United Kingdom.

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http://dx.doi.org/10.1016/j.soard.2013.06.013DOI Listing
December 2014

Gastric band erosion, infection and migration causing jejunal obstruction.

BMJ Case Rep 2013 Jan 17;2013. Epub 2013 Jan 17.

Department of General Surgery, Royal Derby Hospital, Derby, UK.

Complications of laparoscopic adjustable gastric bands (LAGB) are well documented and may include migration, erosion, slippage, infection, pouch dilatation and, rarely, gastric perforation. We describe a rare case involving three such complications simultaneously, namely, gastric erosion, infection and migration through the pylorus-causing proximal jejunal obstruction. As LAGB is now the commonest performed bariatric procedure for the treatment of morbid obesity, we encourage the practising surgeon to be vigilant of these rare but potentially life-threatening complications.
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http://dx.doi.org/10.1136/bcr-2012-007737DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3603993PMC
January 2013

Lymph node ratio versus number of affected lymph nodes as predictors of survival for resected pancreatic adenocarcinoma.

World J Surg 2010 Apr;34(4):768-75

Division of Surgery, School of Graduate Entry Medicine and Health, University of Nottingham Medical School at Derby, Derby City General Hospital, Uttoxeter Road, Derby, DE22 3DT, UK.

Background: The objective of this study was to compare the prognostic significance of the lymph node ratio (LNR) with the absolute number of affected lymph nodes for resected pancreatic ductal adenocarcinoma.

Methods: Data were collected from 84 patients who had undergone pancreatoduodenectomy for pancreatic ductal adenocarcinoma over a 10-year period. Patients were categorized into four groups according to the absolute LNR (0, 0-0.199, 0.2-0.299, > or =0.3). Kaplan-Meier and Cox proportional hazard models were used to evaluate the prognostic effect.

Results: An LNR of > or =0.2 (median survival 8.1 vs. 35.7 months with LNR < 0.2; p < 0.001) and > or =0.3 (median survival 5.9 vs. 29.6 months with LNR < 0.3; p < 0.001), tumor size (p < 0.017), positive resection margin (p < 0.001), and nodal involvement (p < 0.001) were found to be significant prognostic markers following univariate analysis. Following multivariate analysis, only LNR at both levels [> or =0.2 (p = 0.05; HR 1.8) and LNR of > or =0.3 (p = 0.01; HR 2.7)] were independent predictors of a poor outcome. The number of lymph nodes examined had no effect on overall survival in either node-positive patients (p = 0.339) or node-negative patients (p = 0.473).

Conclusions: The LNR represents a stronger independent prognostic indicator than the absolute number of affected lymph nodes in patients with resected pancreatic ductal adenocarcinoma.
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http://dx.doi.org/10.1007/s00268-009-0336-4DOI Listing
April 2010

An alternative use of pressure infusor in thyroid surgery.

Ann R Coll Surg Engl 2005 Jul;87(4):291

Department of General and Endocrine Surgery, Nottingham City Hospital, UK.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1963937PMC
July 2005

Intestinal obstruction in an adult with Down's syndrome.

J R Soc Med 2004 Jul;97(7):334-5

Division of Gastrointestinal Surgery, West Block, Queen's Medical Centre, Nottingham NG7 2UH, UK.

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http://dx.doi.org/10.1258/jrsm.97.7.334DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1079529PMC
July 2004

An antiapoptotic role for gastrin and the gastrin/CCK-2 receptor in Barrett's esophagus.

Cancer Res 2004 Mar;64(6):1915-9

Academic Unit of Cancer Studies, West Block, Queen's Medical Center, University Hospital, University of Nottingham, Nottingham NG7 2UH, United Kingdom.

Mechanisms by which premalignant Barrett's metaplasia (BM) progresses to esophageal adenocarcinoma are currently being sought. This study investigated the role played by the polypeptide hormone gastrin, specifically its antiapoptotic effects through activation of protein kinase B/Akt (PKB/Akt). In esophageal cell lines with low basal levels of activated PKB/Akt, phosphorylation could be induced by exogenous amidated gastrin. High basal levels of activated PKB/Akt were linked to endogenous gastrin expression and were reduced by treatment with a cholecystokinin-type 2 receptor (CCK-2R) antagonist. Expression of a constitutively active splice variant of the CCK-2R additionally increased basal activation of PKB/Akt. It is proposed that gastrin acting in an autocrine and endocrine manner via a CCK-2R isoform may activate PKB/Akt and that with expression of gastrin and CCK-2R isoforms increasing in BM samples, gastrin may aid progression of BM through amplification of antiapoptotic pathways. Evidence for this proposal was provided through the observed specific up-regulation of PKB/Akt in BM samples.
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http://dx.doi.org/10.1158/0008-5472.can-03-2713DOI Listing
March 2004
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