Delta-integrated relaxation pressures as a new high-resolution manometry metric to predict the positive outcome of laparoscopic Heller-Dor in patients with achalasia

BACKGROUND

There is no consensus on the definition of failure after treatment in patients with achalasia. The Eckardt score is used to define clinical outcomes. However, objective metrics are lacking. This study aimed to identify whether any high-resolution manometry (HRM) parameters may be useful in predicting a positive outcome after laparoscopic Heller-Dor (LHD).

METHODS

Patients who underwent LHD between 2012 and 2022 were enrolled. The patients were divided according to the outcome: the success group (SG) and the failure group (FG). In addition to the common HRM parameters, we measured the difference between pre- and postoperative integrated relaxation pressures (∆-IRPs). A receiver operating characteristic (ROC) curve analysis was performed to assess the accuracy of each HRM parameter.

RESULTS

Of note, 336 patients (92.3%) were classified in the SG, and 28 patients (7.7%) were classified in the FG. No difference was found in terms of manometric types, symptom duration, and history of previous treatments. Preoperative lower esophageal sphincter (LES) pressure and IRP were higher in the SG than in the FG (41 vs 35 mm Hg [P =.03] and 33 vs 26 mm Hg [P =.002], respectively). The postoperative LES metrics were similar between the 2 groups, except for the ∆-IRP that was higher in the SG (23 mm Hg [IQR, 15-31]) than in the FG (14 mm Hg [IQR, 9-17]) (P =.0002). In the univariate analysis, age, LES preoperative pressure, IRP, and ∆-IRP were factors able to predict a positive clinical outcome. In the multivariate analysis, the ∆-IRP was the only parameter independently related to clinical success (odds ratio, 0.94; 5%-95% CI, 0.89-0.99). The ROC curve for the ∆-IRP showed an area under the curve of 0.71, with a threshold value set at 16.5 mm Hg (sensibility of 71% and specificity of 70%).

CONCLUSION

Our data showed that the ∆-IRP with a threshold of 16.5 mm Hg could represent a new objective tool for predicting the long-term positive outcome of LHD in patients with esophageal achalasia.

Effects of the COVID-19 pandemic on surgical treatment for thoracic malignant tumor cases in Japan: a national clinical database analysis

OBJECTIVE

Surgical care has been significantly affected by the COVID-19 pandemic. This study was conducted to evaluate the effects of the pandemic on lung cancer and mediastinal tumor surgery.

METHODS

Changes in the number of surgical procedures for lung cancer and mediastinal tumors were analyzed using the National Clinical Database of Japan. Patient characteristics, including disease stage and histological type, from 2019 to 2022 were evaluated using annual datasets.

RESULTS

Comparisons with 2019 showed that the number of patients who underwent surgery for primary lung cancer or a mediastinal tumor decreased in 2020 and then remained stable. There were no clinically significant changes in the trend over the four-year period regarding the number of patients for each clinical and pathological stage of lung cancer. Regarding mediastinal tumors, there was no significant difference in tumor size between years. There was a slight change in the selection of surgical indication during the second quarter of 2020, although its impact on annual trends in the stage distribution for lung cancer and primary disease for mediastinal tumors was minimal.

CONCLUSIONS

Analyses of lung cancer and mediastinal tumor surgery cases in Japan during the COVID-19 pandemic showed no significant disease profile changes related to treatment delay.

Neoplastic Progression Risk in Females With Barrett's Esophagus: A Systematic Review and Meta-Analysis of Individual Patient Data

BACKGROUND AND AIMS

Females with Barrett's esophagus (BE) have a lower risk of neoplastic progression than males, but sufficiently powered risk analyses are lacking. This systematic review and meta-analysis of individual patient data (IPD) aimed to provide more robust evidence on neoplastic progression risk in females.

METHODS

We conducted a systematic literature search of 3 electronic databases (Medline, Embase, Google Scholar) from inception until August 2023. Eligible studies (1) reported original data on progression from nondysplastic BE, indefinite for dysplasia, or low-grade dysplasia to high-grade dysplasia or esophageal adenocarcinoma; and (2) included female and male patients. IPD were quality controlled by 2 independent reviewers. The primary outcome was the association between sex and neoplastic progression risk, adjusted for risk factors using multivariable Cox regression analysis. Secondary outcomes were sex differences in time to progression and annual progression rate.

RESULTS

IPD were obtained from 11 of 66 eligible studies, including 2196 (31%) females. Neoplastic progression risk was lower in females (hazard ratio for males vs females, 1.44; 95% confidence interval, 1.13-1.82) after adjusting for age, smoking, medication use, hiatal hernia, BE length, and baseline pathology. The annual progression rate was 0.88% in females vs 1.29% in males. Time to progression was similar in both sexes: 3.7 years (interquartile range, 2.1-7.7 years) in females and 4.2 years (interquartile range, 2.0-8.1 years) in males.

CONCLUSION

Although females had a lower neoplastic progression risk, sex differences were smaller than previously reported, and time to progression was similar for both sexes. Future research should focus on other factors than sex to identify low- and high-risk BE patients.

Patient reported outcomes and decision regret scores in redo-paraesophageal hernia repair

INTRODUCTION

Recurrent paraesophageal hernia (PEH) repair presents significant technical challenges, with limited data weighing the benefit to the operative risk. This study aims to describe our experience with recurrent PEH repair, including long-term surgical and patient reported outcomes (PROs).

METHODS

We conducted a retrospective review of recurrent PEH repairs from June 2018-March 2023 using our institutional database. A blinded review of post-operative imaging was conducted to assess for recurrence. Quality of life (QOL) and decision regret were measured using the GERD Health-Related Quality-of-Life (GERD-HRQL) questionnaire and Decision Regret Scale (DRS) at maximum follow up.

RESULTS

Eighty-eight patients underwent recurrent PEH repair at our institution for PEH, classified as type II (13.6%), type III (72.7%) and type IV (13.6%). There was significant heterogeneity in operative techniques used: one-third of patients had mesh placed at the hiatus, 11.4% had a Collis gastroplasty, and one-third of patients underwent fundoplication. Intraoperative complications included gastric (5.7%), esophageal (2.3%), vascular (1.1%) and pulmonary (1.1%) injuries. Follow up was available for 73 patients with median follow up of 35.2 months. Of patients with radiographic follow up, 20 (35.7%) had a radiographic recurrence: 12 (21.4%) were 2-5 cm and 8 (14.3%) were > 5 cm. Patients reporting PROs (53 patients; 60.2%) reported low symptom severity (mean GERD-HRQL 13.1 ± 12) and low decision regret (mean DRS 13.3 ± 19.4) with 75.5% scoring in the lowest quartile (DRS < 25). Radiographic recurrence was associated with worse QOL (p < 0.05), but no significant difference in decision regret (p = 0.125).

CONCLUSION

We found significant heterogeneity amongst recurrent PEH repair techniques with continued high recurrence rate during follow up. Radiographic recurrence was correlated with worse QOL, yet patients reported low symptom severity and low decision regret, suggesting continued value in these challenging operations. Future studies should aim to identify more effective techniques to reduce recurrence rates in this patient population.

American Society for Gastrointestinal Endoscopy guideline on the diagnosis and management of GERD: summary and recommendations

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based approach for strategies to diagnose and manage GERD. This document was developed using the Grading of Recommendations Assessment, Development, and Evaluation framework and serves as an update to the 2014 ASGE guideline on the role of endoscopy in the management of GERD. This updated guideline addresses the indications for endoscopy in patients with GERD as well as in the emerging population of patients who develop GERD after sleeve gastrectomy or peroral endoscopic myotomy. It also discusses how to endoscopically evaluate gastroesophageal junctional integrity in a comprehensive and uniform manner. Importantly, this guideline also discusses management strategies for GERD including the role of lifestyle interventions, proton pump inhibitors (PPIs), and endoscopic antireflux therapy (including transoral incisionless fundoplication [TIF], radiofrequency energy, and combined hiatal hernia repair and TIF [cTIF]) in the management of GERD. The ASGE suggests upper endoscopy for the evaluation of GERD in patients with alarm symptoms, with multiple risk factors for Barrett's esophagus, and with a history of sleeve gastrectomy. The ASGE recommends careful endoscopic evaluation, reporting, and photo-documentation of objective GERD findings with attention to gastroesophageal junction landmarks and integrity in patients who undergo upper endoscopy to improve care. In patients with GERD symptoms, the ASGE recommends lifestyle modifications. In patients with symptomatic and confirmed GERD with predominant heartburn symptoms, the ASGE recommends medical management including PPIs at the lowest dose for the shortest duration possible while initiating discussion about long-term management options. In patients with confirmed GERD with small hiatal hernias (≤2 cm) and Hill grade I or II who meet specific criteria, the ASGE suggests evaluation for TIF as an alternative to chronic medical management. In patients with persistent GERD with large hiatal hernias (> 2cm) and Hill grade III or IV, the ASGE suggests either cTIF or surgical therapy based on multidisciplinary review. This document summarizes the methods, analyses, and decision processes used to reach the final recommendations and represents the official ASGE recommendations on the above topics.

Nutrition education: Optimising preparation and recovery for benign oesophageal surgery

BACKGROUND

Patients requiring upper gastrointestinal surgery for benign oesophageal conditions are at nutrition risk before and after surgery. There is a dearth of published evidence guiding clinicians on effective collaboration with patients to mitigate perioperative nutritional challenges. We conducted a qualitative study aiming to explore patients' perioperative food, nutrition, and educational experiences to guide future care.

METHODS

Adult patients who had undergone elective, benign oesophageal surgery were invited to participate in semi-structured interviews within 3 weeks of hospital discharge. Interviews were transcribed and analysed with a reflexive form of inductive thematic analysis in addition to synthesised member checking.

RESULTS

Interviews with 12 patients identified three major themes. First, nutrition education fosters a better surgical recovery experience: patients expressed a desire to be prepared for their upcoming surgery and engage in the recovery process with informed food choices. Most patients preferred preoperative education given limited capacity for learning during hospital admission. Second, patients have priorities for nutrition information: patients expressed that educational material should be printed, comprehensive, practical, include familiar foods and focus on managing postoperative physical symptoms. Third, food impacts social and emotional experiences of surgery: resumption of a normal diet was a sign of recovery that enabled social reintegration. Identified themes resonated with Knowles' six-core principles of andragogy.

CONCLUSIONS

Patients with benign oesophageal conditions perceived nutrition education to be a vital aspect of surgical preparation and recovery. Re-designing perioperative education with patient input has the potential to improve outcomes and experiences.

American Society for Gastrointestinal Endoscopy guideline on the diagnosis and management of GERD: methodology and review of evidence

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based approach for strategies to diagnose and manage GERD. This document was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework and serves as an update to the prior ASGE guideline on the role of endoscopy in the management of GERD (2014). The updated guideline addresses the indications for endoscopy in patients with GERD, including patients who have undergone sleeve gastrectomy (SG) and peroral endoscopic myotomy (POEM). It also discusses endoscopic evaluation of gastroesophageal junctional integrity comprehensively and uniformly. Important, this guideline discusses management strategies for GERD including lifestyle interventions, proton pump inhibitors (PPIs), and endoscopic antireflux therapy including transoral incisionless fundoplication (TIF), radiofrequency energy, and TIF combined with hiatal hernia repair (cTIF). The ASGE recommends upper endoscopy for the evaluation of GERD in patients with alarm symptoms. The ASGE suggests upper endoscopy for symptomatic patients with a history of SG and POEM. The ASGE recommends careful endoscopic evaluation, reporting, and photo-documentation of objective GERD findings and gastroesophageal junction landmarks and integrity to improve patient care and outcomes. In patients with GERD symptoms, the ASGE recommends lifestyle modifications. In patients with symptomatic and confirmed GERD with predominant heartburn symptoms, the ASGE recommends medical management including PPIs at the lowest dose for the shortest duration while initiating discussion about long-term management options. In patients with confirmed GERD with small hiatal hernia (≤2 cm) and Hill grade I or II flap valve who meet specific criteria, the ASGE suggests evaluation for TIF as an alternative to long-term medical management. In patients with confirmed GERD with a large hiatal hernia (>2 cm) and Hill grade 3 or 4 flap valve, the ASGE suggests evaluation for combined endoscopic-surgical TIF (cTIF) in a multidisciplinary review. This document clearly outlines the methodology, analysis, and decision used to reach the final recommendations and represents the official ASGE recommendations on the above topics.

RFC4 confers radioresistance of esophagus squamous cell carcinoma through regulating DNA damage response

Radioresistance in esophageal squamous cell carcinoma (ESCC) is a critical factor leading to treatment failure and recurrence, yet its underlying molecular mechanisms remain unclear. This study aimed to investigate the role of replication factor C4 (RFC4) in ESCC radioresistance and to explore the underlying mechanisms. We utilized online bioinformatics tools to analyze the properties, functions, and prognostic significance of RFC4 in ESCC. We established cell lines with varying RFC4 expression levels and subjected them to radiation exposure. RFC4 expression was assessed using quantitative real-time polymerase chain reaction (qRT-PCR), immunohistochemistry, and immunoblotting. Cell proliferation was evaluated with MTT, 5-ethynyl-2'-deoxyuridine (EdU), and colony formation assays. Apoptosis and cell cycle distribution were analyzed by flow cytometry. Western blotting and immunofluorescence were used to study the impact of RFC4 on the DNA damage response in ESCC cells. A xenograft mouse model was employed to assess tumor growth in vivo. RFC4 expression was significantly upregulated in ESCC tissues and cells, particularly in radioresistant cases. Functional experiments revealed that RFC4 promotes cell proliferation, inhibits apoptosis, induces cell cycle arrest, and mitigates radiation-induced DNA damage responses. Mechanistically, RFC4-mediated radioresistance in ESCC may involve the inactivation of the p53 signaling pathway. In animal studies, RFC4 knockdown, either alone or in combination with radiation therapy, effectively suppressed the growth of xenograft tumors. These findings highlight the potential of targeting RFC4 to overcome radioresistance by modulating the DNA damage response in ESCC, offering promising therapeutic avenues for patients with ESCC.NEW & NOTEWORTHY Our research indicates that replication factor C4 (RFC4) plays a role in conferring radioresistance to esophageal squamous cell carcinoma (ESCC) by bolstering DNA damage repair, primarily through the inhibition of the p53 signaling pathway. This finding positions RFC4 as a promising therapeutic target for combating radioresistance in ESCC, although further research is required to fully comprehend its intricate role in the disease.

Hiatal Hernia Repair: A Century Between Soresi and da Vinci

A minimally invasive approach is the most common technique for hiatal hernia repair. The robotic platform offers a unique advantage that addresses the limitations of a laparoscopic repair. The steps of a robotic hiatal hernia repair include reduction of hernia contents, dissection of hernia sac, circumferential dissection of esophagus with 2.5 to 3 cm of intraabdominal esophagus, crural closure, and partial or complete fundoplication. The robotic hiatal hernia repair has comparable perioperative outcomes to the laparoscopic approach. This article discusses current controversies, limitations, and new technologies.

Laparoscopic fundoplication improves esophageal motility in patients with gastroesophageal reflux disease: a high-volume single-center controlled study in the era of high-resolution manometry and 24-hour pH impedance

BACKGROUND

Most existing literature studies reported that laparoscopic fundoplication (LF) is safe in the setting of ineffective or weak peristalsis. However, the effect of the wrap on esophageal motility is still debated. This study aimed to assess how a functioning and effective fundoplication could affect esophageal motility in patients with gastroesophageal reflux disease (GERD).

METHODS

This study analyzed prospectively collected data on patients who underwent laparoscopic Nissen (LN) fundoplication or laparoscopic Toupet (LT) fundoplication for GERD at our department between 2010 and 2022. Demographic and clinical characteristics were recorded. Patients were evaluated using the Gastroesophageal Reflux Disease Questionnaire (GerdQ), barium swallow, endoscopy, high-resolution manometry (HRM), and 24-hour pH impedance (multichannel intraluminal impedance and pH monitoring [MII-pH]) before and after surgery. HRM was reviewed by 2 experts, following the criteria of the Chicago Classification (version 4.0). LF failure was objectively defined in case of abnormal postoperative MII-pH according to the Lyon 2.0 criteria with/without an abnormal GerdQ.

RESULTS

During the study period, 124 patients with GERD (89 males and 35 females) were recruited. Of note, 58 patients underwent LN fundoplication, and 66 patients underwent LT fundoplication. All procedures were completed laparoscopically, and the 90-day postoperative mortality was nil. At the postoperative MII-pH, good outcome was recorded in 103 patients, and failure was recorded in 21 patients. There was a significant association between a successful LF and the normalization of esophageal motility (P < .05).

CONCLUSION

Our data confirmed that LF is an effective treatment in patients with GERD, regardless of esophageal motility status. Moreover, our results indicate that LF could determine a normalization of motility abnormalities in patients with GERD.

Targeting ferroptosis in gastrointestinal tumors: Interplay of iron-dependent cell death and autophagy

Ferroptosis is a regulated cell death mechanism distinct from apoptosis, autophagy, and necroptosis, marked by iron accumulation and lipid peroxidation. Since its identification in 2012, it has developed into a potential therapeutic target, especially concerning GI disorders like PC, HCC, GC, and CRC. This interest arises from the distinctive role of ferroptosis in the progression of diseases, presenting a new avenue for treatment where existing therapies fall short. Recent studies emphasize the promise of focusing on ferroptosis to fight GI cancers, showcasing its unique pathophysiological mechanisms compared to other types of cell death. By comprehending how ferroptosis aids in the onset and advancement of GI diseases, scientists aim to discover novel drug targets and treatment approaches. Investigating ferroptosis in gastrointestinal disorders reveals exciting possibilities for novel therapies, potentially revolutionizing cancer treatment and providing renewed hope for individuals affected by these tumors.

Delayed surgery during the Covid-19 pandemic did not affect long-term outcomes of pancreatic adenocarcinoma

BACKGROUND

During the Covid-19 pandemic cancer surgery was severely affected due to relocation of healthcare resources and the resulting restructuring of cancer pathways. Although this potentially affected rapidly progressing malignancies like pancreatic cancer the most, little is known about long-term outcomes following pancreatectomy.

MATERIALS AND METHODS

Survival data from two pancreatic surgery centres in the UK was analysed with patients being compared across pre-pandemic (C19-) and intra-pandemic (C19+) groups. Demographic, pathological and surgical pathway parameters were evaluated with multivariate analysis and propensity score matching.

RESULTS

Out of 123 patients, 60 had surgery during the pandemic. The main strategy to reduce disruptions to pancreatic surgery was relocation of services to private sector facilities without emergency medicine departments. Although time to surgery was delayed by almost 20 days during the pandemic, there were no significant differences in overall survival at 22 months vs. 24 months or disease free survival at 15 months vs. 16 months for the C19+ and C19- groups, respectively. Adjuvant chemotherapy, Charlson comorbidity score, tumour stage and resection margin status were found to be independent predictors for overall survival whereas only adjuvant chemotherapy and Charlson comorbidity score were predictive of disease free survival.

CONCLUSION

This article provides a template for the effective restructuring of pancreatectomy pathways during a pandemic with associated lockdowns and provides the first evidence that the quality of outcomes can be maintained in this difficult environment. It is hoped that these results will provide a framework for addressing surgical oncology challenges in future pandemics.

Spontaneous cervical and mediastinal hematoma due to rupture of inferior thyroid artery

A 62-year-old man was referred to our hospital presenting with a sore throat, dyspnea, and cervical swelling. Initial precontrast CT scans revealed a cervical and mediastinal hematoma, along with a hemothorax. Further dynamic contrast-enhanced CT scans indicated contrast media extravasation dorsal to the right thyroid gland lobe, suggesting a rupture of the right inferior thyroid artery or a parathyroid adenoma. Following endotracheal intubation, angiography confirmed extravasation from the right inferior thyroid artery. Transarterial embolization (TAE) was successfully performed using a gelatin sponge. The cervical and mediastinal hematoma were surgically excised, and the right inferior parathyroid gland was simultaneously resected. Pathological examination revealed no neoplastic components.

Risk of metachronous peritoneal metastases after surgery for obstructive colon cancer: Multivariate analysis from a series of 1,085 patients

BACKGROUND

Data in the literature suggest that obstruction is an independent predictor of poor prognosis in colon cancer. Of all possible sites of recurrence, peritoneal metastases are associated with worse survival. Our aim was to report the incidence of metachronous peritoneal metastases from a cohort of patients undergoing resection of obstructive colon cancer with curative intent and to identify predictive factors for metachronous peritoneal metastases.

METHODS

From 2000 to 2015, a total of 2,325 patients were treated for obstructive colon cancer in French surgical centers, members of the French National Surgical Association (AFC). Patients with palliative management, synchronous metastatic disease, and with postoperative mortality were excluded. A multivariate analysis was performed to determine independent predictive factors of metachronous peritoneal metastases.

RESULTS

The cohort included 1,085 patients. The median follow-up was 21.5 months. Metachronous peritoneal metastases occurred in 12% of patients and were diagnosed after a median interval of 13.5 months. The cumulative 3-year metachronous peritoneal metastasis rate was 10.9%. Three-year overall survival was 85% for patients who did not develop recurrence, 71% for those who develop recurrence without peritoneal metastases, and 56% for those with metachronous peritoneal metastases (P < .0001). In multivariate analysis, 3 variables were identified as independent risk factors for metachronous peritoneal metastases: pT4 stage (odds ratio: 1.98; 95% confidence interval: 1.17-3.36; P = .011), pN2 stage (odds ratio: 2.57; 95% confidence interval: 1.89-4.45; P = .0007), and fewer than 12 lymph nodes examined (odds ratio: 2.01; 95% confidence interval: 1.08-3.74; P = .028).

CONCLUSION

This study showed a significant risk of metachronous peritoneal metastases after curative-intent resection of obstructive colon cancer. The awareness of factors predisposing to metachronous peritoneal metastases could improve the treatment strategy of these patients.

Outcomes of intraperitoneal chemotherapy for the treatment of gastric cancer with peritoneal metastasis: A comprehensive systematic review and meta-analysis

BACKGROUND

Peritoneal metastasis is common in gastric cancer and linked to poor survival. Treatment of peritoneal metastasis with intraperitoneal chemotherapy has become an accepted practice in some centres. This systematic review and meta-analysis intends to provide a comprehensive evaluation of published evidence for the use of intraperitoneal chemotherapy is gastric cancer patients with peritoneal metastasis.

METHODS

A systematic literature search for studies reporting the use of intraperitoneal chemotherapy for the treatment gastric cancer with macroscopic peritoneal metastasis was performed up until June 2024. Studies were not eligible for inclusion if they described the use of intraperitoneal chemotherapy solely as an adjunct to gastrectomy or cytoreductive surgery. Pooled- and meta-analysis was used to summarise study outcomes.

RESULTS

Fifty-three studies reporting the outcomes of 2446 gastric cancer patients who received intraperitoneal chemotherapy for the treatment of peritoneal metastasis, were included. Three principal methods of intraperitoneal chemotherapy administration were described: catheter based (normothermic) intraperitoneal chemotherapy (n = 28); pressurised intraperitoneal aerosolised chemotherapy (n = 14), and; hyperthermic intraperitoneal chemotherapy (n = 11). The proportion of patients with complete peritoneal disease regression after receiving intraperitoneal chemotherapy was 27 % (95%CI, 14-41). Median overall survival determined was 16.4 months (95%CI, 14.4-18.4). Meta-analysis of data from eight studies comparing combined intraperitoneal and systemic chemotherapy with systemic chemotherapy alone identified a survival benefit for patients receiving intraperitoneal chemotherapy (Hazard ratio 0.57 [95%CI, 0.48-0.67],P < 0.001).

CONCLUSION

Despite variation in published treatment approaches and a lack of evidence from well-designed clinical trials, intraperitoneal chemotherapy may be considered safe and in selected circumstances efficacious.

Serum and Plasma miRNA Expression Levels in Sudden Sensorineural Hearing Loss

Sudden sensorineural hearing loss (SSNHL) is a rapidly developing acquired idiopathic disorder. Differential expressions of microRNAs (miRNAs) have been identified in the acute serum of SSNHL patients. miRNAs are transmitted in both serum and plasma, but it is unknown which better reflects changes associated with inner ear disease. Therefore, we sought to compare the serum and plasma miRNA expression levels in adult SSNHL patients. We extracted and reverse transcribed total RNA from serum and plasma, and analyzed the product with quantitative real-time PCR. hsa-miR-191-5p was used for normalization, and miRNA expression levels were calculated using the delta Ct method. Serum and plasma samples from 17 SSNHL patients (mean age 51.9 years, standard deviation 13.9 years) showed no significant differences in miR-128-3p, miR-132-3p, miR-375-3p, miR-590-5p, miR-30a-3p, miR-140-3p, miR-186-5p, and miR-195-5p expression levels on Wilcoxon signed-rank test analyses. We conclude that plasma and serum are equally suitable for investigating potential miRNA SSNHL disease markers.

Exosomal miRNAs involvement in pathogenesis, diagnosis, and treatment of rheumatoid arthritis

Rheumatoid arthritis (RA) is the most common chronic autoimmune arthropathy worldwide. The initiation, and progression of RA involves multiple cellular and molecular pathways, and biological interactions. Micro RNAs (miRNAs) are characterized as a class of small non-coding RNAs that influence gene expression at the post-transcriptional level. Exosomes are biological nano-vesicles that are secreted by different types of cells. They facilitate communication and signalling between cells by transferring a variety of biological substances, such as proteins, lipids, and nucleic acids like mRNA and miRNA. Exosomal miRNAs were shown to be involved in normal and pathological conditions. In RA, deregulated exosomal miRNA expression was observed to be involved in the intercellular communication between synovial cells, and inflammatory or regulatory immune cells. Furthermore, circulating exosomal miRNAs were introduced as available diagnostic and prognostic biomarkers for RA pathology. The current review categorized and summarized dysregulated pathologically involved and circulating exosomal miRNAs in the context of RA. It highlighted present situation and future perspective of using exosomal miRNAs as biomarkers and a specific gene therapy approach for RA treatment.

Unraveling the pathogenesis of Barrett's esophagus and esophageal adenocarcinoma: the "omics" era

Barrett's esophagus (BE) represents a pre-cancerous condition that is characterized by the metaplastic conversion of the squamous esophageal epithelium to a columnar intestinal-like phenotype. BE is the consequence of chronic reflux disease and has a potential progression burden to esophageal adenocarcinoma (EAC). The pathogenesis of BE and EAC has been extensively studied but not completely understood, and it is based on two main hypotheses: "transdifferentiation" and "transcommitment". Omics technologies, thanks to the potentiality of managing huge amounts of genetic and epigenetic data, sequencing the whole genome, have revolutionized the understanding of BE carcinogenesis, paving the way for biomarker development helpful in early diagnosis and risk progression assessment. Genomics and transcriptomics studies, implemented with the most advanced bioinformatics technologies, have brought to light many new risk loci and genomic alterations connected to BE and its progression to EAC, further exploring the complex pathogenesis of the disease. Early mutations of the TP53 gene, together with late aberrations of other oncosuppressor genes (SMAD4 or CKND2A), represent a genetic driving force behind BE. Genomic instability, nonetheless, is the central core of the disease. The implementation of transcriptomic and proteomic analysis, even at the single-cell level, has widened the horizons, complementing the genomic alterations with their transcriptional and translational bond. Increasing interest has been gathered around small circulating genetic traces (circulating-free DNA and micro-RNAs) with a potential role as blood biomarkers. Epigenetic alterations (such as hyper or hypo-methylation) play a meaningful role in esophageal carcinogenesis as well as the study of the tumor micro-environment, which has led to the development of novel immunological therapeutic options. Finally, the esophageal microbiome could be the protagonist to be investigated, deepening our understanding of the subtle association between the host microbiota and tumor development.

Challenges and adaptations in pancreatic cancer surgery during the COVID-19 pandemic in a high-volume center

BACKGROUND

The COVID-19 pandemic affected healthcare systems worldwide, disrupting elective surgeries including those for cancer treatment. This study examines the effects of the pandemic on outcomes of pancreatic cancer surgeries at a specialized high-volume surgery center.

MATERIALS AND METHODS

This study compared surgical volume and outcomes of pancreas resections between the pre-pandemic (January 2019 to February 2020), early pandemic (March 2020 to January 2021), and late pandemic (February 2021 to December 2021) periods. Perioperative and postoperative data were retrospectively analyzed from a prospectively maintained database together with surgical complications, mortality rates, and hospital stays.

RESULTS

There was no significant reduction in the number of pancreas resections performed during the pandemic. The rate of primary resectable tumors was significantly lower during the late pandemic phase (66% vs. 65.9% vs. 56.5%; P = 0.024), and subsequently application of neoadjuvant therapies increased in the late pandemic phase (26% vs. 25.4% vs. 33.8%; P = 0.079). The number of chemotherapy cycles were also higher during the late pandemic phase (P = 0.009). Surgical complication rates were higher during the late pandemic phase (47.8% vs. 45.6% vs. 56%; P = 0.043), but mortality rates remained low (30-day mortality: 1.6% vs. 1% vs. 3.7%, P = 0.116; 90-day mortality: 2.5% vs. 1.6% vs. 3.7%, P = 0.296).

CONCLUSION

Our results indicate effective management of pancreatic cancer despite the challenges presented by the pandemic. These findings suggest that centralized, specialized surgical centers can maintain high-quality care of patients with pancreatic cancer during crises like the COVID-19 pandemic. These findings underscore the importance of timely surgical interventions for cancer patients, even when the healthcare system is disrupted.

Evaluating Postoperative Morbidity and Outcomes of Robotic-Assisted Esophagectomy in Esophageal Cancer Treatment-A Comprehensive Review on Behalf of TROGSS (The Robotic Global Surgical Society) and EFISDS (European Federation International Society for Digestive Surgery) Joint Working Group

BACKGROUND

Esophageal cancer, the seventh most common malignancy globally, requires esophagectomy for curative treatment. However, esophagectomy is associated with high postoperative morbidity and mortality, highlighting the need for minimally invasive approaches. Robotic-assisted surgery has emerged as a promising alternative to traditional open and minimally invasive esophagectomy (MIE), offering potential benefits in improving clinical and oncological outcomes. This review aims to assess the postoperative morbidity and outcomes of robotic surgery.

METHODS

A comprehensive review of the current literature was conducted, focusing on studies evaluating the role of robotic-assisted surgery in esophagectomy. Data were synthesized on the clinical outcomes, including postoperative complications, survival rates, and recovery time, as well as technological advancements in robotic surgery platforms. Studies comparing robotic-assisted esophagectomy with traditional approaches were analyzed to determine the potential advantages of robotic systems in improving surgical precision and patient outcomes.

RESULTS

Robotic-assisted esophagectomy (RAMIE) has shown significant improvements in clinical outcomes compared to open surgery and MIE, including reduced postoperative pain, less blood loss, and faster recovery. RAMIE offers enhanced thoracic access, with fewer complications than thoracotomy. The RACE technique has improved patient recovery and reduced morbidity. Fluorescence-guided technologies, including near-infrared fluorescence (NIRF), have proven valuable for sentinel node biopsy, lymphatic mapping, and angiography, helping identify critical structures and minimizing complications like anastomotic leakage and chylothorax. Despite these benefits, challenges such as the high cost of robotic systems and limited long-term data hinder broader adoption. Hybrid approaches, combining robotic and open techniques, remain common in clinical practice.

CONCLUSIONS

Robotic-assisted esophagectomy offers promising advantages, including enhanced precision, reduced complications, and faster recovery, but challenges related to cost, accessibility, and evidence gaps must be addressed. The hybrid approach remains a valuable option in select clinical scenarios. Continued research, including large-scale randomized controlled trials, is necessary to further establish the role of robotic surgery as the standard treatment for resectable esophageal cancer.

Exosomal miR-130a-3p confers cisplatin resistance in esophageal cancer by regulating ferroptosis via the suppression of METTL14-mediated m6A RNA methylation of FSP1

Exosomal microRNA (miRNA)s have been proven to affect recipient cell chemoresistance in several cancers. This research attempted to uncover the role of exosomal miRNA and the regulatory mechanism in cisplatin resistance of esophageal cancer (EC). Cisplatin-resistant EC cells (KYSE-150-CisR and TE-1-CisR) were established by the parental cells (KYSE-150 and TE-1) treated with a gradual increase of cisplatin concentration. Exosomes from both cisplatin-resistant EC cells and the parental one were obtained with ultracentrifugation (CisR-exo and CisS-exo), and identified by transmission electron microscopy and nanoparticle tracking analysis. The effect of CisR-exo on the cisplatin resistance of EC was assessed by in vitro (and in vivo functional experiments.Intracellular reactive oxygen species and iron were determined by the corresponding kits. The m6A dot blot assay and methylated RIP-qPCR was conducted to analyze the m6A modification level. Dual-luciferase reporter assay was performed to confirm the intermolecular interaction. Increased levels of miR-130a-3p were observed in both KYSE-150CisR and TE-1CisR cells, as well as their derived CisR-exos when compared with the parental cells and CisS-exos. Exosomal miR-130a-3p from cisplatin-resistant EC cells conferred cisplatin resistance to EC in vitro and in vivo, which might be mediated by the suppression of ferroptosis. Mechanically, KYSE-150CisR derived exosomal miR-130a-3p interacted with METTL14 to inhibit FSP1 (a ferroptosis suppressor) m6A modification of recipient cells. Overexpressing METTL14 restrained the cisplatin resistance disseminated by CisR-exos in KYSE-150 cells. Cisplatin-resistant EC cell-isolated exosomal miR-130a-3p suppressed the m6A modification of FSP1 to modulate ferroptosis, enhancing cisplatin resistance.

Reimbursement policies of Swiss health insurances for the surgical treatment of symptomatic breast hypertrophy: a retrospective cohort study

BACKGROUND

Patients with symptomatic breast hypertrophy typically suffer from chronic back pain, recurrent skin irritation at the inframammary fold and/or low self-esteem resulting in impaired quality of life. Reduction mammaplasty has been shown to effectively treat symptomatic breast hypertrophy with high patient satisfaction. Despite the obvious benefits, reimbursement requests for reduction mammaplasty are initially often refused by the patient's health insurance company, thereby frequently resulting in additional examinations and eventually extra expenses. The study aim was to evaluate the reimbursement policy by health insurance companies for treatment costs of reduction mammaplasty in a patient cohort, to quantify the generation of additional costs due to initial refusal of reimbursement, as well as to assess back pain after surgical treatment.

METHODS

A retrospective cohort study was conducted in two Swiss centres. Inclusion criteria were a diagnosis of symptomatic breast hypertrophy, cost approval for reduction mammaplasty by the health insurance between October 2014 and March 2021 and informed consent for the study. The exclusion criteria were private payers for reduction mammaplasty and patients aged below 18. Primary outcome measures included median duration between the first request for reimbursement sent to the health insurance and the receipt of its approval, the number of requests needed per patient, as well as the number and type of additional outpatient visits conducted by specialists other than plastic surgeons, including the need for further diagnostic investigations and therapeutic measures. Secondary outcome measures included the additional costs generated in patients with more than one request. Finally, back pain after surgical treatment was assessed using a visual analogue scale (VAS).

RESULTS

 A total of 46 patients with symptomatic breast hypertrophy and approval for reimbursement were included in the study. The median duration to obtain cost approval for reduction mammaplasty was 9.4 weeks (ranging from 1 to 154 weeks). Reimbursement was approved after 1, 2, 3 or 4 requests in 26, 6, 11 and 3 patients, respectively. If the first request was refused, further clinical evaluation by specialists, additional imaging of the cervical spine and physiotherapy was necessary in 70%, 35% and 80% of the patients, respectively. A patient requiring more than one request to obtain cost approval for reduction mammaplasty generated additional mean costs of approximately 2400 CHF, i.e. 2181 CHF, 164 CHF and 46 CHF for ongoing physiotherapy, additional outpatient visit by a specialist doctor and complementary imaging compared to patients needing only one request for cost approval. The level of back pain could be reduced from 7.0 before surgery to 1.6 after surgery.

CONCLUSION

 Patients with symptomatic breast hypertrophy who needed more than one request for cost approval (43%) had to undergo further outpatient visits and/or radiological examinations, as well as physiotherapy, despite a clear indication for surgery, resulting in a prolonged symptomatology and increasing healthcare costs.

Activation of S1PR2 on macrophages and the hepatocyte S1PR2/RhoA/ROCK1/MLC2 pathway in vanishing bile duct syndrome

Immunologic bile duct destruction is a pathogenic condition associated with vanishing bile duct syndrome (VBDS) after liver transplantation and hematopoietic stem-cell transplantation. As the bile acid receptor sphingosine 1-phosphate receptor 2 (S1PR2) plays a critical role in recruitment of bone marrow-derived monocytes/macrophages to sites of cholestatic liver injury, S1PR2 expression was examined using cultured macrophages and patient tissues. Bile canaliculi destruction precedes intrahepatic ductopenia; therefore, we focused on hepatocyte S1PR2 and the downstream RhoA/Rho kinase 1 (ROCK1) signaling pathway and bile canaliculi alterations using three-dimensional hepatocyte culture models that form obvious bile canaliculus-like networks. Multiplex immunohistochemistry revealed increased numbers of S1PR2+CD45+CD68+FCN1+ inflammatory macrophages and S1PR2+CD45+CD68+MARCO+ Kupffer cells in liver tissues showing ductopenia due to graft-versus-host disease and rejection post-liver transplant compared with normal liver. Macrophage expression of proinflammatory cytokines, including MCP1, was reduced following S1PR2 inhibition. Taurocholic acid and S1P2 agonist induced hepatocyte S1PR2 and reduced RhoA/ROCK1 expression, resulting in bile canaliculi dilatation. S1PR2 inhibition reversed the effect on RhoA/ROCK1 expression, resulting in maintenance of bile canaliculi through myosin light chain 2 (MLC2) phosphorylation. Activation of S1PR2 on macrophages and S1PR2 on hepatocytes may disrupt bile canaliculi dynamics in VBDS under regulation by RhoA/ROCK1 through MLC2 phosphorylation.

Significant Alterations of Colorectal Cancer Care in the COVID-19 Pandemic With High Adherence to Quality Criteria in German Cancer Centers (CC) ‒ Data From the AIO CancerCOVID Consortium (AIO-YMO/KRK 520/ass)

BACKGROUND

Colorectal cancer (CRC) remains a leading cause of death despite notable advancements through guideline-based management. We present data on changes of CRC care during the COVID-19 pandemic in Germany.

METHODS

Retrospective data from 22 AIO CCs and an academic Institute of Pathology compared the first (fw, 03-05.2020) and second wave (sw, 11-12.2020) of the pandemic with corresponding 2019 periods. Parameters were: number of cases diagnosed, age, sex, tumor stage, surgical procedures, quality criteria of CRC care (presentation in multidisciplinary tumor boards (MTB), psychological or social consultation), number of precancerous and malignant colorectal lesions (CRL). Data points were compared as mean values with confidence intervals estimated according to Clopper and Pearson (1934). Hypothesis tests were conducted using Poisson regression models that included interaction terms (year*sex or year*age over70). Statistical significance was considered at P < .05.

RESULTS

A total of 4316 cases diagnosed (AIO CC) revealed a substantial reduction (fw -20.58%; sw -23.48%). Hypothesis test showed a significant decline in incidence due to the fw and sw of the pandemic. Quality criteria of cancer care remained stable except for trial participation. Analysis from 60,695 CRL detected a decrease in precancerous (fw: -16 %/sw: -4 %) and malignant (fw: -18 %) lesions while malignant CRL increased in the sw (+8 %). Hypothesis test revealed a significant decline only for the fw 2020 and detected age > 70 as independent risk factor in both waves.

CONCLUSION

We detected substantial alterations in cancer care during the pandemic, including detected precancerous CRL. CCs showed high resilience in quality criteria for CRC care.

Fusion of tumor cells and mesenchymal stem/stroma cells: a source of tumor heterogeneity, evolution and recurrence

The heterogeneity and evolution of tumors remain significant obstacles in cancer treatment, contributing to both therapy resistance and relapse. Mesenchymal stem/stromal cells (MSCs) are multipotent stromal cells within the tumor microenvironment that interact with tumor cells through various mechanisms, including cell fusion. While previous research has largely focused on the effects of MSC-tumor cell fusion on tumor proliferation, migration, and tumorigenicity, emerging evidence indicates that its role in tumor maintenance, evolution, and recurrence, particularly under stress conditions, may be even more pivotal. This review examines the connection between MSC-tumor cell fusion and several critical factors like tumor heterogeneity, cancer stem cells, and therapy resistance, highlighting the crucial role of cell fusion in tumor survival, evolution, and recurrence. Additionally, we explore potential therapeutic strategies aimed at targeting this process.

Causal analysis of dietary preferences and the risk of endometriosis using large-scale population data

Dietary factors have recently been recognized as potentially influential in the pathogenesis of endometriosis (EM), yet studies on the causal relationship between dietary preferences and EM are limited. The present study aimed to explore the causal relationships between 187 dietary preferences and EM using Mendelian randomization (MR) methods. This study utilised genome-wide association study data from over 500,000 European participants for dietary preferences and 64,658 EM patients from Finland. Dietary preferences with potential causal relationships to EM were identified using two-sample MR methods. P-values from the inverse variance weighted (IVW) analysis were corrected using the false discovery rate (FDR) method to ensure accuracy. Additionally, heterogeneity analysis, pleiotropy assessment, leave-one-out analysis, and reverse MR analysis were conducted to further validate and solidify the findings of the study. After FDR correction, IVW analysis revealed that asparagus preference was significantly protective against EM, including in American Society for Reproductive Medicine (ASRM) stages 1-2 and 3-4. Conversely, preferences for different types of coffee and orange juice were associated with an increased likelihood of EM across these stages. Subgroup analysis indicated that asparagus preference had a protective effect against deep EM, ovarian EM, pelvic peritoneal EM, and rectovaginal septum and vaginal EM. In contrast, coffee preference increased the risk of pelvic peritoneal EM, fallopian tube EM, and unspecified EM, whereas orange juice preference increased the risk of deep EM, rectovaginal septum and vaginal EM, pelvic peritoneal EM, and unspecified EM. Reverse MR analysis did not identify causal relationships between EM and the specific dietary preferences that were analysed in this study. These findings suggest that asparagus preference significantly reduces the risk of developing EM, whereas preferences for orange juice and different types of coffee may increase the risk, offering new insights into EM management through dietary modifications.

Unlocking the Potential of RNA Sequencing in COVID-19: Toward Accurate Diagnosis and Personalized Medicine

COVID-19 has caused widespread morbidity and mortality, with its effects extending to multiple organ systems. Despite known risk factors for severe disease, including advanced age and underlying comorbidities, patient outcomes can vary significantly. This variability complicates efforts to predict disease progression and tailor treatment strategies. While diagnostic and therapeutic approaches are still under debate, RNA sequencing (RNAseq) has emerged as a promising tool to provide deeper insights into the pathophysiology of COVID-19 and guide personalized treatment. A comprehensive literature review was conducted using PubMed, Scopus, Web of Science, and Google Scholar. We employed Medical Subject Headings (MeSH) terms and relevant keywords to identify studies that explored the role of RNAseq in COVID-19 diagnostics, prognostics, and therapeutics. RNAseq has proven instrumental in identifying molecular biomarkers associated with disease severity in patients with COVID-19. It allows for the differentiation between asymptomatic and symptomatic individuals and sheds light on the immune response mechanisms that contribute to disease progression. In critically ill patients, RNAseq has been crucial for identifying key genes that may predict patient outcomes, guiding therapeutic decisions, and assessing the long-term effects of the virus. Additionally, RNAseq has helped in understanding the persistence of viral RNA after recovery, offering new insights into the management of post-acute sequelae, including long COVID. RNA sequencing significantly improves COVID-19 management, particularly for critically ill patients, by enhancing diagnostic accuracy, personalizing treatment, and predicting therapeutic responses. It refines patient stratification, improving outcomes, and holds promise for targeted interventions in both acute and long COVID.

Long-term effect of Roux-en-Y gastric bypass versus sleeve gastrectomy on reflux and Barrett's oesophagus: a randomized controlled trial

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is a potentially refluxogenic operation while Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is regarded as an anti-reflux procedure. The aim of this study is to compare long-term incidence of Barrett's Oesophagus (BO) and gastroesophageal reflux disease (GORD) following LSG and LRYGB.

METHODS

Participants of a double-blinded randomized controlled trial comparing banded LRYGB and LSG for remission of type 2 diabetes were contacted to take part. A gastroscopy was performed. Primary outcome was endoscopic and histologic evidence of BO. Secondary outcomes included reflux and regurgitation scores, presence of oesophagitis, proton-pump inhibitor (PPI) usage, Body Mass Index (BMI), and percentage excess weight loss (%EWL).

RESULTS

Forty-eight of 109 patients were enrolled into the study (LSG 26 vs. LRYGB 22). Mean follow-up was 7.5 years for the LSG group, and 7.4 years for the RYGB group (P = 0.22). 8 LSG patients had BO while 3 LRYGB patients had BO (30.8%vs13.6%, P = 0.19). There was no significant difference in the mean reflux (8.1 ± 9.4(0-36) vs. 9.3 ± 8.8(0-34), P = 0.47) and regurgitation scores (7.7 ± 6.9(0-22) vs. 11.5 ± 10.5(0-44), P = 0.23) for LSG versus LRYGB patients or between those with and without BO. PPI usage before and after surgery was 6/26 (23.1%) versus 13/26 (50.0%) and 8/22 (36.4%) versus 12/22 (54.5%) for LSG and LRYGB patients respectively. PPI usage in patients with and without BO was 7/11 versus 18/37. EWL was significantly greater (P = 0.0013) in the LRYGB group (74.8 ± 28.1%) compared to LSG group (49.7 ± 18.7%).

CONCLUSIONS

Long-term incidence of BO trended towards but was not significantly higher for LSG compared to LRYGB group. We support routine endoscopic surveillance for bariatric patients.

Progress on aspiration assessment methods for patients after esophageal cancer surgery in early: A review

Esophageal cancer is a relatively common malignant tumor of the digestive tract. Patients with esophageal cancer show a high incidence of aspiration after surgery, which has a serious impact on their prognosis and rehabilitation. Nevertheless, while existing and past endeavors have concentrated on enhancing the diagnostic and therapeutic strategies for esophageal cancer, the necessity of preventing pneumonia caused by postoperative aspiration remains to be adequately addressed. We compiled the presently published literature and offer the latest developments on the causes of postoperative aspiration in patients with esophageal cancer, screening methods, and swallowing assessment tools. Relevant published papers were collected through a search of the China national knowledge infrastructure, Ovid EMBASE, Web of Science, Cochrane, and PubMed databases. There are various methods for assessing swallowing function after surgery for esophageal cancer. Clinically, it is necessary to select appropriate assessment tools for the swallowing function. Research indicates that the application of risk prediction models can better assess aspiration in patients after esophageal cancer surgery, bridge gaps in qualitative analysis, and alter the clinical outcomes of patients. Predictive models for dysphagia screening in patients after esophagectomy have significant clinical advantages and exhibit good clinical applicability.

Robotic hiatus hernia surgery: learning curve and lessons learned

New procedures like the robotic approach require proficiency to ensure patient safety and satisfactory functional results. Hiatal hernia surgery serves as a suitable training procedure for upper gastrointestinal tract surgeons transitioning to the robotic approach. This study aims to evaluate the outcomes of implementing the robotic approach in hiatal hernia surgery at a tertiary hospital and to assess the associated learning curve. A retrospective review was conducted on 54 patients (58 surgeries) between June 2019 and March 2024, including both primary and revision robotic antireflux surgeries. The study focused on perioperative outcomes, symptom resolution, and the surgical learning curve, assessed using Cumulative Sum analysis. The results showed that global surgical time averaged 124 ± 57 (54-350) min, 127 ± 38 (116-139) for Primary Surgery and 164 ± 84 (115-212) min for Revisional Surgery. There were no conversions to laparoscopic or open approach. The global median of hospital stay was 2 days (2 for Primary Surgery and 3 for Revisional Surgery) and three patients required readmission (2 for Primary Surgery and 1 for Revisional Surgery). Postoperative complications occurred in 3 patients. Symptom resolution was achieved in 90% of Primary Surgery group and 85.7% of Revisional Surgery group. Learning curve described three phases: 1-training (case 1 to 14), 2-plateau (15 to 25) and 3-expertise phase (25 onwards). The robotic approach in hiatal hernia surgery is feasible with minimal morbidity, short hospital stays, and excellent functional results. With previous experience in laparoscopic approach and esophagogastric surgery the learning curve can be reduced to 14 procedures.

Mild acute biliary pancreatitis: still a surgical disease. A post-hoc analysis of the MANCTRA-1 international study

BACKGROUND

The current standard of care for mild acute biliary pancreatitis (MABP) involves early laparoscopic cholecystectomy (ELC) to reduce the risk of recurrence. The MANCTRA-1 project revealed a knowledge-to-action gap and higher recurrence rates in patients admitted to medical wards, attributable to fewer ELCs being performed. The project estimated a 35% to 70% probability of narrowing this gap by 2025. This study evaluates the safety of suboptimal ELC implementation and identifies risk factors for recurrent acute biliary pancreatitis (RAP) in patients not undergoing ELC after an MABP episode.

METHODS

We conducted a post-hoc analysis of the MANCTRA-1 registry, including MABP patients who did not undergo ELC during the index hospitalization, excluding those with related complications. The primary outcome was the 30-day hospital readmission rate due to RAP. We performed multivariable logistic regression to find risk factors associated with the primary outcome.

RESULTS

Between January 2019 and December 2020, 1920, MABP patients from 150 centers were included in the study. The 30-day readmission rate due to RAP was 6%. Multivariable logistic regression found the admission to a medical ward (internal medicine or gastroenterology) (OR = 1.95, p = 0.001) and a positive COVID-19 test (OR = 3.08, p = 0.029) as independent risk factors for RAP.

CONCLUSION

Our analysis offers valuable insights into the management of MABP, particularly in centers where ELC cannot be fully implemented due to logistical and clinical constraints, worsened by the COVID-19 pandemic. Regardless of the admitting ward, prompt access to surgical care is crucial in reducing the risk of early recurrence, highlighting the need to implement surgical consultation pathways within MABP care bundles.

Outcomes after cystectomy in Australian rural and metropolitan hospitals by intensive care admissions

OBJECTIVES

To examine demographics and in-hospital outcomes for patients admitted to Australian intensive care units (ICUs) following cystectomy of the urinary bladder. Additionally, to compare outcomes between metropolitan and rural hospitals.

PATIENTS AND METHODS

A retrospective cohort analysis was undertaken of all adult patients admitted to participating Australian ICUs (Australian and New Zealand Intensive Care Society Adult Patient Database) following cystectomy/cystoprostatectomy between January 2011 and December 2021. The primary outcome was in-hospital mortality. Secondary outcomes were ICU and hospital length of stay.

RESULTS

Over the 10-year period, 3376 adult patients were admitted to 135 Australian ICUs after cystectomy. Of these, 3083 patients (91.3%) were treated in 106 metropolitan ICUs and 293 patients (8.7%) were treated in 29 rural ICUs. There was no difference in adjusted mortality between metropolitan and rural hospitals admitted to an ICU after cystectomy (odds ratio 1.32, 95% confidence interval 0.44-3.48; P = 0.6).

CONCLUSION

There was no difference in in-hospital mortality for cystectomy patients requiring ICU admission between metropolitan and rural hospitals. These findings may be used to inform decisions about the rural provision of cystectomy services.

Cerium oxide mimetic enzyme based colorimetric detection of potential oesophageal cancer biomarkers

Oesophageal cancer (OC) is a prevalent malignant tumor that poses a significant threat to individuals. Current mainstream detection method is endoscopy, which requires professional operators and expensive instruments. Therefore, it is crucial to develop a rapid, easy-to-operate, and low-cost detection method. In this study, an RNA colorimetric biosensor was successfully constructed using cerium oxide mimetic enzyme. The sensor is constructed on 96-well plates, which are immobilized with DNA-RNA-DNA complexes in microtiter wells when target RNA is present. This immobilization is based on the principle of base complementary pairing. The CeO2 immobilized has the unique advantage of catalyzing the bluing of 3,3',5,5'-tetramethylbenzidine (TMB) directly without the need any additional oxidant in microtiter wells. This property allows for the detection of RNA and enables the visualization of multiple sample assays. Furthermore, the RNA colorimetric sensor demonstrates good selectivity, immunity to interference, and high stability. Under optimal conditions, the sensor exhibited linearity in the range of 10-13 to 10-9 M with a detection limit of 33.26 fM. Therefore, this study presents a new detection method for oesophageal cancer screening.

Russian Consensus: Standardization of Indications for Surgical Treatment of GERD

Aim: to present the results of an Expert Consensus on standardization of indications for surgical treatment of gastroesophageal reflux disease (GERD). Materials and methods. The issues of standardization of indications for surgical treatment of GERD were discussed by 39 experts – leading gastroenterologists and surgeons from 7 cities of Russia, representing 17 institutions. The list of questions for discussion was formed by the initiative group and sent to the experts. The experts reviewed recent literature, including existing clinical guidelines and consensuses, assessed the evidence base and suggested statements for voting based on the analysis of relevant provisions of foreign consensuses, high-level scientific publications, which set out information obtained in the course of studies that meet the criteria of evidence-based medicine, positions on this issue in the Russian Federation, and suggested statements for voting. Delphi method was used to reach the consensus.Results. GERD is the most common benign esophageal disorder. Surgery is considered one of the treatment methods for GERD. In real clinical practice, selection of patients who may benefit from surgery is challenging. The results of surgical and conservative treatment of GERD are comparable. Surgical treatment should be performed in a specialized hospital only after a joint examination with a gastroenterologist confirming the diagnosis of GERD. An appropriate volume of preoperative diagnostic workup, matters related to surgical interventions in case of incomplete response to proton pump inhibitors (PPIs) and when extraesophageal manifestations of GERD are present were discussed. The consensus reviews the indications, contraindications and possible results of antireflux operations in patients with GERD. The value of endoscopy, esophageal manometry, pH monitoring/pH-impedance monitoring and X-ray polypositional examination of the upper gastrointestinal tract as a preoperative examination of the patient is analysed. Conclusions. The experts reached the consensus on 20 statements on standardization of indications for surgical treatment of GERD.

Influence of SARS-CoV2 Pandemic on Colorectal Cancer Diagnosis, Presentation, and Surgical Management in a Tertiary Center: A Retrospective Study

Background: Oncological surgery during the COVID-19 pandemic was performed only in carefully selected cases, due to variation in the allocation of resources. The purpose of this study was to highlight the impact of the pandemic lockdown on the presentation, diagnosis, and surgical management of colorectal cancers as well as the post-pandemic changes in this area. Material and methods: This single center, retrospective comparative study contained 1687 patients, divided into three groups with equal time frames of two years, consisting of a pre-pandemic, pandemic, and post-pandemic period, in which preoperative and perioperative as well as postoperative parameters were compared. Results: Statistically significant differences regarding environment, type of admission, and ASA score, as well as a more advanced tumoral stage, increased number of important postoperative complications, and a lower minimally invasive surgical approach, were highlighted within the pandemic group. Statistically significant differences regarding emergency diagnosis as well as late diagnosis were highlighted. There were no significant differences regarding the tumor location, postoperative 30-day mortality, or hospitalization duration. Conclusions: COVID-19 significantly impacted the surgical timing in colorectal cancer, as well as addressability for the rural population, with a marked decrease in elective cases as well as an increased number of cases diagnosed in an emergency setting, with locally advanced tumors. However, no significant changes in postoperative mortality or hospitalization duration were highlighted. In addition, most of the changes highlighted were reverted in the post-pandemic period. Further studies are required to observe the long-term effects in terms of morbidity and mortality, regarding the delay of diagnosis and oncological treatment.

Complicated foregut duplication cyst presenting as broncho-oesophageal fistula

Oesophageal duplication cysts are a subtype of foregut cysts, associated with the presence of ectopic gastric mucosa. Gastric acid secreted by this mucosa can lead to complications. We report one such unusual case of complication leading to the formation of broncho-oesophageal fistula in a duplication cyst. A girl in her middle childhood presented with a long-duration cough and multiple respiratory infections. On investigation, a right-sided paraoesophageal air-filled cystic lesion was identified, with a possible communication with the airway, confirmed by an oral contrast study. On further workup, a positive uptake was noted on Meckel's scan, signifying the presence of ectopic gastric mucosa. The findings were confirmed surgically and on histopathology and were consistent with a duplication cyst with broncho-oesophageal fistula. An unexplained upper respiratory tract symptomatology should mandate imaging, which would enable early detection and appropriate surgical management of such cysts in infancy and childhood.

Evaluating quality of life improvements in endometriosis patients following laparoscopic surgery using EHP-30 scale

This study aims to evaluate whether laparoscopic surgery enhances health-related quality of life (HRQoL) in endometriosis patients, utilizing the Endometriosis Health Profile-30 (EHP-30) questionnaire. The study also explores the correlations between disease severity, preoperative scores, and the subsequent changes following surgical intervention. This is a prospective observational study. Seventy women undergoing laparoscopic surgery for endometriosis at Fujian Maternity and Child Health Hospital were prospectively recruited. Each participant was assessed using the EHP-30 questionnaire both 4 weeks prior to and 3 months post-surgery to obtain preoperative and postoperative subscale scores. The Wilcoxon signed-rank test was applied to determine the statistical significance of changes in these scores. Spearman's rank correlation coefficient was employed to explore the relationships between preoperative EHP-30 scores, serum CA125 levels, and intraoperative revised American Society for Reproductive Medicine (rASRM) scores. Statistically significant correlations were further examined using multivariate linear regression analysis to adjust for potential confounders. Laparoscopic surgery resulted in a significant reduction in EHP-30 subscale scores (P ≤ 0.002), indicating a marked improvement in HRQoL among endometriosis patients. Spearman correlation analysis revealed positive correlations between preoperative serum CA125 levels (P = 0.005) and intraoperative rASRM scores with preoperative pain (P = 0.035) and sexual intercourse scores (P = 0.046). Additionally, multivariate linear regression analyses demonstrated that changes in pain scores (ΔPain), control and powerlessness (ΔControl and Powerlessness), and work life (ΔWork Life) were significantly interrelated (P < 0.01). Emotional well-being (ΔEmotional Well-being), control and powerlessness (ΔControl and Powerlessness), and work life (ΔWork Life) also exhibited significant mutual influences (P < 0.01). Furthermore, changes in social support (ΔSocial Support), self-image (ΔSelf-image), and treatment perception (ΔTreatment) were positively correlated (P < 0.01), as were changes in sexual intercourse (ΔSexual Intercourse) and concern about infertility (ΔConcern on Infertility) (P < 0.01). Laparoscopic surgery for endometriosis significantly improves HRQoL by alleviating pain and positively influencing daily functioning and emotional well-being. These findings highlight the critical role of laparoscopic surgery as an effective intervention for enhancing the quality of life in endometriosis patients.

Treatment of oesophageal and laryngo-pharyngeal symptoms of reflux in patients diagnosed with SIBO and IMO with antibiotics

Gastro-oesophageal reflux disease (GERD) may present with esophageal and/or extra-oesophageal, laryngo-pharyngeal (LPR) symptoms including cough, throat clearing and dysphonia. A definitive diagnosis can be challenging, and existing treatments are often ineffective in resolving them. Oesophageal symptoms thought to be caused by GERD can overlap with those from functional dyspepsia (FD) and previous studies have proposed intestinal dysbiosis such as small intestinal bacteria overgrowth (SIBO) and intestinal methogenic overgrowth (IMO) as potential causes. This study aims to establish the relationship between SIBO/IMO and LPR symptoms, and if their treatment improves LPR symptoms. We performed a retrospective cohort study of patients with SIBO or IMO in a high-volume, tertiary referral center for anti-reflux procedures between 2018 and 2023. The primary outcome measures were GERD-HQRL and LPR/RSI scores after treatment for SIBO/IMO, and anti-reflux medication use. Twenty-three patients were eligible. The mean decrease in GERD-HQRL score was 11.8 (3.31) (P = 0.0017). The mean decrease in RSI score was 8.57 (1.97) (P = 0.0003). In patients with raised DeMeester scores, the GERD-HQRL scores improved by 17.2 (5.02) (P = 0.009) and RSI scores by 9.33 (3.60) (P = 0.03). The symptom association probability was highest at 72.7% (n = 8) for belching; followed by 80% for heartburn (n = 4) and 66.7% for regurgitation (n = 4). The use of PPIs decreased in 95% (n = 19) of patients; 18 had stopped PPIs completely. All patients avoided potential surgical interventions. The diagnosis and treatment of SIBO in patients with atypical reflux symptoms may prevent unnecessary surgical and pharmacological treatments. Further prospective work is required to confirm this.

Immunonutrition to improve the quality of life of upper gastrointestinal cancer patients undergoing neoadjuvant treatment prior to surgery (NEOIMMUNE): double-blind randomized controlled multicenter clinical trial

BACKGROUND

Malnutrition is common with esophagogastric cancers and is associated with negative outcomes. We aimed to evaluate if immunonutrition during neoadjuvant treatment improves patient's health-related quality of life (HRQOL) and reduces postoperative morbidity and toxicities during neoadjuvant treatment.

METHODS

A multicenter double-blind randomized controlled trial (RCT) was undertaken. Included patients had untreated nonmetastatic esophagogastric tumor, aged 18 ≥ years with a life expectancy of >3 months. The study was powered for 80% power to detect a clinically relevant difference in EORTC-QLQC30 with standard deviation of 15 between groups. Primary end point was the quality of life as measured by the global health status at 30 days after surgery. An intention-to-treat analysis was employed.

RESULTS

The study was terminated at the interim analysis stage. About 300 patients were randomized: 149 to the IMPACT group and 151 to the control-formula group. Patient groups were well-balanced in terms of age, sex, body mass index, WHO performance status, and clinical tumor stage. Analysis of the primary end point for the study of global health status at 30-day postoperatively failed to show any significant differences between the groups (55.4 ± 18.6 [IMPACT] vs. 55.9 ± 19.8 [control]; P = 0.345). No significant differences between the groups were detected in the majority of domains from EORTC QLQC30 and OG25 tools after neoadjuvant therapy and 30 days postoperatively. Finally, no significant differences were seen between groups in neoadjuvant therapy or postoperative complications, or tumor response.

CONCLUSION

The results of this multicenter double-blind RCT fail to demonstrate any HRQOL benefits to the utilization of immunonutrition during neoadjuvant therapy in patients with esophagogastric cancer.

Factors influencing the cost-effectiveness of radiofrequency ablation for Barrett's esophagus with low-grade dysplasia in Australia

Endoscopic eradication therapy using radiofrequency ablation (RFA) is considered an acceptable alternative to surveillance monitoring for Barrett's esophagus with low-grade dysplasia (LGD). This study aimed to estimate whether RFA for LGD is cost-effective and to determine which factors influence cost-effectiveness. A Markov model was developed to estimate the incremental cost per quality-adjusted life year (QALY) gained for RFA compared with endoscopic surveillance. An Australian longitudinal cohort study (PROBE-NET) provides the basis of the model. Replacing surveillance with RFA yields 10 fewer cases of HGD and 9 fewer esophageal adenocarcinoma (EAC)-related deaths per 1000 patients' treatment, given on average 0.192 QALYs at an additional cost of AU$9211 (€5689; US$6262) per patient (incremental cost-effectiveness ratio AU$47,815 per QALY). The model is sensitive to the rate of EAC from LGD health state, the utility values, and the number of RFA sessions. Hence, the incremental benefit ranges from 0.080 QALYs to 0.198 QALYs leading to uncertainty in the cost-effectiveness estimates. When the cancerous progression rate of LGD falls <0.47% per annum, the cost-effectiveness of RFA becomes questionable. RFA treatment of LGD provides significantly better clinical outcomes than surveillance. The additional cost of RFA is acceptable if the LGD to EAC rate is >0.47% per annum and no more than three RFA treatment sessions are provided. Accurate estimates of the risk of developing EAC in patients with LGD are needed to validate the analyses.

Restoration of miR-200 expression suppresses proliferation and mobility of pancreatic cancer cell

A number of various human malignancies have been associated with abnormal microRNAs (miRNA) expression. There are evidence that miR-200 operates as both tumor suppressor and an onco-miR in a variety of tumors. In this study, we evaluated the effects of miR-200 on the proliferation and migration of pancreatic cancer cells, as well as the underlying molecular pathways. Clinical tissue samples were used to investigate the expression of miR-200 in pancreatic cancer and normal tissues, and the gene expression omnibus (GEO) database provided bioinformatics confirmation. Using the pCMV vector, miR-200 was transfected into PANC-1 pancreatic cancer cells. After transfection, expression of cancer-related genes (at the mRNA and protein levels) was evaluated. The miR-200-transfected pancreatic cancer cells' survival, invasion, migration, and apoptosis were also investigated. According to the bioinformatics analysis, decreased miR-200 expression was associated with a worse prognosis in pancreatic cancer patients. Moreover, low levels of miR-200 in pancreatic cancer tissues were approved. After transfection, pancreatic cancer cells exhibit a sustained increase in expression of miR-200, which inhibits cell viability, invasion, and migration. Additional investigations revealed that increasing expression of miR-200 increases the proportion of pancreatic cancer cells that endure apoptosis. Changes in the mRNA and protein expression of apoptosis- and metastasis-related genes may account for these findings. Our results indicate that miR-200 functions as a tumor suppressor in pancreatic cancer cells and that upregulating miR-200 levels may be a useful therapeutic strategy for pancreatic cancer patients to halt the progression of the illness.

Word of the Wise: A Propensity-Matched Comparative Analysis of Breast Reduction Incision Patterns on Clinical Outcomes and Quality of Life

INTRODUCTION

Breast reduction surgery addresses both functional complaints and aesthetic concerns. Two commonly used incision patterns in the US are the Wise and vertical patterns, but there are limited data comparing their clinical and quality of life (QoL) outcomes. This study evaluates and compares these outcomes between the two techniques.

METHODS

A retrospective review from 2016 to 2022 examined subjects who underwent breast reduction with either vertical or Wise incision patterns. A propensity-scored match was performed based on age, body mass index (BMI), ptosis grade, and breast tissue removal. Surgical and patient-reported outcomes (BREAST-Q) were analysed.

RESULTS

Out of 379 patients, a total of 92 breasts (46 patients) were identified after propensity-score matching, with a mean age of 30.4 years and BMI of 26.5 kg/m2. Vertical incisions were more likely to have the superomedial pedicle utilized and a larger nipple diameter. There was no significant difference in ptosis grade and tissue removal. There were no differences in clinical outcomes, aesthetic outcomes, reoperations, readmissions, or emergency room visits (p > 0.05). QoL analysis identified a significant improvement within both cohorts across domains: satisfaction with breast, psychosocial well-being, and physical well-being (p < 0.001). However, patients with the Wise pattern technique demonstrated a significant improvement in sexual well-being (p = 0.002).

CONCLUSION

Both the vertical and Wise incision patterns are safe and provide significant QoL improvements. While both techniques improve multiple QoL domains, the Wise pattern offers additional benefits in sexual well-being. These findings can guide surgeons in discussing outcomes with patients.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Esophageal Candida Infection and Esophageal Cancer Risk in Patients With Achalasia

Importance

Patients with achalasia face a higher risk of developing esophageal cancer (EC), but the surveillance strategies for these patients remain controversial due to the long disease duration and the lack of identified risk factors.

Objective

To investigate the prevalence of esophageal Candida infection among patients with achalasia and to assess the association of Candida infection with EC risk within this population.

Design, Setting, and Participants

This retrospective cohort study included patients with achalasia diagnosed at or referred for treatment and monitoring to the Erasmus University Medical Center in Rotterdam, the Netherlands, between January 1, 1980, and May 31, 2024. Data analysis was conducted from August 1 to October 31, 2024.

Exposure

Esophageal Candida infection.

Main Outcomes and Measures

The primary outcomes were the prevalence of esophageal Candida infection and its association with EC development among patients with achalasia. Associations were estimated using time-dependent Cox proportional hazards regression models with esophageal Candida infection as a time-varying covariate, adjusting for age at diagnosis and sex.

Results

This study included 234 patients with achalasia (median [IQR] age at diagnosis, 45 [32-63] years; 117 [50%] male), with a median follow-up time of 13 (4-22) years. Esophageal Candida infection was identified in 29 patients (12%), while EC was observed in 24 patients (10%). Esophageal cancer risk analysis was performed for 207 patients with 2 or more consecutive endoscopy follow-up visits (median [IQR] age at diagnosis, 43 [32-60] years; 104 [50%] male). The median (IQR) follow-up time for this subgroup was 16 (9-26) years. Among these patients, esophageal Candida infection was independently associated with an increased risk of EC (adjusted hazard ratio [AHR], 8.24 [95% CI, 2.97-22.89]). Additionally, age at diagnosis (AHR, 1.06 [95% CI, 1.03-1.10]) and male sex (AHR, 3.34 [95% CI, 1.08-10.36]) were independently associated with EC risk.

Conclusions and Relevance

This retrospective cohort study found that prior esophageal Candida infection, older age at diagnosis, and male sex were associated with increased risk of EC among patients with achalasia. These findings provide an important rationale for optimizing the monitoring of patients with achalasia.

Meta-analysis and systematic review of long-term oncological safety of immediate breast reconstruction in patients with locally advanced breast cancer

BACKGROUND

Immediate breast reconstruction (IBR) in locally advanced breast cancer (LABC) (stage 3A and above) is widely debated, both in terms of delay of adjuvant therapy and oncological safety. This study aims to systematically review and evaluate the long-term oncological safety of IBR in patients with LABC undergoing mastectomy.

METHODS

Search conducted using Medline, Embase, PubMed and Google Scholar between 1 and 24 December 2023 involving patients with LABC who underwent mastectomy with or without IBR were included. The meta-analysis included studies comparing IBR with mastectomy alone in patients with LABC with the primary outcomes of 5-year overall survival, disease-free survival and local and distant recurrence rates.

RESULTS

A total of 19,907 patients were included spanning 10 papers. Of these, 89.1% underwent mastectomy alone, while 10.9% underwent IBR (51.2% autologous and 48.8% implant-based reconstruction). The 5-year overall survival rate was higher in IBR compared to mastectomy alone (IBR n = 2038/2491 81.8%, vs. Mx only n = 7468/10,124 73.7%, RR 1.10 [95% CI 1.07-1.12], P < 0.001). No significant difference found in 5-year disease-free survival (IBR n = 510/689 74.0% vs. Mx only n = 1339/1924 69.6%, RR 1.06 [95% CI 0.98-1.15], P = 0.17), 5-year local recurrence groups (IBR n = 52/646 8.0% vs. Mx only n = 122/1708 7.1%, RR 0.80 [95% CI 0.46-1.38], P = 0.42), or 5-year distant recurrence rates (IBR n = 117/594 19.6% vs. Mx only n = 211/882 23.9%, P = 0.11).

CONCLUSION

IBR in LABC may be associated with improved overall 5-year survival rates without affecting disease-free survival or recurrence rates. Therefore, IBR may be a safe option in the treatment of LABC when considering optimal oncological outcomes.

Reshaping Our Understanding of Sensation and Pain Following Breast Reduction Surgery

Background

This study evaluated the sensory and breast pain outcomes in inferior versus superomedial pedicle breast reduction.

Methods

Twenty patients undergoing the inferior pedicle technique were matched to 20 patients undergoing the superomedial pedicle technique based on age, BMI, and resection weight. Patients were evaluated preoperatively and postoperatively at 1, 3, 6, and 12 months. Monofilament testing was performed on the nipple-areola complex (NAC) and surrounding breast. Patient-reported outcomes included nipple and breast sensation (5-point Likert scale), pain intensity (0-10), and the Patient-reported Outcome Measurement Information System Neuropathic Pain Quality scale.

Results

At the NAC, mean monofilament values and patient-reported sensation were significantly better in the inferior versus the superomedial pedicle group at 1 and 3 months postoperatively (P < 0.05) and comparable at 6 and 12 months (P > 0.05). At 12 months, 72.5% of patients reported complete (5 of 5) nipple sensation (77.5% inferior versus 67.5% superomedial, P > 0.05). At the breast, the mean monofilament values and patient-reported sensation were similar between pedicle groups throughout follow-up. At 12 months, 82.5% of the patients reported complete (5 of 5) breast sensation (85.0% inferior versus 80% superomedial, P > 0.05). Rates of postoperative breast pain were similar between groups throughout follow-up (P > 0.05). At 12 months, 25% of patients reported breast pain, with neuropathic qualities in 85% of cases.

Conclusions

The inferior pedicle may allow for earlier restoration of quantitative and patient-reported NAC sensation, but long-term sensation is comparable between techniques. A quarter of patients reported persistent breast pain regardless of the pedicle type.

Androgen Signaling in Prostate Cancer: When a Friend Turns Foe

Androgen (AR) signaling is the main signaling for the development of the prostate and its normal functioning. AR is highly specific for testosterone and dihydrotestosterone, significantly contributing to prostate development, physiology, and cancer. All these receptors have emerged as crucial therapeutic targets for PCa. In the year 1966, the Noble prize was awarded to Huggins and Hodge for their groundbreaking discovery of AR. As it is a pioneer transcription factor, it belongs to the steroid hormone receptor family and consists of domains, including DNA binding domain (DBD), hormone response elements (HRE), C-terminal ligand binding domain (LBD), and N-terminal regulatory domains. Structural variations in AR, such as AR gene amplification, LBD mutations, alternative splicing of exons, hypermethylation of AR, and co- regulators, are major contributors to PCa. It's signaling is crucial for the development and functioning of the prostate gland, with the AR being the key player. The specificity of AR for testosterone and dihydrotestosterone is important in prostate physiology. However, when it is dysregulated, AR contributes significantly to PCa. However, the structural variations in AR, such as gene amplification, mutations, alternative splicing, and epigenetic modifications, drive the PCa progression. Therefore, understanding AR function and dysregulation is essential for developing effective therapeutic strategies. Thus, the aim of this review was to examine how AR was initially pivotal for prostate development and how it turned out to show both positive and detrimental implications for the prostate.

Patient-reported outcomes, postoperative pain and pain relief after day case surgery (POPPY): methodology for a prospective, multicentre observational study

BACKGROUND

In the UK, approximately 70% of surgical procedures are undertaken as day-cases. Little information exists about recovery from day-case surgery, yet international data highlights patients are at risk of developing significant longer-term health problems including chronic post-surgical pain and persistent postoperative opioid use. The Patient-reported Outcomes, Postoperative Pain and pain relief after daY case surgery (POPPY) study was a national prospective multicentre observational study, measuring short- and longer-term patient-reported outcomes, postoperative pain and pain relief after day-case surgery.

METHODS

This was a collaborative project led by resident anaesthetists under the Research and Audit Federation of Trainees umbrella. Adult day-case surgical patients were recruited on the day of surgery. Baseline data including patient characteristics; procedure details; pre-operative analgesic use; pre-existing pain; and quality of life scores were recorded. Patients were followed up through automated short message service messages. Short-term (postoperative days 1, 3 and 7) outcomes included: quality of recovery; pain severity; impact of pain on function; and analgesic use. Longer-term outcomes (postoperative day 97) included: quality of life; analgesic use; incidence of chronic post-surgical pain; and incidence persistent postoperative opioid use. Additional outcomes were completed by those patients with chronic post-surgical pain and persistent postoperative opioid use, with 30 patients recruited to a qualitative semi-structured interview study exploring postoperative expectations, recovery, postoperative pain and opioid use.

RESULTS

An embedded pilot study at four sites recruited 129 patients. Responses to the automated short message service were gained from 129 patients (100%) at day 1; 116 (89.9%) at day 3; 108 (83.7%) at day 7; and 77 (59.7%) at day 97 postoperatively. The pilot enabled refinement of the methods and processes before the national roll out.

CONCLUSION

This paper outlines the methods for the POPPY study, the largest UK multicentre prospective observational study considering short- and longer-term outcomes following day-case surgery.

Prostate Artery Embolization in the Setting of Prostate Cancer: Review and Opinion

Prostate Artery Embolization (PAE) is a novel minimally invasive angiographic technique that has been used effectively to treat men with lower urinary tract symptoms (LUTS) from benign prostatic hyperplasia (BPH). However, applications of PAE for men with prostate cancer have been minimally studied. This review serves as an update on the status of PAE in men with prostate cancer, as well as a discussion of emerging indications.

Fundoplication at the time of paraesophageal hernia repair does not decrease the rate of hernia recurrence or postoperative reflux

BACKGROUND

Fundoplication at the time of paraesophageal hernia (PEH) repair is thought to help prevent the development or persistence of postoperative gastroesophageal reflux (GERD) and might also prevent hernia recurrence. However, the published data is not strong enough to definitively recommend this approach. This study was designed to evaluate the effectiveness and complications of a fundoplication at the time of paraesophageal hernia repair.

METHODS

This was a retrospective cohort study of all patients who underwent a paraesophageal hernia repair at a single institution over a 14 year period from 2010 to 2023. Patients were divided into 2 cohorts, those who underwent fundoplication at the time of PEH repair and those who did not. Rates of PEH recurrence, rates of reoperation for a recurrent PEH, postoperative dysphagia rates, and postoperative GERD rates were then compared between the two cohorts.

RESULTS

There were 1,155 patients included in the study. There were 610 (53%) patients who underwent PEH repair with fundoplication and 545 (47%) who did not undergo a fundoplication. 113 (19%) of the patients who underwent fundoplication developed a hernia recurrence compared to 67 (12%) who had a PEH repair alone (p = 0.004). However, each cohort had similar rates of requiring reoperation (p = 0.4). Inclusion of a fundoplication did lead to higher rates of postoperative dysphagia > 30 days postoperatively, 12% vs 7% (p = 0.002), but did not lead to decreased rates of symptomatic GERD postoperatively, 7% with a fundoplication and 7% without (p = 0.93).

CONCLUSION

In this present study, fundoplication at the time of PEH repair did not prevent hernia recurrence, need for reoperation, or decrease postoperative GERD rates but does increase postoperative dysphagia. While there are definite indications for fundoplication at the time of PEH repair (i.e., type 1 hernia), these data do not support the routine use of fundoplication during PEH repair with a normal gastroesophageal flap valve intraoperatively.

Quality of Life Following Laparoscopic Hiatal Hernia Repair and Anterior 180° Partial Fundoplication for Symptomatic Sliding Hiatal Hernia

BACKGROUND

Laparoscopic hiatal hernia repair (LHHR) is the treatment of choice for symptomatic sliding hiatal hernia. This study evaluates health-related quality of life (HRQOL) outcomes following LHHR with anterior 180° partial fundoplication.

METHODS

Forty consecutive patients underwent LHHR with anterior 180° partial fundoplication between June 2020 and December 2022. Patients were included based on one of the following criteria: persistent symptoms despite optimal medical therapy (55%), preference for a surgical solution over lifelong medication (37.5%), or complications including reflux oesophagitis/Barrett's esophagus (7.5%). HRQOL was assessed using the SF-36 questionnaire preoperatively and at 1, 6, and 12 months postoperatively.

RESULTS

Significant improvements were observed in physical functioning (66.3 ± 24.7 to 95.6 ± 7.7, p < 0.001), bodily pain (38.1 ± 28.1 to 79.2 ± 18.6, p < 0.001), general health (37.7 ± 16.2 to 66.1 ± 23.6, p < 0.001), social function (62.5 ± 23.7 to 85.6 ± 16.1, p < 0.001), and mental health (68.2 ± 21.4 to 83.7 ± 12.5, p < 0.001) at 12 months. Role limitations due to physical health improved gradually, becoming significant at 12 months (60.0 ± 45.6 to 86.9 ± 16.8, p < 0.001). Early improvements in vitality (p = 0.02) and role limitations due to emotional health (p = 0.331) showed some decline by 12 months. The median hospital stay was 3 days, with no major complications. At 1 year, 72.5% of patients were medication-free, while anatomical recurrence was observed in 7.5%. Patients with recurrence showed lower physical functioning (82.3 vs. 96.8, p = 0.02) and bodily pain scores (65.7 vs. 80.5, p = 0.04) but still demonstrated significant improvement from baseline. Body mass index, education level, age, and defect area did not influence outcomes (all p > 0.05).

CONCLUSION

LHHR with anterior 180° partial fundoplication significantly improves quality of life across multiple domains, with sustained benefits at 12 months post-surgery, particularly in physical function, pain, and social functioning. Most domains reached or surpassed population norms by 12 months, establishing this approach as an effective treatment for symptomatic sliding hiatal hernia.