Robotic transanal minimally invasive surgery (TAMIS) with the newest robotic surgical platform: a multi-institutional North American experience

BACKGROUND

Transanal minimally invasive surgery (TAMIS) offers intra-luminal full-thickness excision of rectal neoplasia. Robotic TAMIS (RT) allows for greater versatility in motion while operating in the limited space of the rectum. We present our experience with this technique in practice using the DaVinci Xi™ platform.

METHOD

This is a multi-institutional retrospective analysis for patient undergoing Robotic TAMIS for resection of rectal lesions at two tertiary referral hospitals in the United States. Morbidity, mortality, anatomic measurement, and final pathology were analyzed.

RESULTS

Thirty-four patients planned for Robotic TAMIS were identified. Average follow-up was 188 days. The average BMI was 29.5 ± 5.9. All patients had an American Society of Anesthesiologist (ASA) Class of 2 or greater and 21 (62%) were ASA 3 or greater. Rectal lesions located from 2 to 15 cm from the dentate line were successfully resected. Lesions up to 4.5 cm in the longest dimension were successfully resected. The average operative time was 100 ± 70 min, which correlated to a robotic console time of 76 ± 67 min. Patients were placed in Lithotomy in 32 (94%) cases and were prone in only 2 (6%) cases. There were no intraoperative complications or conversions to another technique. The only postoperative complication was a medically managed Clostridium difficile infection in 1 patient. Three patients were upstaged to T2 on final pathology and underwent successful formal resections. BMI was a statistically significant predictor of a longer operation.

CONCLUSIONS

With increased reach and operative range of motion, Robotic TAMIS is a safe and effective method for excising low-risk rectal neoplasia with a wide range of anatomical measurements. Higher BMI is a significant predictor of a longer and likely more challenging operation.

Postoperative Outcomes in Vedolizumab-Treated Patients Undergoing Major Abdominal Operations for Inflammatory Bowel Disease: Retrospective Multicenter Cohort Study

BACKGROUND

Vedolizumab is now widely available for the treatment of moderate to severe ulcerative colitis (UC) and Crohn's disease (CD). We sought to quantify the rates of postoperative complications with preoperative vedolizumab compared with anti-tumor necrosis factor (anti-TNF) therapy.

METHODS

A multicenter retrospective review of adult inflammatory bowel disease (IBD) patients who underwent an abdominal operation between May 20, 2014, and December 31, 2015, was performed. The study cohort was comprised of patients who had received vedolizumab within 12 weeks of their abdominal operation, and the control cohort was IBD patients who had received anti-TNF therapy.

RESULTS

A total of 146 patients received vedolizumab within 12 weeks before an abdominal operation (64% female; n = 93; median age, 33 years; range, 15-74 years), and 289 patients received anti-TNF therapy (49% female; n = 142; median age, 36 years; range, 17-73 years). Vedolizumab-treated patients were younger (P = 0.015) and were more likely to have taken corticosteroids (P < 0.01) within the 12 weeks before surgery. Vedolizumab-treated patients had a significantly increased risk of any postoperative surgical site infection (SSI; P < 0.01), superficial SSI (P < 0.01), deep space SSI (P = 0.39), and mucocutaneous separation of the diverting stoma (P < 0.00) as compared with patients taking anti-TNF therapy. On multivariate analysis, after adjusting for body mass index, steroids at the time of operation, and institution, exposure to vedolizumab remained a significant predictor of postoperative SSI (P < 0.01).

CONCLUSIONS

We observed that vedolizumab-treated patients were at significantly increased risk of postoperative SSIs after a major abdominal operation, as compared with anti-TNF-treated patients.

Assessment of the Addition of Hypoalbuminemia to ACS-NSQIP Surgical Risk Calculator in Colorectal Cancer

The aim of this study was to evaluate the benefit of adding hypoalbuminemia to the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) Surgical Risk Calculator when predicting postoperative outcomes in colorectal cancer patients.The ACS-NSQIP Surgical Risk Calculator offers qualified risk evaluation in surgical decision-making and informed patient consent. To date, malnutrition defined as hypoalbuminemia, an important independent surgical risk factor in colorectal cancer, is not included.This is a retrospective, multi-institutional study of ACS-NSQIP patients (n = 18,532) who received colorectal surgery from 2009 to 2012. Models were constructed for predicting postoperative mortality and morbidity using the risk factors of the ACS-NSQIP Surgical Risk Calculator before and after adding hypoalbuminemia as a risk factor. The 2 models' performance was then compared using c-statistics and Brier scores. The ACS-NSQIP database in 2008 was used for validation of the created models.The prevalence of hypoalbuminemia (27.8%) is higher in colorectal cancer, when compared with other most common cancers. In univariate analyses, hypoalbuminemia was significantly associated with postoperative mortality and morbidity in colorectal cancer patients. In multivariate logistic regression analyses, 15 postoperative complications, including mortality and serious morbidities, were significantly predicted by hypoalbuminemia. Most of the models with hypoalbuminemia showed better performance and validation in predicting postoperative complications than those without hypoalbuminemia.In colorectal cancer, hypoalbuminemia, with levels below 3.5 g/dL, serves as an excellent assessment tool and preoperative predictor of postoperative outcomes. When combined with hypoalbuminemia as a risk factor, the ACS-NSQIP Surgical Risk Calculator offers more accurate information and estimation of surgical risks to patients and surgeons when choosing treatment options.

Myeloid-Derived Suppressor Cells as an Immune Parameter in Patients with Concurrent Sunitinib and Stereotactic Body Radiotherapy

PURPOSE

The clinical effects of sunitinib on human myeloid-derived suppressor cell (MDSC) subsets and correlation of the T-cell-mediated immune responses and clinical outcomes in patients with oligometastases treated by stereotactic body radiotherapy (SBRT) have been evaluated.

EXPERIMENTAL DESIGN

The numbers of granulocytic and monocytic MDSC subsets, effector T cells, and regulatory T cells in the peripheral blood were evaluated pre- and post-sunitinib treatment and concurrent with SBRT. Correlations between MDSC, Treg, and T-cell responses and clinical outcomes were analyzed.

RESULTS

Patients with oligometastases of various cancer types had elevated granulocytic MDSC and certain subsets of monocytic MDSC population. Sunitinib treatment resulted in a significant reduction in monocytic MDSC, phosphorylated STAT3, and arginase levels in monocytic MDSC (CD33(+)CD14(+)CD16(+)), and an increase in T-cell proliferative activity in cancer patients. Interestingly, the effects of sunitinib on reducing the accumulation and immune-suppressive function of MDSC were significantly correlated with Treg reduction, in responders but not in nonresponding patients. SBRT synergized the therapeutic effects of sunitinib, especially as related to decreased numbers of monocytic MDSC, Treg, and B cells, and augmented Tbet expression in primary CD4 and CD8 T cells. These effects were not observed in patients receiving radiation therapy alone. Most interestingly, the responders, defined by sunitinib-mediated reduction in CD33(+)CD11b(+) myeloid cell populations, tend to exhibit improved progression-free survival and cause-specific survival.

CONCLUSIONS

Sunitinib treatment increased the efficacy of SBRT in patients with oligometastases by reversing MDSC and Treg-mediated immune suppression and may enhance cancer immune therapy to prevent tumor recurrence post-SBRT.

Immune cells: more than simple carriers for systemic delivery of oncolytic viruses

Oncolytic virotherapy on its own has numerous drawbacks, including an inability of the virus to actively target tumor cells and systemic toxicities at the high doses necessary to effectively treat tumors. Addition of immune cell-based carriers of oncolytic viruses holds promise as a technique in which oncolytic virus can be delivered directly to tumors in smaller and less toxic doses. Interestingly, the cell carriers themselves have also demonstrated antitumor effects, which can be augmented further by tailoring the appropriate oncolytic virus to the appropriate cell type. This review discusses the multiple factors that go into devising an effective, cell-based delivery system for oncolytic viruses.

Myeloid-derived suppressor cells as a vehicle for tumor-specific oncolytic viral therapy

One of the several impediments to effective oncolytic virus therapy of cancer remains a lack of tumor-specific targeting. Myeloid-derived suppressor cells (MDSC) are immature myeloid cells induced by tumor factors in tumor-bearing hosts. The biodistribution kinetics of MDSC and other immune cell types in a murine hepatic colon cancer model was investigated through the use of tracking markers and MRI. MDSCs were superior to other immune cell types in preferential migration to tumors in comparison with other tissues. On the basis of this observation, we engineered a strain of vesicular stomatitis virus (VSV), an oncolytic rhabdovirus that bound MDSCs and used them as a delivery vehicle. Improving VSV-binding efficiency to MDSCs extended the long-term survival of mice bearing metastatic colon tumors compared with systemic administration of wild-type VSV alone. Survival was further extended by multiple injections of the engineered virus without significant toxicity. Notably, direct tumor killing was accentuated by promoting MDSC differentiation towards the classically activated M1-like phenotype. Our results offer a preclinical proof-of-concept for using MDSCs to facilitate and enhance the tumor-killing activity of tumor-targeted oncolytic therapeutics.

Paired immunoglobin-like receptor-B regulates the suppressive function and fate of myeloid-derived suppressor cells

Myeloid-derived suppressor cells (MDSCs) bear characteristics of precursors for both M1 and M2 macrophages. The molecular mechanism underlying the differentiation into M1 and M2 macrophages and the relationship of this differentiation to antitumor responses remains largely undefined. Herein, we investigate the potential function of paired immunoglobulin-like receptor B (PIR-B), also known as leukocyte immunoglobulin-like receptor subfamily B member 3 (LILRB3) in MDSC differentiation, and its role in tumor-induced immunity. Our studies indicated that MDSCs genetically ablated for PIR-B (Lilrb3(-/-)) underwent a specific transition to M1-like cells when entering the periphery from bone marrow, resulting in decreased suppressive function, regulatory T cell activation activity, primary tumor growth, and lung metastases. Activation of Toll-like receptor (TLR), signal transducers, and activators of transcription 1 (STAT1), and nuclear factor-kappa B (NF-κB) signaling in Lilrb3(-/-) MDSC promoted the acquisition of M1 phenotype. Inhibition of the PIR-B signaling pathway promoted MDSC differentiation into M1 macrophages.

Combined Inhibition of Epidermal Growth Factor Receptor and Cyclooxygenase-2 as a Novel Approach to Enhance Radiotherapy

Targeting epidermal growth factor receptor (EGFR) is a promising approach to increasing radiosensitivity of head and neck cancers but treatment resistance remains an important clinical problem. We hypothesize that combined EGFR and cyclooxygenase-2 (COX-2) inhibition, using small molecule inhibitors erlotinib and celecoxib, respectively would further increase the antitumor activity of radiotherapy. The effects of combinations of celecoxib, erlotinib and ionizing radiation (IR) on cell growth, cell cycle progression and apoptosis of head and neck cancer cell lines were assessed in vitro by cell viability, clonogenic survival, flow cytometry and Annexin V assays and in vivo. The effects of celecoxib, erlotinib and IR on primary and downstream molecular targets were analyzed by immunoblotting & ELISA assays. Compared to single or double agent approaches, concurrent celecoxib, erlotinib and IR was the most effective regimen at reducing clonogenic survival, increasing apoptosis and inhibiting tumor growth in vivo. Concurrent treatment with celecoxib and erlotinib ± IR inhibited multiple prosurvival proteins including p-ERK1/2, p-EGFR, p-AKT, p-STAT3, COX-2 and PGE-2. The combination of celecoxib, erlotinib and IR is a promising strategy to overcoming resistance to combined EGFR inhibition and IR alone.

Development and function of myeloid-derived suppressor cells generated from mouse embryonic and hematopoietic stem cells

Emerging evidence suggests that myeloid-derived suppressor cells (MDSCs) have great potential as a novel immune intervention modality in the fields of transplantation and autoimmune diseases. Thus far, efforts to develop MDSC-based therapeutic strategies have been hampered by the lack of a reliable source of MDSCs. Here we show that functional MDSCs can be efficiently generated from mouse embryonic stem (ES) cells and bone marrow hematopoietic stem (HS) cells. In vitro-derived MDSCs encompass two homogenous subpopulations: CD115(+)Ly-6C(+) and CD115(+)Ly-6C(-) cells. The CD115(+)Ly-6C(+) subset is equivalent to the monocytic Gr-1(+)CD115(+)F4/80(+) MDSCs found in tumor-bearing mice. In contrast, the CD115(+)Ly-6C(-) cells, a previously unreported population of MDSCs, resemble the granulocyte/macrophage progenitors developmentally. In vitro, ES- and HS-MDSCs exhibit robust suppression against T-cell proliferation induced by polyclonal stimuli or alloantigens via multiple mechanisms involving nitric oxide synthase-mediated NO production and interleukin (IL)-10. Impressively, they display even stronger suppressive activity and significantly enhance ability to induce CD4(+)CD25(+)Foxp3(+) regulatory T-cell development compared with tumor-derived MDSCs. Furthermore, adoptive transfer of ES-MDSCs can effectively prevent alloreactive T-cell-mediated lethal graft-versus-host disease, leading to nearly 82% long-term survival among treated mice. The successful in vitro generation of MDSCs may represent a critical step toward potential clinical application of MDSCs.

Targeting immune suppressing myeloid-derived suppressor cells in oncology

Emerging data suggests that host immune cells with a suppressive phenotype represent a significant hurdle to successful therapy for metastatic cancer. Among the suppressor cells, T regulatory cells (Treg) and myeloid-derived suppressor cells (MDSC) are significantly increased in hosts with advanced malignancies. MDSC mediate the suppression of the tumor antigen-specific T cell response through the induction of T cell anergy and the development of Treg in tumor-bearing mice. These results provide robust evidence of an in vivo immunoregulatory function of MDSC in the establishment of tumor antigen-specific tolerance and the development of Treg in tumor-bearing hosts. To achieve effective anti-tumor immunity, tumor-induced immunosuppression must be reversed. Our preliminary results indicate that c-kit ligand (stem cell factor) expressed by tumor cells may be required for MDSC accumulation in tumor-bearing mice, and that blocking the c-kit ligand/c-kit receptor interaction can prevent the development of Treg and reverse immune tolerance induced by MDSC. Since c-kit can be readily inhibited by several small molecule inhibitors including imatinib, sunitinib and dasatinib, targeting immune suppressing cells can be readily accomplished in the clinic.

Admiral Lord Nelson's death: known and unknown – A historical review of the anatomy

STUDY DESIGN

Reviewing documents about Lord Admiral Nelson's wound inflicted at the Battle of Trafalgar and studying the collected data in connection with ballistics and human anatomy.

OBJECTIVES

Attempting to find out the actual cause of death of Lord Nelson as soon as 4 h postinjury by a musket ball.

SETTING

United Kingdom.

METHODS

(1) Review of the original report of Mr W Beatty, Lord Nelson's surgeon, on his examination of His Lordship's wound. (2) Investigating the course of the musket ball in connection with an atlas of human anatomy. (3) Investigating the course of the musket ball on a cadaver by RP (one of the authors). (4) Reviewing modern medical literature.

RESULTS

The report of Mr Beatty suggested that division of a large branch of the pulmonary artery was the cause of Lord Nelson's early death. Assuming the left pulmonary artery was injured, anatomical studies based on atlases and dissection on a cadaver failed to support a simple straight-line course of the musket ball that could have divided the artery and damage the spinal cord on its path forward.

CONCLUSION

The question remains open as to how the musket ball following a relatively straight-line trajectory by entering the body at the acromion, could have divided the left pulmonary artery and damaged the spinal cord later in its course. The mechanism needs further investigation.

Self-assembling protein microarrays

Protein microarrays provide a powerful tool for the study of protein function. However, they are not widely used, in part because of the challenges in producing proteins to spot on the arrays. We generated protein microarrays by printing complementary DNAs onto glass slides and then translating target proteins with mammalian reticulocyte lysate. Epitope tags fused to the proteins allowed them to be immobilized in situ. This obviated the need to purify proteins, avoided protein stability problems during storage, and captured sufficient protein for functional studies. We used the technology to map pairwise interactions among 29 human DNA replication initiation proteins, recapitulate the regulation of Cdt1 binding to select replication proteins, and map its geminin-binding domain.

[Diagnosis and operative treatment of spinal metastases]

Metastases remarkable outnumber primary tumours of the spine. Approximately 70% of all tumours of the vertebral column are metastatic. Because of high incidence, fatal consequences and difficulties of treatment they present one of the most difficult problems in spinal pathology. The main purpose of operative treatment is prevention of para- or tetraplegia and pain control to extend patient's ability for independent live. Investigations contributing to the diagnosis and operative options are considered on the basis of authors' experience.

The one bone spine: a failure of notochord/sclerotome signalling?

Three cases of extensive vertebral fusions with absent clivo-axial angle are presented. The 'bone-within-bone' appearance in two patients with almost complete fusion of the spine suggested ossification of the notochord and perinotochordal sheath. On the basis of the radiological appearances and the results of recent molecular genetic studies on vertebrate embryos, the suggested time of segmentation failure along the axis of the craniovertebral junction and between vertebrae is the third to fifth week of gestation. The possible roles of the Pax-1 gene and of signalling between notochord and sclerotome are discussed, concluding that an early defect of the notochord may be responsible for this type of failure of segmentation. Indications for surgery in these cases included cord compression with brachialgia and 'chin-on-chest' deformity causing severely restricted visual fields. A critical review of clinical lessons learned in the operative treatment is presented.

Closing wedge osteotomy with transpedicular fixation in ankylosing spondylitis

The Smith-Petersen anterior opening wedge osteotomy of the lumbar spine is currently the accepted technique for the correction of spinal deformity in ankylosing spondylitis. It has a mortality of 10%, uses force, is uncontrolled, and fixation is often feeble. The authors have devised a posterior closing wedge with transpedicular fixation. This technique is controlled, comparatively safe, and provides secure fixation. The procedure is a relatively safe and reliable means of dealing with a dangerous operation.

Segmental spinal instrumentation using short closed wire loops

The Luque technique of segmental sublaminar instrumentation is now an established method of internal fixation in spinal surgery. The major difficulty encountered with the current technique is the danger of neurologic injury during the passage and handling of conventional wires, especially in extensive procedures. Great care is required to prevent inadvertent percussion of the wires already passed. The authors believe that by using short closed wire loops, these dangers have been minimized. Simple additional instrumentation has been devised to facilitate application of these loops. Apart from ease of application and handling, the short wire loops may offer a safer method of segmental sublaminar fixation.

Painful scoliosis secondary to an osteoid osteoma of the rib

A 14-year-old girl with painful scoliosis was found to have an osteoid osteoma involving the body of the left seventh rib. Excision of the tumor was facilitated by intraoperative bone scanning that precisely located its position. Following surgery, preoperative pain was completely relieved and the spinal curvature had partially regressed. The importance of early diagnosis and excision of tumors is emphasized to prevent the establishment of a permanent structural scoliosis.

Lumbar vertebral canal morphometry for computerised tomography in spinal stenosis

Computerised tomography is described in recent literature as a sophisticated but noninvasive technique with a particularly appropriate application in the discovery of space-occupying lesions in the lumbar vertebral canal and nerve root tunnels. Although the spinal stenosis syndrome must remain a clinical diagnosis in the first instance, computerised tomography is expected to play an increasing role in confirming the presumptive diagnosis of developmental or degenerative spinal stenosis, and in confirming the presence of a trefoil configuration or narrow lateral recess. However, the diagnosis of spinal stenosis on computerised tomography is impossible unless dimensions can be compared with established ranges of normal. The morphometry of a large sample of human skeletons of both sexes, in two race groups, and for each of the five lumbar vertebral levels, is intended to provide this information.

The trefoil configuration of the lumbar vertebral canal. A study of South African skeletal material

The shallow lateral recesses of the trefoil shape of the lumbar spinal canal have been implicated in the production of the spinal stenosis syndrome. In the present study, 485 skeletons of South African Blacks and Whites were examined in order to establish the incidence and possible genesis of the trefoil configuration. The overall incidence was 14 per cent, with little variation between the sexes or races. The incidence was not related to increasing age, measured stenosis of the spinal canal or osteophytosis. Of 74 trefoil-shaped vertebrae, 68 (92 per cent) were found at the fifth lumbar level. It is suggested that the trefoil configuration is a common non-pathological condition, usually of the fifth lumbar vertebral canal, and is probably a developmental variation of normal anatomy.

Spondylolysis. A skeletal investigation of two population groups

The lumbar spines of 485 skeletons of adult South African "Whites" and "Blacks" of both sexes were examined to determine the incidence and morphology of defects in the pars interarticularis. The overall incidence was 3.5%, without significant variation between races and sexes. The incidence of lumbar spina bifida in the whole sample was 1.9%, but was 11.8% in those skeletons with spondylolysis. Some instances of unilateral spondylolysis demonstrated obvious callus formation, suggesting a capability for normal repair. It is possible that the defects in bilateral cases represent established non-union of fractures of the pars interarticularis resulting from excessive mobility, and are not due to dysplasia of bone. It is noted, for the first time, that the superior facets of affected vertebrae are abnormally enlarged, and that the inferior facets of the separate neural arch are characteristically elliptical.

The morphometry and pathological anatomy of the lumbar spine in South African negroes and caucasoids with specific reference to spinal stenosis

Direct measurements were made on 2,166 lumbar vertebrae of 433 adult negro and caucasoid skeletons. On statistical analysis, forty-five vertebrae in twenty-seven skeletons were found to be stenotic, the mid-sagittal diameter being the significantly reduced dimension. Whereas spinal stenosis syndromes are rare in South African negroes, the lumbar canal is marginally narrower in the negro. There is a uniformity of configuration and capacity of the lumbar spinal canal, which transcends race and sex. By a new method of determining the dorsal limit of the lumbar canal on lateral plain radiography, the overall average lower limit of normal of the mid-sagittal diameter is established at 15 millimetres, and of the transverse diameter 20 millimetres. Bony degenerative changes are more likely to cause neurological compression in the nerve root tunnel than in the spinal canal. The role of skeletal narrowing of the spinal canal as an exclusive cause of the spinal stenosis syndrome may have been exaggerated.

Chylothorax: a complication of Dwyer's anterior instrumentation

The authors report the development of an extensive right chylothorax several days after Dwyer's anterior instrumentation in a 6-year-old girl with a severe progressing infantile scoliosis. Instrumentation extended from T11 to L4 with removal of the tenth rib and with splitting of the diaphragm. The postoperative course was initially without any problems. However, respiratory distress on the tenth day after surgery was accompanied by mediastinal shift and the symptoms were relieved with aspiration of 600 ml of chyle from the right pleural cavity. The literature on this complication of chylothorax is reviewed; it has been observed in cardiothoracic surgery. The management of the case is reported in detail and methods of detection and treatment are discussed.

Measurements of the lumbar spinal canal in 2 racial groups

Direct measurements of 1,340 lumbar vertebrae in 275 skeletons in two racial groups are reported. The average figure, and the upper and lower limits of normal are reported for the anteroposterior diameter of the canal and for Spinal Index. Radiological studies have established a technique for defining the posterior margin of the spinal canal on plain X-ray films. It is formed by a line joining the apex of the superior to the inverted apex of the inferior articular facet. The Spinal Index is not a reliable factor. The anteroposterior diameter alone is the essential parameter in assessing spinal stenosis. The negroid canal is marginally less spatial than that of the caucasoid.