Systematic review and meta-analysis of published trials comparing the effectiveness of transanal endoscopic microsurgery and radical resection in the management of early rectal cancer

AIM

A systematic analysis was conducted of trials comparing the effectiveness of transanal endoscopic microsurgery (TEMS) with radical resection (RR) for T1 and T2 rectal cancer.

METHOD

An electronic search was carried out of trials reporting the effectiveness of TEMS and RR in the treatment of T1 and T2 rectal cancers.

RESULTS

Ten trials including 942 patients were retrieved. There was a trend toward a higher risk of local recurrence (odds ratio 2.78; 95% confidence interval 1.42, 5.44; z = 2.97; P < 0.003) and overall recurrence (P < 0.01) following TEMS compared with RR. The risk of distant recurrence, overall survival (odds ratio 0.90; 95% confidence interval 0.49, 1.66; z = 0.33; P = 0.74) and mortality was similar. TEMS was associated with a shorter operation time and hospital stay and a reduced risk of postoperative complications (P < 0.0001). The included studies, however, were significantly diverse in stage and grade of rectal cancer and the use of neoadjuvant chemoradiotherapy.

CONCLUSION

Transanal endoscopic microsurgery appears to have clinically measurable advantages in patients with early rectal cancer. The studies included in this review do not allow firm conclusions as to whether TEMS is superior to RR in the management of early rectal cancer. Larger, better designed and executed prospective studies are needed to answer this question.

Use of antibiotic prophylaxis in elective inguinal hernia repair in adults in London and south-east England: a cross-sectional survey

Purpose

Evidence regarding whether or not antibiotic prophylaxis is beneficial in preventing post-operative surgical site infection in adult inguinal hernia repair is conflicting. A recent Cochrane review based on 17 randomised trials did not reach a conclusion on this subject. This study aimed to describe the current practice and determine whether clinical equipoise is prevalent.

Methods

Surgeons in training were recruited to administer the Survey of Hernia Antibiotic Prophylaxis usE survey to consultant-level general surgeons in London and the south-east of England on their practices and beliefs regarding antibiotic prophylaxis in adult elective inguinal hernia repair. Local prophylaxis guidelines for the participating hospital sites were also determined.

Results

The study was conducted at 34 different sites and received completed surveys from 229 out of a possible 245 surgeons, a 93 % response rate. Overall, a large majority of hospital guidelines (22/28) and surgeons’ personal beliefs (192/229, 84 %) supported the use of single-dose pre-operative intravenous antibiotic prophylaxis in inguinal hernia repair, although there was considerable variation in the regimens in use. The most widely used regimen was intravenous co-amoxiclav (1.2 g). Less than half of surgeons were adherent to their own hospital antibiotic guidelines for this procedure, although many incorrectly believed that they were following these.

Conclusion

In the south-east of England, there is a strong majority of surgical opinion in favour of the use of antibiotic prophylaxis in this procedure. It is therefore likely to be extremely difficult to conduct further randomised studies in the UK to support or refute the effectiveness of prophylaxis in this commonly performed procedure.

Quantification of non-specific binding of magnetic micro- and nanoparticles using cell tracking velocimetry: Implication for magnetic cell separation and detection

The maturation of magnetic cell separation technology places increasing demands on magnetic cell separation performance. While a number of factors can cause sub-optimal performance, one of the major challenges can be non-specific binding of magnetic nano- or microparticles to non-targeted cells. Depending on the type of separation, this non-specific binding can have a negative effect on the final purity, the recovery of the targeted cells, or both. In this work, we quantitatively demonstrate that non-specific binding of magnetic nanoparticles can impart a magnetization to cells such that these cells can be retained in a separation column and thus negatively impact the purity of the final product and the recovery of the desired cells. Through experimental data and theoretical arguments, we demonstrate that the number of MACS magnetic particles needed to impart a magnetization that is sufficient to cause non-targeted cells to be retained in the column to be on the order of 500-1,000 nanoparticles. This number of non-specifically bound particles was demonstrated experimentally with an instrument, cell tracking velocimeter, CTV, and it is demonstrated that the sensitivity of the CTV instrument for Fe atoms contained in magnetic nanoparticles on the order of 1 x 10(-15) g/mL of Fe.

Novel monoclonal antibody that enhances natural killer (NK) cell cytotoxicity against multiple myeloma (MM): Preclinical data and interim phase I clinical trial results

3032

Background: MM is increasing in incidence and remains incurable. NK cells have modest killing activity against MM cells in part because of inhibitory signals from HLA class 1 antigens which act via the KIR receptors on NK cells. A novel anti-KIR blocking antibody (1–7F9 named IPH 2101) enhances patient NK cell cytotoxicity against autologous MM tumor cells in vitro and appears safe in an ongoing phase 1 clinical trial. Methods: NK cells from healthy controls or patients were pre-treated with IPH 2101 or IgG4 isotype control and co-cultured with MM cell lines or autologous MM tumor targets. NK cell production of interferon-gamma (IFN-γ) or granzyme B (GrB) were measured by ELISPOT. An open-label, single-agent, phase 1 dose escalation study of IPH 2101 is being conducted in patients with relapsed/refractory MM. KIR binding, pharmacokinetics, pharmacodynamics, effects on NK cell maturation, and biological effects of IPH 2101 are being monitored in all patients. Results: At an effector to target (E:T) ratio of 1:1, IPH 2101 significantly enhances NK cell IFN-γ release against MM targets (mean 33 spots/well ± 12, SEM vs. 11 ± 0.3, p = 0.005). At an E:T ratio of 10:1, IPH 2101 enhances NK cell cytotoxicity, by GrB release, of patient NK cells against autologous MM tumor cells (mean 111 spots/well ± 14, SEM vs 56 ± 10, p = 0.002). By Western blot, IPH 2101 may reduce levels of src, a kinase known to be involved in inhibitory KIR signaling. Dose escalation in the phase 1 study has been completed from 0.0003 mg/kg to 0.075 mg/kg in 14 evaluable patients. At the highest dose tested, KIR occupancy has been detected at a mean 95% ± 1.4 at 2 hours post dose, lasting up to 56% ± 18 during 2 weeks post dose. At this dose level, PK data show good correspondence with previous modeling activity. No deleterious effect on NK cell maturation has been seen. IPH 2101 has been well tolerated to date. Conclusions: IPH 2101 improves autologous NK cell killing of MM tumor cells by blocking inhibitory KIR. In the ongoing clinical trial, the antibody appears safe and well tolerated at the doses tested. This immunotherapeutic approach may hold promise as treatment for MM and further study is warranted.

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Treatment of Alhagi Residues with Tartaric Acid for the Removal of Zn(II) Ions from Aqueous Solution

Alhagi cellulose tartrate (ACT) with a high carboxyl group content was prepared by treatment of Alhagi residues (AR) with tartaric acid (TA) at high temperature. Factors influencing the reaction were investigated, viz. tartaric acid concentration, dehydration temperature, particle size and dehydration time. The prepared Alhagi cellulose tartrate samples were characterized using FT-IR spectroscopy and by estimation of the carboxyl group content. The esterified samples were utilized for the adsorptive removal of Zn(II) ions from aqueous solution with all the factors influencing the process being studied. These factors were the pH value of the adsorbate solution, the adsorbent concentration, agitation time and temperature.

The Langmuir and Freundlich models were applied to the data obtained from the adsorption studies. It was demonstrated that the Alhagi cellulose tartrate samples could be used effectively for the adsorption of Zn(II) ions from aqueous solutions. The thermodynamics constants of the adsorption process, viz. ΔH0, ΔS0 and ΔG0, were evaluated. The results showed that the adsorption of Zn(II) ions onto ACT was exothermic and spontaneous. The adsorption data followed second-order kinetics, with the equilibrium data being only satisfactorily described by the Langmuir isotherm.

Therapy-related myelodysplasia and leukemia occur infrequently following VP-16 priming and autotransplantation without total body irradiation

The use of VP-16 for stem cell mobilization has been cited as a significant risk factor for the development of therapy-related myelodysplasia/leukemia (tMDS/tAML) following autologous transplantation. The present study analyzed a large cohort of patients who underwent autotransplantation following stem cell mobilization with VP-16 and radiation-free preparation in order to determine the risk of tMDS/tAML. The estimated incidence of 9.9% at 7 years suggests that in the absence of TBI, VP-16 priming is not associated with an increased incidence of tMDS/tAML.

Cubital tunnel syndrome. Treatment by decompression without transposition of ulnar nerve

Cubital tunnel syndrome is the second most common entrapment neuropathy in the upper limb; however, surgical treatment of the ulnar nerve entrapment at the elbow remains controversial. None of the presently advocated procedures (simple decompression of the ulnar nerve, medial epicondylectomy, subcutaneous, submuscular or intramuscular anterior transposition of the ulnar nerve) has proven optimal regarding long-term results. This paper presents the experience of treating cubital tunnel syndrome with simple decompression in 40 patients. Three months after surgery 23/36 patients did not feel any pain in their operated hands. In 11/36 cases we observed an improvement of preoperative pain. Sensory disturbances disappeared completely in 24/40 cases. 11/40 patients reported an improvement of preoperative dysesthesia or hypesthesia. In 12/22 patients we observed complete recovery of preoperative pareses of adductor muscle of thumb or hypothenar muscles weakness. 7/22 cases demonstrated an improvement of these pareses. In total 28 patients (70 %) had an excellent outcome without residual symptoms. For 5 patients treatment results were classified as good with slight residual pain and sensory disturbance (12.5 %). In 4 cases (10 %) we only observed a fair outcome with persistent severe sensory and motor deficits but slow improvement over the last three months. Three patients did not demonstrate any improvement (7.5 %). The mean duration of postoperative disablement in our working patients (18/40) was 28 days. In summary, simple decompression of the ulnar nerve seems to be an adequate and successful minimally invasive technique for the treatment of cubital tunnel syndrome.

Stereotactic biopsies guided by an optical navigation system: technique and clinical experience

Frame-based stereotactic biopsies are time-consuming procedures making necessary head fixation in a ring, explicit coordinate calculation and setting of the parameters. Frameless systems make many of these intermediate steps unnecessary, impose less mechanical restrictions regarding access to the lesions, and with slight modifications can be used to perform stereotactic biopsies. A special adaptation designed to fix the holder and the biopsy instrument is described. The neuronavigation optical tracking system of Radionics was used. CT scans were performed with 6 skin markers. Calibration was performed after head fixation in the Mayfield clamp. Mean calibration error was 2.19 +/- 0.81 mm. The light-emitting diode holder of the pointer was fixed into 2 Leila arms and moved under visual control based on CT images. The target point was selected, Leila arms fixed and a burr hole performed. The cannula was introduced to the target, being fitted with a depth stop in a length identical to that of the pointer on the screen. If necessary a second trajectory was easily selected. 49 patients underwent a frameless stereotactic biopsy. All targets except seven were superficial or in the white matter. In selected cases the biopsies were taken from deep-seated lesions. A histological diagnosis was obtained in 100 % of the cases. Four cases deteriorated postoperatively, two of these related to intratumoral bleeding. Navigation is a simple and effective method to perform biopsies of superficial and relatively large lesions. Frame-based procedures are restricted to brainstem tumors and lesions less than 1.5 cm in diameter.

Gastric perforation in a case of gastric volvulus

We describe a case of organoaxial gastric volvulus in which the axis was through the body of the stomach. The intraabdominal part of the volvulus was complicated by bleeding from two necrotic ulcers, one of which was perforated by the tip of a nasogastric tube.