Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

Cost Analysis of Laparoscopic Low Anterior Resection vs. Transanal Endoscopic Microsurgery for Rectal Neoplasms

Despite the increasing application of transanal endoscopic microsurgery (TEM) for rectal lesions, the cost of the equipment may play a role in a hospital's hesitancy to invest in the platform. This study compares the cost of TEM to laparoscopic low anterior resection (LAR). Patients who underwent laparoscopic LAR (n = 24) for rectal neoplasm between 2006 and 2014 were case-matched based on sex, age, comorbidities, lesion size and location to patients who underwent TEM at a busy secondary care urban hospital. Procedure-related costs and costs associated with readmissions for complications and related subsequent surgeries in the first 3 years were calculated. There were 42 hospital admissions for 24 LAR patients, totalling 326 hospital days. For 24 TEM patients, there were 25 hospital admissions, totalling 56 hospital days. Subsequent operations for LAR patients included 2 washout and diverting ileostomies (8%), 2 adhesionolysis (8%), 4 ventral hernia repairs (16%) and 11 ileostomy reversals (46%). In the TEM group, there was one operation for recurrence (4%). The mean cost of LAR, including all related hospital costs in the subsequent 3 years, was CAD 14,851 (95% CI: CAD 10,124-19,579). The mean cost of TEM was CAD 2449 (95% CI: CAD 2133-2767; p < 0.0001), with a savings of CAD 12,402 per patient. TEM for rectal neoplasm is associated with significantly lower hospital costs, which far outweigh the costs of acquiring and maintaining the technology.

Sarcopenia is associated with toxicity in patients undergoing neo-adjuvant chemotherapy for oesophago-gastric cancer

BACKGROUND

Patients with potentially curative oesophago-gastric cancer typically undergo neo-adjuvant chemotherapy prior to surgery. The majority of anti-cancer drugs have a narrow therapeutic index. The aim of this study was to determine if features of body composition, assessed using computed tomography (CT) scans, may be predictive of dose-limiting toxicity (DLT) in patients undergoing neo-adjuvant chemotherapy for oesophago-gastric cancer. The influence of sarcopenia and DLT on overall survival was also evaluated.

METHODS

89 Patients having potentially curative oesophago-gastric cancer surgery were studied. Patients studied had histologically confirmed oesophago-gastric cancer with no evidence of distant metastasis on pre-operative staging. CT scan was performed in all cases at diagnosis. DLT was defined as toxicity leading to postponement of treatment, a drug dose reduction or definitive interruption of drug administration.

RESULTS

DLT occurred in 37 out of 89 patients (41.6%) undergoing chemotherapy. Sarcopenia (odds ratio, 2.95; 95% confidence interval, 1.23-7.09; p = 0.015) was associated with DLT on multivariate analysis. Median overall survival for patients who were sarcopenic was 569 days (IQ range: 357-1230 days) vs. 1013 days (IQ range: 496-1318 days) for patients who were not sarcopenic (p = 0.04). There was no significant difference in overall survival in patients who experienced DLT compared with those that did not (p = 0.665).

CONCLUSIONS

Sarcopenia is a significant predictor of DLT in oesophago-gastric cancer patients undergoing neo-adjuvant chemotherapy. These results raise the potential for use of assessment of skeletal muscle mass using CT scans to predict toxicity and individualize chemotherapy dosing.

Abstract C75: CYP2S1 and CYP2W1 mediate 2-(3,4-dimethoxyphenyl)-5-fluorobenzothiazole (GW610, NSC 721648) sensitivity in breast and colorectal cancer cells

Phortress, the lysylamide prodrug of 2-(4-amino-3-methylphenyl)-5-fluorobenzothiazole (5F203, NSC 703786) is under clinical evaluation. CYP1A1-catalyzed bioactivation of 5F203 is crucial for antitumor activity. 2-(3,4-Dimethoxyphenyl)-5-fluorobenzothiazole (GW610, NSC 721648) is a structurally related experimental antitumor agent. In order to understand the mechanism of action of GW610, we investigated roles of cytochrome P450 enzymes CYP2S1 and CYP2W1 in mediating benzothiazoles activity. Stable isogenic breast (MCF-7, MDA-MB-468) and colorectal (HCC2998, KM12) cancer cell lines depleted for CYP1A1, CYP2S1 or CYP2W1 were generated. The sensitivity of these cells to 5F203 and GW610 was compared with vector control cells.

5F203 exhibited potent activity against breast cancer cells, whereas GW610 was effective against both breast and colorectal carcinoma cells.

CYP1A1 was induced in breast and colon cancer cells, whereas induction of CYP2S1 and CYP2W1 was observed in breast cancer cells only following treatment with 5F203 or GW610. Depletion of CYP1A1 abrogated 5F203 and GW610 activity; in contrast, CYP2S1 depletion enhanced sensitivity of breast and colon cancer cells to 5F203 and GW610. Intriguingly, CYP2W1 knockdown caused marked resistance to GW610 in HCC2998 (&gt;7-fold) and KM12 (&gt;90-fold) colorectal cancer cells only.

CYP2S1 and CYP2W1 mediate 2-(3,4-dimethoxyphenyl)-5-fluorobenzothiazole (GW-610, NSC 721648) sensitivity in breast and colorectal cancer cells

Both 2-(4-amino-3-methylphenyl)-5-fluorobenzothiazole (5F-203; NSC 703786) and 2-(3,4-dimethoxyphenyl)-5-fluorobenzothiazole (GW-610; NSC 721648) are antitumor agents with novel mechanism(s). Previous studies have indicated that cytochrome (CYP) P450 1A1 is crucial for 5F-203 activity. In the present study, we investigated the functional role of 2 newly identified CYP P450 enzymes, CYP2S1 and CYP2W1, in mediating antitumor activity of benzothiazole compounds. We generated isogenic breast cancer (MDA-MB-468, MCF-7) and colorectal cancer (CRC; KM12 and HCC2998) cell lines depleted for CYP1A1, CYP2S1, or CYP2W1. The sensitivity of these cells to 5F-203 and GW-610 was then compared with vector control cells. 5F-203 exhibited potent activity against breast cancer cells, whereas GW-610 was effective against both breast and colorectal cancer cells. CYP1A1 was induced in both breast cancer and CRC cells, while CYP2S1 and CYP2W1 were selectively induced in breast cancer cells only following treatment with 5F-203 or GW-610. Depletion of CYP1A1 abrogated the sensitivity of breast cancer and CRC cells to 5F-203 and GW-610. Although depletion of CYP2S1 sensitized both breast cancer and CRC cells toward 5F-203 and GW-610, CYP2W1 knockdown caused marked resistance to GW-610 in CRC cells. Our results indicate that CYP-P450 isoforms, with the exception of CYP1A1, play an important role in mediating benzothiazole activity. CYP2S1 appears to be involved in deactivation of benzothiazoles, whereas CYP2W1 is important for bioactivation of GW-610 in CRC cells. Because CYP2W1 is highly expressed in colorectal tumors, GW-610 represents a promising agent for CRC therapy.

Indoor air quality risk factors for severe lower respiratory tract infections in Inuit infants in Baffin Region, Nunavut: a pilot study

Inuit infants have extremely high rates of lower respiratory tract infection (LRTI), but the causes for this are unclear. The aims of this study were to assess, in young Inuit children in Baffin Region, Nunavut, the feasibility of an epidemiologic study of the association between indoor air quality (IAQ) and respiratory health; to obtain data on IAQ in their housing; and to identify and classify risk factors for LRTI. Twenty houses in Cape Dorset, Nunavut with children below 2 years of age, were evaluated using a structured housing inspection and measurement of IAQ parameters, and a respiratory health questionnaire was administered. Twenty-five percent of the children had, at some time, been hospitalized for chest illness. Houses were very small, and had a median of six occupants per house. Forty-one percent of the houses had a calculated natural air change rate <0.35 air changes per hour. NO(2) concentrations were within the acceptable range. Smokers were present in at least 90% of the households, and nicotine concentrations exceeded 1.5 microg/m(3) in 25% of the dwellings. Particulates were found to be correlated closely with nicotine but not with NO(2) concentrations, suggesting that their main source was cigarette smoking rather than leakage from furnaces. Mattress fungal levels were markedly increased, although building fungal concentrations were low. Dust-mites were virtually non-existent. Potential risk factors related to IAQ for viral LRTI in Inuit infants were observed in this study, including reduced air exchange and environmental tobacco smoke exposure. Severe lower respiratory tract infection is common in Inuit infants. We found reduced air change rates and high occupancy levels in houses in Cape Dorset, which may increase the risk of respiratory infections. This suggests the measures to promote better ventilation or more housing may be beneficial. Further health benefits may be obtained by reducing bed sharing by infants and greater turnover of mattresses, which were found to have high levels of fungi.

Preoperative fasting for preventing perioperative complications in children

BACKGROUND

Children, like adults, are required to fast before general anaesthesia with the aim of reducing the volume and acidity of their stomach contents. It is thought that fasting reduces the risk of regurgitation and aspiration of gastric contents during surgery. Recent developments have encouraged a shift from the standard 'nil-by-mouth-from-midnight' fasting policy to more relaxed regimens. Practice has been slow to change due to questions relating to the duration of a total fast, the type and amount of intake permitted.

OBJECTIVES

To systematically assess the effects of different fasting regimens (duration, type and volume of permitted intake) and the impact on perioperative complications and patient wellbeing (aspiration, regurgitation, related morbidity, thirst, hunger, pain, comfort, behaviour, nausea and vomiting) in children.

SEARCH STRATEGY

We searched Cochrane Wounds Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL, the National Research Register, relevant conference proceedings and article reference lists and contacted experts.

SELECTION CRITERIA

Randomised and quasi randomised controlled trials of preoperative fasting regimens for children were identified.

DATA COLLECTION AND ANALYSIS

Data extraction and trial quality assessment was conducted independently by two authors. Trial authors were contacted for additional information including adverse events.

MAIN RESULTS

Forty-three randomised controlled comparisons (from 23 trials) involving 2350 children considered to be at normal risk of regurgitation or aspiration during anaesthesia. Only one incidence of aspiration and regurgitation was reported. Children permitted fluids up to 120 minutes preoperatively were not found to experience higher gastric volumes or lower gastric pH values than those who fasted. The children permitted fluids were also less thirsty and hungry, better behaved and more comfortable than those who fasted. Clear fluids preoperatively did not result in a clinically important difference in the children's gastric volume or pH. Evidence relating to the preoperative intake of milk was sparse. The volume of fluid permitted during the preoperative period did not appear to impact on children's intraoperative gastric volume or pH contents.

AUTHORS' CONCLUSIONS

There is no evidence that children who are not permitted oral fluids for more than six hours preoperatively benefit in terms of intraoperative gastric volume and pH over children permitted unlimited fluids up to two hours preoperatively. Children permitted fluids have a more comfortable preoperative experience in terms of thirst and hunger. This evidence applies only to children who are considered to be at normal risk of aspiration/regurgitation during anaesthesia.

Effect of granulocyte-macrophage colony-stimulating factor on candidacidal activity of neutrophils, monocytes or monocyte-derived macrophages and synergy with fluconazole

The effect of in-vitro granulocyte-macrophage colony-stimulating factor (GM-CSF) treatment of neutrophils, monocytes or monocyte-derived macrophages (MDM) on candidacidal activity was tested. Synergy of effector cells with fluconazole (FCZ) for enhanced killing was also investigated. Incubation of neutrophils with GM-CSF 0.67 microg/L plus Candida albicans Sh27 for 24 h significantly increased candidacidal activity (36% versus 74%). Synergy with FCZ for killing was also significantly increased from 93% to 97% when neutrophils were incubated with GM-CSF. Monocytes cultured with GM-CSF and C. albicans for 24 h had significantly increased fungistatic activity compared to controls and synergy with FCZ for killing was significantly enhanced from 40% to 59%. Monocytes cultured for 3 days with GM-CSF had increased fungistatic activity compared to control MDM and showed synergy with FCZ for significantly enhanced killing (46%) compared to control MDM (12%).