Acute colonic pseudo-obstruction post-cesarean section is not a benign entity: A case series and review of the literature

Acute colonic pseudo-obstruction (ACPO) is an infrequent occurrence after cesarean section. Anecdotal evidence suggests that the clinical course of ACPO in the obstetric setting is different to that seen in non-pregnant adult patients with ACPO secondary to alternative causes, such as systemic illnesses, the use of certain medications, and after non-abdominal surgery. The risk of progression to ischemia and perforation, as well as the need for emergency surgery, appears to be higher after cesarean section. Here we describe the clinical course of ACPO in four patients after cesarean section from our institution, followed by a review of the literature and a discussion of the important issues surrounding this condition in the postpartum time period. The findings from our cohort of patients and the reports from the medical literature support a hands-on combined approach from a group of specialists including obstetricians, surgeons, radiologists, and enterostomal therapists. Immediate imaging followed by regular observation is mandatory for any patient being managed conservatively. Early use of endoscopic decompression should be considered for patients who are not resolving with a conservative approach. Clinical signs of peritonism or radiological signs of ischemia or perforation in patients with ACPO mandate immediate surgical intervention. Appropriate postoperative care is necessary to deal with the complex physiological and psychological consequences of emergency surgery and potential stoma formation so soon after cesarean section.

Multidisciplinary Surgical Approach to Increase Survival for Advanced Ovarian Cancer in a Tertiary Gynaecological Oncology Centre

PURPOSE

The purpose of this paper is to report on changes in overall survival, progression-free survival, and complete cytoreduction rates in the 5-year period after the implementation of a multidisciplinary surgical team (MDT).

METHODS

Two cohorts were used. Cohort A was a retrospectively collated cohort from 2006 to 2015. Cohort B was a prospectively collated cohort of patients from January 2017 to September 2021.

RESULTS

This study included 146 patients in cohort A (2006-2015) and 174 patients in cohort B (2017-2021) with FIGO stage III/IV ovarian cancer. Median follow-up in cohort A was 60 months and 48 months in cohort B. The rate of primary cytoreductive surgery increased from 38% (55/146) in cohort A to 46.5% (81/174) in cohort B. Complete macroscopic resection increased from 58.9% (86/146) in cohort A to 78.7% (137/174) in cohort B (p < 0.001). At 3 years, 75% (109/144) patients had disease progression in cohort A compared with 48.8% (85/174) in cohort B (log-rank, p < 0.001). Also at 3 years, 64.5% (93/144) of patients had died in cohort A compared with 24% (42/174) of cohort B (log-rank, p < 0.001). Cox multivariate analysis demonstrated that MDT input, residual disease, and age were independent predictors of overall (hazard ratio [HR] 0.29, 95% confidence interval [CI] 0.203-0.437, p < 0.001) and progression-free survival (HR 0.31, 95% CI 0.21-0.43, p < 0.001). Major morbidity remained stable throughout both study periods (2006-2021).

CONCLUSIONS

Our data demonstrate that the implementation of multidisciplinary-team, intraoperative approach allowed for a change in surgical philosophy and has resulted in a significant improvement in overall survival, progression-free survival, and complete resection rates.

On combining the beam path of similar wavelength lasers for dual-laser Thomson scattering

A novel method for the path combination of two lasers with very similar wavelengths has been implemented to enable the evaluation of a dual-laser calibration Thomson scattering (TS) technique. The first experimental test of this TS technique has been performed in a RFX-mod plasma device, where, due to experimental constraints, the combination of a Nd:YAG (λ = 1064 nm) and a Nd:YLF (λ = 1053 nm) laser system was the only viable choice available. The method requires that the beam path of both lasers be combined into a single path with the same polarization. This presents a unique challenge due to the small difference between the two laser wavelengths. In this paper, we describe two methods for beam combination: first via a prism, eventually dismissed as unpractical, and second via a polarizing beam splitter in reverse with a dual-wavelength waveplate. We detail the optical setup, waveplate design, and successful implementation of this second method.

Patient-reported outcomes after oesophagectomy in the multicentre LASER study

BACKGROUND

Data on the long-term symptom burden in patients surviving oesophageal cancer surgery are scarce. The aim of this study was to identify the most prevalent symptoms and their interactions with health-related quality of life.

METHODS

This was a cross-sectional cohort study of patients who underwent oesophageal cancer surgery in 20 European centres between 2010 and 2016. Patients had to be disease-free for at least 1 year. They were asked to complete a 28-symptom questionnaire at a single time point, at least 1 year after surgery. Principal component analysis was used to assess for clustering and association of symptoms. Risk factors associated with the development of severe symptoms were identified by multivariable logistic regression models.

RESULTS

Of 1081 invited patients, 876 (81.0 per cent) responded. Symptoms in the preceding 6 months associated with previous surgery were experienced by 586 patients (66.9 per cent). The most common severe symptoms included reduced energy or activity tolerance (30.7 per cent), feeling of early fullness after eating (30.0 per cent), tiredness (28.7 per cent), and heartburn/acid or bile regurgitation (19.6 per cent). Clustering analysis showed that symptoms clustered into six domains: lethargy, musculoskeletal pain, dumping, lower gastrointestinal symptoms, regurgitation/reflux, and swallowing/conduit problems; the latter two were the most closely associated. Surgical approach, neoadjuvant therapy, patient age, and sex were factors associated with severe symptoms.

CONCLUSION

A long-term symptom burden is common after oesophageal cancer surgery.

Short-term outcomes in older patients with peritoneal malignancy treated with cytoreductive surgery and HIPEC: Experience with 245 patients from a national centre

BACKGROUND

Cytoreductive Surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is increasingly accepted as the optimal management of selected patients with peritoneal malignancy. There is limited published evidence on outcomes in older patients treated by this complex therapeutic strategy.

METHODS

A retrospective review of a prospective database of all patients who underwent CRS with HIPEC in a single institution over seven years. A comparative analysis of outcomes in patients under 65 undergoing CRS and HIPEC with patients ≥65 years was performed. The key endpoints were morbidity, mortality, reintervention rate and length of stay in the high dependency/intensive care (HDU/ICU) units.

RESULTS

Overall, 245 patients underwent CRS and HIPEC during the study period, with 76/245 (31%) ≥65 years at the time of intervention. Tumour burden measured by the peritoneal carcinomatosis index (PCI) score was a median of 11 for both groups. Median length of hospital stay in the ≥65-year-old group was 14.5 days versus 13 days in the <65-year-old group (∗p = 0.01). Patients aged ≥65-years spent a median of one more day in the critical care unit ∗(p = 0.001). Significant morbidity (Clavien-Dindo ≥ Grade IIIa) was higher in the ≥65-year than the <65-year group (18.4% versus 11.2%). There were no perioperative deaths in the ≥65-year group.

CONCLUSION

This study demonstrates higher perioperative major morbidity in ≥65-year group, but with low mortality in patients undergoing CRS/HIPEC for disseminated intraperitoneal malignancy. This increased morbidity does not translate into higher rates of re-interventions and highlights the importance of optimal patient selection.

Multidisciplinary Surgical Approach to Increase Complete Cytoreduction Rates for Advanced Ovarian Cancer in a Tertiary Gynecologic Oncology Center

BACKGROUND

Surgical resection remains the cornerstone of ovarian cancer management. In 2017, the authors implemented a multi-disciplinary surgical team comprising gynecologic oncologists as well as colorectal, hepatobiliary, and upper gastrointestinal (GI) surgeons to increase gross macroscopic resection rates. This report aims to describe changes in complete cytoreduction rates and morbidity after the implementation of a multi-disciplinary surgical team comprising gynecologic oncologists as well as colorectal, hepatobiliary, and upper GI surgeons in a tertiary gynecologic oncology unit.

METHODS

The study used two cohorts. Cohort A was a retrospectively collated cohort from 2006 to 2015. Cohort B was a prospectively collated cohort of patients initiated in 2017. A multidisciplinary approach to preoperative medical optimization, intraoperative management, and postoperative care was implemented in 2017. The patients in cohort B with upper abdominal disease were offered primary cytoreduction with or without hyperthermic intraperitoneal chemotherapy (HIPEC). Before 2017, the patients with upper abdominal disease received neoadjuvant chemotherapy (cohort A).

RESULTS

This study included 146 patients in cohort A (2006-2015) and 93 patients in cohort B (2017-2019) with stages 3 or 4 ovarian cancer. The overall complete macroscopic resection rate (CC0) increased from 58.9 in cohort A to 67.7% in cohort B. The rate of primary cytoreductive surgery (CRS) increased from 38 (55/146) in cohort A to 42% (39/93) in cohort B. The CC0 rate for the patients who underwent primary CRS increased from 49 in cohort A to 77% in cohort B. Major morbidity remained stable throughout both study periods (2006-2019).

CONCLUSIONS

The study data demonstrate that implementation of a multidisciplinary team intraoperative approach and a meticulous approach to preoperative optimization resulted in significantly improved complete resection rates, particularly for women offered primary CRS.

Hospital outbreak of linezolid-resistant and vancomycin-resistant ST80 Enterococcus faecium harbouring an optrA-encoding conjugative plasmid investigated by whole-genome sequencing

BACKGROUND

Linezolid is an antibiotic used to treat infections caused by multi-drug-resistant Gram-positive bacteria. Linezolid resistance in enterococci has been reported with increasing frequency, with a recent rise in resistance encoded by optrA, poxtA or cfr.

AIM

To investigate a hospital outbreak of linezolid- and vancomycin-resistant Enterococcus faecium (LVREfm) using whole-genome sequencing (WGS).

METHODS

Thirty-nine VREfm from patient screening (19 isolates, 17 patients) and environmental sites (20 isolates) recovered in October 2019 were investigated. Isolates were screened using polymerase chain reaction for optrA, poxtA and cfr, and underwent Illumina MiSeq WGS. Isolate relatedness was assessed using E. faecium core genome multi-locus sequence typing (cgMLST). One LVREfm underwent MinION long-read WGS (Oxford Nanopore Technologies) and hybrid assembly with MiSeq short-read sequences to resolve an optrA-encoding plasmid.

FINDINGS

Twenty isolates (51.3%) were LVREfm and optrA-positive, including the LVREfm from the index patient. A closely related cluster of 28 sequence type (ST) 80 isolates was identified by cgMLST, including all 20 LVREfm and eight linezolid-susceptible VREfm, with an average allelic difference of two (range 0-10), indicating an outbreak. Nineteen (95%) LVREfm harboured a 56,684-bp conjugative plasmid (pEfmO_03). The remaining LVREfm exhibited 44.1% sequence coverage to pEfmO_03. The presence of pEfmO_03 in LVREfm and the close relatedness of the outbreak cluster isolates indicated the spread of a single strain. The outbreak was terminated by enhanced infection prevention and control (IPC) and environmental cleaning measures, ceasing ward admissions and ward-dedicated staff.

CONCLUSION

WGS was central in investigating an outbreak of ST80 LVREfm. The rapid implementation of enhanced IPC measures terminated the outbreak.

A pilot study of avelumab in Epstein-Barr virus-associated gastric cancer

TPS473

Background: Gastric Cancer (GC) is the third most common cause of cancer related deaths worldwide. The median overall survival of patients with stage 4 disease is approximately 1 year. Current accepted treatment approach with chemotherapy is applied with little consideration for known genetic or biologic heterogeneity. Whilst immune-based approaches in GC look promising it is clear that single-agent PD1/PDL1 inhibition benefit a minority. We must clarify a means of identifying prospectively those patients who may benefit from this treatment. A recent landmark paper by The Cancer Genome Atlas (TCGA) proposed a classification of GC into four subtypes: Epstein-Barr-virus (EBV)-positive, microsatellite instable (MSI), chromosomal instable (CI), and genomically stable (GS). Two of the four – EBV and MSI subtypes – are likely to be immunogenic and amenable to PD1/PDL1 inhibition. Recent advances have shown EBV-positive tumors to be infiltrated by lymphocytes and be enriched for PDL1. Methods: This single centre single-arm pilot study in gastric or junctional adenocarcinoma will explore the hypothesis that administering anti-PDL1 therapy (Avelumab) in a prospectively identified population enriched for potential responders will result in improved outcomes. The anticipated frequency of EBV associated-GC (c10%) means that approximately N = 100 patients will be screened to identify N = 10 participants. If a positive signal for efficacy is seen this will provide a basis for a larger, multicentre study. Previously treated Patients with confirmation of stage 4 EBV- positive gastric or oesophago-gastric adenocarcinoma meeting eligibility criteria will be enrolled. Avelumab will be administered at a dose of 10mg/kg IV every 14days. Primary endpoint is to determine the 6-month progression free survival (PFS) of Avelumab in EBV-associated GC. Secondary endpoints include overall response rate, overall survival, median PFS time and feasibility/accrual rate at 12 months. Exploratory endpoints will be to evaluate changes in immune parameters in the peripheral blood over time. Kaplan-Meier methods for primary efficacy endpoint with two-tailed one-sample proportion test will be used to evaluate the evidence to reject the null hypothesis. Clinical trial information: 2018-002085-39.

On the analysis of inhomogeneous magnetic field spectrometer for laser-driven ion acceleration

We present a detailed study of the use of a non-parallel, inhomogeneous magnetic field spectrometer for the investigation of laser-accelerated ion beams. Employing a wedged yoke design, we demonstrate the feasibility of an in-situ self-calibration technique of the non-uniform magnetic field and show that high-precision measurements of ion energies are possible in a wide-angle configuration. We also discuss the implications of a stacked detector system for unambiguous identification of different ion species present in the ion beam and explore the feasibility of detection of high energy particles beyond 100 MeV/amu in radiation harsh environments.

Metachronous adenocarcinoma of the remnant oesophagus 15 years following multimodal therapy

A 53-year-old man underwent neo-adjuvant chemo-radiotherapy and a 2 stage oesophagectomy for a junctional oesophageal tumour in 1996. In March 2012, a metachronous oesophageal tumour was identified, 7cm above the anastomotic margin, on a background of non-inflamed squamous mucosa. He is currently being managed with chemo-radiotherapy. Oesophageal cancer is associated with a historically poor survival rate, with primary concerns being local recurrence or death from disseminated disease. This case highlights the challenges which must be faced, as treatment strategies improve and consequently survival rates increase.

Eosinophilic ascites with marked peripheral eosinophilia: a diagnostic challenge

Eosinophilic disease of the gastrointestinal tract is rare and is characterized by the presence of gastrointestinal symptoms in association with eosinophilic infiltration of any part of the gastrointestinal tract. Clinical presentation of eosinophilic gastroenteritis (EGE) varies not only by the part of the gastrointestinal tract involved but also with the depth of eosinophilic infiltration of the gut wall. We describe the case of a 41-year-old woman with a history of atopy who presented with severe abdominal pain and diarrhoea. Investigations showed large-volume eosinophil-rich ascites and a markedly elevated peripheral blood eosinophil count and immunoglobulin E level. Bone marrow aspirate, trephine biopsy and T-cell studies showed no evidence of underlying haematological malignancy. Vasculitic disease and parasitic infection were systematically excluded. Colonic and upper gastrointestinal biopsies confirmed a diagnosis of EGE with eosinophilic ascites. The patient was treated with systemic corticosteroids and dietary allergen elimination with dramatic therapeutic response. The diagnostic and therapeutic challenges associated with EGE in its various forms are discussed.

Management of maple syrup urine disease in the peri-operative period

Maple syrup urine disease (MSUD) has an incidence of 1:125,000 newborns in Ireland. Patients, when fasting, or in a catabolic state build up toxic metabolites leading to progressive neurological dysfunction. We describe the necessary peri-operative management of a patient with MSUD who developed symptomatic gallstones requiring a laparoscopic cholecystectomy.

Factors involved in unplanned admissions from general surgical day-care in a modern protected facility

The aim in this audit study was to identify the rate of and the reasons for unanticipated admissions in general day surgery. All day ward procedures performed during the one year period from January 2011 to January 2012 were reviewed. Of 560 procedures performed, 25 (4.4%) patients were admitted. The age range of the patients admitted was from 26 to 83 years. The average BMI of the admitted patient was 28.9 (range 24-39).The average stay in hospital was 1.7 days (range 1-3 days). The reason for admission was potentially preventable in ten (40%) patients. This included eight (80%) out of ten admissions for control of postoperative pain, nausea and vomiting. Two (20%) were admitted for surgical observation due to high risk of bleeding. Fifteen (60%) of admissions were due to a non-preventable source, including 5 with a drain inserted at a perceived difficult laparoscopic cholecystectomy, 5 for urinary retention post open inguinal hernia repair, 2 for a cardiology review and 2 for further urgent investigations because of an unexpected intraoperative finding of malignancy. The rate of un-planned admission can be reduced by controlling potentially preventable causes, however a small contribution from unexpected scenarios is inevitable.

Double trouble--duplication of the gallbladder requiring repeat laparoscopic cholecystectomy

Duplication of the gallbladder is a surprisingly common phenomenon. Clinically, these patients present with straightforward gallbladder pathologies. It is a challenging preoperative diagnosis on ultrasound, and most cases are diagnosed intra-operatively. We present a case of gallbladder duplication, where the patient presented with biliary colic, had a straightforward laparoscopic cholecystectomy, and then represented with biliary colic four years later.

Clinicopathologic features of sentinel node metastases predictive of positive axillary clearance in grade 1 invasive breast carcinoma

BACKGROUND

Sentinel node (SN) biopsy is widely used to stage breast carcinoma and, when positive, typically leads to axillary clearance (AC).

AIMS

This study assesses clinicopathologic features of grade 1 breast carcinoma SNs with the aim of identifying a group of patients, who are likely to have a negative AC and can, therefore, safely be spared further surgery.

RESULTS

Two hundred and forty-seven patients with grade 1 invasive carcinoma were identified, of whom 29 had a positive SN. Four patients (13.8%) had a positive AC. Positive AC occurred in 3 of 6 (50%) patients whose SN showed extranodal extension (EE), but in only 1 of 23 (4.3%) patients without EE. All patients were staged as pN1(sn) following SN biopsy: only one, who had a 5.27 mm metastasis with EE, was pN2 following AC.

CONCLUSIONS

Extranodal extension is a significant predictor of a positive AC in this group. In its absence, AC did not alter the post-SN biopsy pN stage.

Potential impact of text message reminders on non-attendance at outpatient clinics

BACKGROUND

Non-attendance at outpatient clinic leads to significant time wasting and inefficient use of resources.

AIMS

To establish the magnitude of the problem of clinic non-attendance and to ascertain the potential impact of a simple strategy to reduce inefficiency in Irish healthcare.

METHODS

The number of patients due to attend general surgical clinic in a single year was ascertained. Telephone questionnaire of 97 patients who failed to attend was performed. A survey of potential impact of text message reminder was conducted.

RESULTS

Appointments were sent to 18,362 patients. Of these, 31% (n = 5692) were new to clinic. The rate of non-attendance was 16.8% (n = 3085). Varied reasons were given for non-attendance. Text message reminder would encourage 51% of those surveyed to attend or cancel in advance.

CONCLUSION

The rate of non-attendance is 17%. A reminder would eradicate more than half of non-attendance, allowing significantly more new patients to be seen, translating to more efficient use of clinic time.

Lower limb dysesthesia--an ominous sign in lumbar fractures

Attempts at diagnosing dural lacerations secondary to fractures of the lumbar vertebrae on plain radiographs has varied considerably. If undiagnosed these injuries can cause serious complications. We present a clinical sign not previously documented to our knowledge. Plain radiographs in this case failed to show significant canal compromise but excessive hip pain, with the limb held in a characteristic posture, heralded cauda equina injury in a burst lumbar fracture. The limb was held in hip and knee flexion, with resistance to passive extension due to lower limb dysesthesia. This sign helped in determining the investigation and treatment of our patient.

Anterior displacement correlates with neurological impairment in cervical facet dislocations

We studied all patients with either unifacetal or bifacetal dislocations treated in our National Spinal Injuries Unit between January 1996 and December 2000. There were 25 cases, of which 13 were unifacetal and 12 bifacetal. Craniocervical traction was employed in 21 cases and closed reduction achieved in 11. Eighteen patients underwent surgical stabilisation. Traction weights of up to 36 kg were employed, but there was no relationship found between the level of dislocation and traction weight. Anterior translation was measured by a newly described method, and we found a statistically significant correlation between the neurological score on admission and the degree of anterior translation.

Methylprednisolone in acute spinal cord injuries

BACKGROUND

Methylprednisolone is the only neuroprotective therapy advocated in acute non-penetrating spinal cord injury. Trials indicate improved neurological outcome following early administration of a high dose regime. The National Spinal Injuries Unit (NSIU) has promoted this regime by a simple laminated poster sent to all Irish A&E departments.

AIM

To assess the use of methylprednisolone in patients with spinal cord injuries.

METHODS

A retrospective audit of patient data for all patients admitted with traumatic neurological impairment over a 12-month period.

RESULTS

One hundred ninety-six patients were admitted during the study period, 28 (14%) received intravenous methylprednisolone of which six had clear records documenting compliance. One patient received both dexamethasone and methylprednisolone in high doses and three had incorrect bolus dosages administered. Six patients received methylprednisolone infusion longer than the protocol, while five patients were given infusions shorter than recommended. Three patients were admitted to the unit that could have received the steroid regime at the point of transfer.

CONCLUSIONS

There was poor documentation of prescription orders and timing of administration. Only six patients had clear documentation allowing confirmation of adherence to the protocol of the National Acute Spinal Cord Injury Study (NASCIS) III trial.