Evaluating potential delays and outcomes of patients undergoing surgical resection for locally advanced and recurrent colorectal cancer during a pandemic

INTRODUCTION

The COVID-19 pandemic resulted in a significant disruption of colorectal cancer (CRC) care pathways. This study evaluates the management and outcomes of patients with primary locally advanced or recurrent CRC during the pandemic in a single tertiary referral centre.

METHODS

Patients undergoing elective surgery for advanced or recurrent CRC with curative intent between March 2020 and March 2021 were identified. Following first multidisciplinary team discussion patients were broadly classified into two groups: straight to surgery (n=22, 45%) or neoadjuvant therapy followed by surgery (n=27, 55%). Primary outcome was COVID-19-related complication rate.

RESULTS

Forty-nine patients with a median age of 66 years (interquartile range: 54-73) were included. No patients developed a COVID-19 infection or related complication during hospital admission. Significant delays were identified in the treatment pathway of patients in the straight to surgery group, mostly due to delays in referral from external centres. Nine of 22 patients in the straight to surgery group had evidence of tumour progression compared with 3 of 27 in the neoadjuvant group (p=0.015839). Seven of 27 patients in the neoadjuvant group showed evidence of tumour regression. During the study, surgical waiting times were reduced, and more operations were performed during the second wave of COVID-19.

CONCLUSION

This study suggests that it is possible to mitigate the risks of COVID-19-related complications in patients undergoing complex surgery for locally advanced and recurrent CRC. Delay in surgical intervention is associated with tumour progression, particularly in patients who may not have neoadjuvant therapy. Efforts should be made to prioritise resources for patients requiring time-sensitive surgery for advanced and recurrent CRC.

Tagetes erecta as an organic precursor: synthesis of highly fluorescent CQDs for the micromolar tracing of ferric ions in human blood serum

The present article illustrates the green synthesis of novel carbon quantum dots (CQDs) from biomass viz. Tagetes erecta (TE), and subsequently fabrication of a metal ion probe for the sensing of Fe³⁺ in real samples. TE-derived CQDs (TE-CQDs) have been synthesized by a facile, eco-friendly, bottom-up hydrothermal approach using TE as a carbon source. The successful synthesis and proper phase formation of the envisaged material has been confirmed by various characterization techniques (Raman, XRD, XPS, TEM, and EDS). Notably, the green synthesized TE-CQDs show biocompatibility, good solubility in aqueous media, and non-toxicity. The as-synthesized TE-CQDs show an intense photoluminescence peak at 425 nm and exhibit excitation dependent photoluminescence behavior. The proposed TE-CQD-based probe offers a remarkable fluorescence (FL) quenching for Fe³⁺ with high selectivity (K_q ∼ 10.022 × 10¹³ M⁻¹ s⁻¹) and a sensitive/rapid response in a linear concentration range 0–90 μM (regression coefficient R² ∼ 0.99) for the detection of Fe³⁺. The limit of detection (LOD) of the probe for Fe³⁺ has been found as 0.37 μM in the standard solution. It has further been applied for the detection of Fe³⁺ in real samples (human blood serum) and displays good performance with LOD ∼ 0.36 μM. The proposed TE-CQD-based ion sensing probe has potential prospects to be used effectively in biological studies and clinical diagnosis.

TE-CQDs synthesized via the hydrothermal method for the detection of Fe³⁺ in HBS.

In Situ Fabrication of Activated Carbon from a Bio-Waste Desmostachya bipinnata for the Improved Supercapacitor Performance

Herein, we demonstrate the fabrication of highly capacitive activated carbon (AC) using a bio-waste Kusha grass (Desmostachya bipinnata), by employing a chemical process followed by activation through KOH. The as-synthesized few-layered activated carbon has been confirmed through X-ray powder diffraction, transmission electron microscopy, and Raman spectroscopy techniques. The chemical environment of the as-prepared sample has been accessed through FTIR and UV-visible spectroscopy. The surface area and porosity of the as-synthesized material have been accessed through the Brunauer-Emmett-Teller method. All the electrochemical measurements have been performed through cyclic voltammetry and galvanometric charging/discharging (GCD) method, but primarily, we focus on GCD due to the accuracy of the technique. Moreover, the as-synthesized AC material shows a maximum specific capacitance as 218 F g^-1 in the potential window ranging from - 0.35 to + 0.45 V. Also, the AC exhibits an excellent energy density of ~ 19.3 Wh kg^-1 and power density of ~ 277.92 W kg^-1, respectively, in the same operating potential window. It has also shown very good capacitance retention capability even after 5000th cycles. The fabricated supercapacitor shows a good energy density and power density, respectively, and good retention in capacitance at remarkably higher charging/discharging rates with excellent cycling stability. Henceforth, bio-waste Kusha grass-derived activated carbon (DP-AC) shows good promise and can be applied in supercapacitor applications due to its outstanding electrochemical properties. Herein, we envision that our results illustrate a simple and innovative approach to synthesize a bio-waste Kusha grass-derived activated carbon (DP-AC) as an emerging supercapacitor electrode material and widen its practical application in electrochemical energy storage fields.

Tumour growth rate of carcinoma of the colon and rectum: retrospective cohort study

BACKGROUND

The growth pattern of colorectal cancer is seldom investigated. This cohort study aimed to explore tumour growth rate in colorectal cancers managed non-surgically or deemed not resectable, and to determine its implication for prognosis.

METHODS

Consecutive patients with colonic or rectal adenocarcinoma were identified through the colorectal multidisciplinary team database at Leeds Teaching Hospitals NHS Trust over a 2-year interval. Patients who received no treatment (surgery, stenting, colonic defunctioning procedures, chemotherapy, radiotherapy) and who underwent CT twice more than 5 weeks apart were included. Multidetector CT/three-dimensional image analysis was performed independently by three experienced radiologists.

RESULTS

Of 804 patients reviewed, 43 colorectal cancers were included in the final analysis. Median age at first CT was 80 (73-85) years and the median interval between scans was 150 (i.q.r. 72-471) days. An increase in T category was demonstrated in 31 of 43 tumours, with a median doubling time of 211 (112-404) days. The median percentage increase in tumour volume was 34·1 (13·3-53·9) per cent per 62 days. The all-cause 3-year mortality rate was 81 per cent (35 of 43) with a median survival time of 1·1 (0·4-2·2) years after the initial diagnostic scan. In those obstructed, the relative risk of death from subsequent perforation was 1·26 (95 per cent c.i. 1·07 to 1·49; P = 0·005).

CONCLUSION

This study documented a median doubling time of 211 days, with a concerning suggestion of tumour progression, which has implications for the current management standard.

Laparoscopic versus open colorectal surgery in the acute setting (LaCeS trial): a multicentre randomized feasibility trial

BACKGROUND

Approximately 30 000 people undergo major emergency abdominal gastrointestinal surgery annually, and 36 per cent of these procedures (around 10 800) are carried out for emergency colorectal pathology. Some 14 per cent of all patients requiring emergency surgery have a laparoscopic procedure. The aims of the LaCeS (laparoscopic versus open colorectal surgery in the acute setting) feasibility trial were to assess the feasibility, safety and acceptability of performing a large-scale definitive phase III RCT, with a comparison of emergency laparoscopic versus open surgery for acute colorectal pathology.

METHODS

LaCeS was designed as a prospective, multicentre, single-blind, parallel-group, pragmatic feasibility RCT with an integrated qualitative study. Randomization was undertaken centrally, with patients randomized on a 1 : 1 basis between laparoscopic or open surgery.

RESULTS

A total of 64 patients were recruited across five centres. The overall mean steady-state recruitment rate was 1·2 patients per month per site. Baseline compliance for clinical and health-related quality-of-life data was 99·8 and 93·8 per cent respectively. The conversion rate from laparoscopic to open surgery was 39 (95 per cent c.i. 23 to 58) per cent. The 30-day postoperative complication rate was 27 (13 to 46) per cent in the laparoscopic arm and 42 (25 to 61) per cent in the open arm.

CONCLUSION

Laparoscopic emergency colorectal surgery may have an acceptable safety profile. Registration number: ISRCTN15681041 ( http://www.controlled-trials.com).

The fabrication of an MoS2 QD-AuNP modified screen-printed electrode for the improved electrochemical detection of cefixime

Herein, we report a voltammetric method for the nanomolar detection of cefixime, a third-generation antibiotic. The determination of cefixime is validated on a glassy carbon electrode (GCE) as well as on a screen-printed carbon electrode (SPCE). In the present study, we have reported a facile "one step simple hydrothermal synthesis" of MoS2 quantum dots and with the oxidation of aurochloric acid for the further formation of an MoS2 QD-AuNP composite. The as-synthesized nanocomposite was characterized via UV-Vis spectroscopy, FTIR spectroscopy, XRD, TEM and EDX techniques, and further applied in the modification of working electrodes, showing excellent electroactivity. The sensing of cefixime was done via cyclic and differential pulse voltammetry techniques. The presence of the only anodic peak in the voltammogram reveals the irreversible oxidation of cefixime in the potential range of about 1.3 ± 0.1 V vs. Ag/AgCl. The study was also performed at different scan rates, which indicate a diffusion-controlled mechanism. The proposed cefixime sensor showed a linear response in the concentration range of 0.33-90.82 μM (at S/N = 3) with a limit of detection (LOD) of 3.9-4.5 nm. The electrochemical sensitivity is calculated as 8.63 μA μM-1 cm-2 and 7.07 μA μM-1 cm-2 in buffer and pharmaceutical formulation (commercially available cefixime tablet), respectively. The effects of several interferents were also investigated. The proposed sensor is effectively used for estimating cefixime in phosphate buffer and the commercially available cefixime tablets with no cross-reactivity or matrix effects and shows a promising prospect for real applications.

Initial clinical experience with high-pitch dual-source CT as a rapid technique for thoraco-abdominal evaluation in awake infants and young children

AIM

To evaluate dual-source high-pitch computed tomography (HPCT) imaging of the chest and abdomen as a rapid scanning technique to obtain diagnostic-quality imaging evaluation of infants and young children without sedation.

MATERIALS AND METHODS

Fifty-three paediatric patients (age 24.1±2 months) who underwent chest or abdomen HPCT (≥1.5) and standard pitch CT (SPCT, <1.5) on a dual-source 128-row multidetector CT system were included in the study. Image quality assessment was performed by two paediatric radiologists for diagnostic confidence, image artefacts, and image noise. Objective image noise was measured.

RESULTS

Most of the CT examinations were performed in children who were >1 year old (n=15 and n=20) followed by ≤1 year old (n=8 and n=10) in SPCT and HPCT, respectively. The mean radiation dose (SSDE) from HPCT was 1.96±1 mGy compared to 2.2±1 mGy for SPCT (p=0.3). No major artefacts were reported and overall image quality of all HPCT examinations was acceptable diagnostically. In addition, objective image noise values were not significantly different between HPCT compared with SPCT (11±3 versus 11±5, p=0.7).

CONCLUSION

Ultra-fast, HPCT can be performed without the need for sedation as a potential alternative to anaesthetised magnetic resonance imaging in infants and young children.

Current concepts in imaging for local staging of advanced rectal cancer

Imaging of rectal cancer has an increasingly pivotal role in the diagnosis, staging, and treatment stratification of patients with the disease. This is particularly true for advanced rectal cancers where magnetic resonance imaging (MRI) findings provide essential information that can change treatment. In this review we describe the rationale for the current imaging standards in advanced rectal cancer for both morphological and functional imaging on the baseline staging and reassessment studies. In addition the clinical implications and future methods by which radiologists may improve these are outlined relative to TNM8.

Inter-rater Variability in the Interpretation of Pre and Post Contrast MRI for Pre-Surgical Evaluation of Osteosarcoma in Long Bones in Pediatric Patients and Young Adults

BACKGROUND AND OBJECTIVES

The value of gadolinium enhanced magnetic resonance imaging (MRI) sequences for extremity osteosarcoma resection planning is unverified. We evaluate the performance of intravenous gadolinium enhanced MRI for identification of neurovascular bundle involvement (NBI) and intraarticular extension (IAE) in patients with osteosarcoma.

METHODS

Two pediatric radiologists independently analyzed MRI examinations of patients with pathology proven extremity osteosarcoma for NBI and IAE. Initial evaluation utilized only non-contrast MRI images (PRE) and, after 2 weeks, subsequent evaluation included both the pre and post contrast images (POST). Cohen's Kappa and McNemar's test were calculated to assess agreement between PRE and POST image interpretations of NBI and IAE.

RESULTS

56 patients with 90 preoperative MRI examinations were analyzed. PRE and POST interpretations were rarely discordant; 4/90 cases for NBI (Kappa 0.91) and 2/90 cases for IAE (Kappa 0.95). McNemar's test did not show a difference between PRE and POST imaging (NBI p=0.62; IAE p=0.48).

CONCLUSION

No significant difference between PRE and POST image interpretation was found. A high level of agreement between PRE and POST image interpretation suggests that pre-contrast MRI may be sufficient for pre-surgical planning for pediatric patients with long bone osteosarcoma.

Pulmonary hemorrhage in neonatal respiratory distress syndrome: Radiographic evolution, course, complications and long-term clinical outcomes

BACKGROUND

Pulmonary hemorrhage (PH) is occasionally seen in premature infants after surfactant treatment for respiratory distress syndrome (RDS). These infants receive frequent chest radiographs (CXR) during and after hospitalization enabling long-term radiographic-clinical correlation.

OBJECTIVE

To chart the natural evolution of CXR findings of PH in RDS and correlate radiographic patterns to supplemental oxygen requirement.

MATERIALS AND METHODS

Retrospective review of clinical notes for gestational age (GA), birth weight (BW), intraventricular hemorrhage (IVH) and oxygen requirement were performed. CXRs were reviewed at 4 time-points; during PH, 28 days postnatal age, 36 weeks and at farthest available clinical follow-up.

RESULTS

18 infants born (2003-2016), GA (24-30 weeks); BW (482-1590 grams) were included. Mean onset of PH was 1.94 (0-5) days. 9/18 (50%) had IVH. 3 died during PH; all had IVH. During PH, CXR showed whiteout 9/18 (50%); patchy opacities 5/18 (27%); diffuse haziness 1/18 (6%) and no change 3/18 (17%). At 28 days postnatal age, CXR showed fine-interstitial (FI) markings 14/15 (93%) and whiteout 1/15 (7%). At 36 weeks,12/14 (85%) had FI and 2/14 (15%) developed cystic-interstitial changes. At farthest follow-up, FI 3/13 (23%); coarse-interstitial 4/13 (30%); peri-bronchial cuffing 5/13 (38%); normal 1/13 (9%) and the majority had hyperinflation 9/13 (69%). At discharge, 9/14 (64%) required home-oxygen and 5/14 (36%) were on room-air. At farthest follow-up, 6/14 (42%) required home-oxygen and 8/14 (58%) were on room-air.

CONCLUSION

Premature infants that survive PH may later develop chronic lung disease of prematurity with an evolving interstitial pattern on CXR that clears overtime as they outgrow the need for supplemental oxygen.

The Significance of ERG and Androgen Receptor Expression in Adenocarcinoma Prostate

Background Fusions of transmembrane protease, serine 2 (TMPRSS2) with erythroblast transformation specific transcription factors have been found in prostate cancer. The v-etserythroblastosis virus E26 oncogene homologue (ERG) is a proto-oncogene of the erythroblast transformation specific transcription factor family. TMPRSS2-ERG fusion is the most common molecular alteration present in about 50% of prostatic adenocarcinomas. Androgen receptor (AR) plays a key role in prostate development and is involved in the progression of prostate cancer. Objective To evaluate the significance of combined ERG and AR expression in cases of prostatic adenocarcinoma. Method The study was conducted at Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. Formalin fixed-paraffin embedded archival prostatic tissue specimens were obtained. A total of 10 cases of prostatic adenocarcinoma were included in the study. Immunohistochemistry for Androgen receptor was done by the standard protocol. Multiplex immunohistochemical staining was done for ERG+CK5 using a primary antibody cocktail of mouse and rabbit antibodies. Result Specific AR immunostaining was exclusively nuclear and was present in all 10 cases in varying intensity. Specific ERG immunostaining was nuclear and was present in seven cases (70%) and absent in three cases (30%). The three cases that were negative for ERG had a Gleason score of ≤ 6 and the AR staining was strong and present in about 90% of the cells. Gleason score was directly related to the ERG staining while AR staining was inversely related to the ERG staining. Conclusion The prognostic value of combined ERG and AR over-expression, its associated genes should be further investigated as potential therapeutic targets in prostate cancer progression. Preliminary data is being presented. Larger prospective studies with survival analysis are essential for prognostic significance.

Access to Round Window Niche via Posterior Tympanotomy and Impact of Drilling Its Overhangs: A Cadaveric Descriptive Study

We intended to study the morphological parameters of round window region and assess the gain in exposure achieved by drilling the round window niche overhang. The Exposure of the round window membrane (RWM) is of prime importance to carry out atraumatic electrode insertion for cochlear implantation. The anatomy of round window has been a subject of considerable debate in literature. Fifty-one Formalin preserved adult cadaveric temporal bones were micro-dissected to carry out an 'optimal' posterior tympanotomy to expose the round window region. The bony overhangs of round window niche (RWN) were next drilled to achieve maximal possible exposure the RWM without violating the annulus of the same. The exposure was classified as per St Thomas' Hospital classification. The round window could not be visualized in 3 bones (5.9%). The commonest morphology of RWN was dome shaped, found in 18 (37.5%) and that of the RWM was oval shaped, found in 14 (29.2%) bones. Pre drilling 41 bones had a > 50% exposure of RWM while post drilling > 50% exposure could be achieved in all the bones except the 3 bones in which RWN could not be visualized to begin with. The drilling of the RWN overhangs exposed RWM in entirety in 91.7% of bones with a visible morphology of RWN pre drilling. RWN and RWM exhibit varied morphology. Drilling of the round window niche overhangs can considerably enhance the exposure of RWM.

Why rolling out routine seven-day surgical services would threaten emergency care

Scheduling of elective weekend operations is entirely within our control and deaths are therefore preventable.

A new technique of extreme lateral positioning for laparoscopic splenic flexure mobilization

AIM

This aim of this study was to describe a novel positioning technique that assists in the expeditious mobilization of the splenic flexure without the need for redraping or compromise of port placement.

METHOD

A prospective case series was studied to evaluate the technique and its ability to facilitate splenic flexure mobilization.

RESULTS

The technique was used in 12 patients. There were no adverse intra- or postoperative events. The median time (interquartile range) for laparoscopic splenic flexure mobilisation was 10 (9-11.25).

CONCLUSION

This novel positioning technique is safe and feasible. We include a detailed video that describes and demonstrates the requisites for its safe conduct. We also include intra-operative footage demonstrating the benefits of the patient's position.

Laparoscopic excision of a retrorectal schwannoma

Retrorectal tumors are uncommon and are usually managed by open surgical excision. Recent advances in laparoscopic techniques have led to the use of laparoscopy for a variety of problems in colorectal surgery, including the excision of retrorectal tumours. This case report, which describes the laparoscopic excision of a benign schwannoma arising from the second sacral nerve root, highlights the benefits of accurate preoperative diagnosis with MR imaging and the advantages of a laparoscopic approach while pointing out principles that should be adhered to when using this approach. The tumour was successfully resected without neural compromise and with a prompt and full postoperative recovery.

Laparoscopic management of an obstructed obturator hernia: should laparoscopic assessment be the default option?

An obturator hernia is a rare diagnosis that is frequently missed. Patients present with few clinical signs to identify the cause, apart from symptoms of intestinal obstruction. Therefore, obturator hernias are often diagnosed at exploratory laparotomy. The use of computed tomography (CT) has increased the chance of definitive preoperative diagnosis. However, despite these advances, patients who present acutely will frequently undergo an open procedure rather than laparoscopy. We present a case of an acute obstructed obturator hernia diagnosed in a 62-year-old female that was successfully managed laparoscopically.

Dysbiosis and pouchitis

BACKGROUND AND METHODS

The exact aetiology of pouchitis is unknown, but an association with dysbiosis has been suggested. This is a retrospective review of 17 studies published between 1985 and 2005, identified by a search of the Medline, Pubmed and Embase databases.

RESULTS

The methodology of the studies varied widely. Many were performed at a time when the distinction between a healthy and an inflamed pouch was vague; misclassification of patients makes the analysis of data difficult and conclusions uncertain.

CONCLUSION

The evidence that dysbiosis is a cause of pouchitis is poor. Nevertheless, available data allow the construction of an algorithm to aid management and suggest a structured approach for future research.

Letter 1: randomized clinical trial of bowel preparation with a single phosphate enema or polyethylene glycol before elective colorectal surgery (Br J Surg 2006; 93: 427-433)

The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses should be sent electronically via the BJS website (www.bjs.co.uk). All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length.

Surgery for recurrent rectal carcinoma: The role of preoperative magnetic resonance imaging

Despite apparent curative resection of rectal carcinoma, local recurrence rates of between 3 and 32% have been reported. For those patients, radical surgical resection offers the only hope of cure. We present a review of the magnetic resonance imaging (MRI) findings and contraindications to curative surgery demonstrated using imaging.

Gangrenous cholecystitis: prediction with CT imaging

The aim of this study is to determine the usefulness of different patterns of gallbladder mucosal enhancement on contrast-enhanced computed tomography (CT) for differentiating between gangrenous and uncomplicated acute cholecystitis. This retrospective evaluation involved 56 patients with histopathologically proved acute cholecystitis (32 with gangrenous and 24 with uncomplicated acute cholecystitis) who had preoperative contrast-enhanced CT imaging. CT in 38 patients showed a gallbladder mucosal enhancement pattern that could be categorized into continuous, discontinuous, and/or irregular categories. In the other 18 patients, the mucosal enhancement pattern could not be classified due to lack of mucosal enhancement or inadequate mucosal enhancement. On contrast-enhanced CT evaluation, continuous and discontinuous and/or irregular mucosal enhancement patterns were seen in 20 and 18 patients, respectively. Among the 20 patients with continuous mucosal enhancement, 17 had uncomplicated acute cholecystitis. Seventeen of the 18 patients with discontinuous and/or irregular mucosal enhancement had gangrenous cholecystitis. The sensitivity and positive predictive value (PPV) of discontinuous and/or irregular mucosal enhancement in the diagnosis of gangrenous cholecystitis were 30.3% and 94.4% (17 of 18), respectively. The sensitivity and PPV of continuous mucosal enhancement in the diagnosis of uncomplicated acute cholecystitis were 30.3% and 85.5% (17 of 20), respectively. There was a statistically significant difference (p=0.0005) between the PPV of discontinuous and/or irregular (94.4%) and that of continuous (15%) mucosal enhancement for predicting gangrenous cholecystitis. The pattern of gallbladder mucosal enhancement on CT can be used as a reliable criterion for distinguishing acute, uncomplicated cholecystitis from gangrenous cholecystitis.

Cardiac arrest: abdominal CT imaging features

We report computed tomographic findings of two unusual cases of sudden cardiac arrest. The imaging features documented include reflux of contrast into the abdomen as indicated by opacification of renal veins, hepatic veins, inferior vena cava, and hepatic and renal parenchyma. The reflux of contrast into the portal vein in one patient has not been described in the literature. The thoracic findings were reflux of contrast into the coronary sinus, nonopacificaton of the left ventricle with intravenous contrast, and lack of cardiac motion artifact.

Ultrasound-guided transthoracic co-axial biopsy of thoracic mass lesions

PURPOSE

To compare the diagnostic yield of fine-needle aspiration biopsy (FNAB) and cutting needle biopsy in thoracic lesions.

MATERIAL AND METHODS

Thirty patients with thoracic mass lesions were subjected to ultrasound-guided co-axial FNAB and cutting needle biopsy using 0.7 mm aspirating and 1.0-mm cutting needles, respectively. The diagnostic yield of the individual modalities was compared with the combined yield.

RESULTS

A conclusive diagnosis was obtained in 76.6% (n=23) of patients by FNAB and in 66.6% (n=20) by cutting needle biopsy. The combined diagnostic yield of FNAB and cutting needle biopsy was 93.3% (n=28) with a significant statistical difference (p<0.03) as compared to cutting biopsy alone. Of the patients, 23.2% (n=7) had benign and 76.6% (n=23) malignant aetiologies. The diagnostic yield of FNAB versus cutting needle biopsy in benign lesions was 57.1% (n=4) and 100% (n=7), respectively. The diagnostic yield of FNAB versus cutting needle biopsy in malignant lesions was 82.6% (n=19) and 56.5%, (n=13). Two patients remained undiagnosed by either modality. There were no complications.

CONCLUSION

FNAB and cutting needle biopsy are complementary to each other and attempts should be made to obtain small tissue cores in addition to routine cytologic specimens in diagnosing thoracic lesions, especially in benign pathologies. US provides a safe guidance modality for lesions abutting the chest wall.

Pressure modulates monocyte migration

Migration of monocytes into the subendothelial space of the aorta has been considered to be an important event in the development of atherosclerosis. Because hypertension is commonly associated with atherosclerosis, we studied the effect of applied pressure on the migration of monocytes. Direct applied pressure increased the migration (P < .001) of monocytes across a filter when compared with normal atmospheric pressure. The migration of monocytes was found to be directly related to the amount of the applied pressure. Amlodipine, a calcium channel blocker, attenuated the migration of monocytes under normal as well as increased pressure conditions in a dose-dependent manner. These studies provide a basis to speculate on the role of direct pressure in the migration of monocytes into the subendothelial space and the possibility that vasoactive agents may modulate the migration of monocytes independent of their pressure-lowering effect.

Anorectal melanoma--an incurable disease?

PURPOSE

This study was designed to describe recurrence and survival rates after operative treatment for anorectal melanoma and to identify predictive factors for recurrence.

METHODS

Records of 50 patients with anorectal melanoma from 1939 to 1993 were reviewed.

RESULTS

Overall five-year survival and disease-free survival were 22 and 16 percent, respectively. At the time of diagnosis, 26 percent of patients had metastatic disease, and all died within 12 (mean, 6.3) months. Five-year survival and recurrence rates were identical after either abdominoperineal resection (APR) or wide local excision, both with curative intent. Gender, size of tumor, presence of melanin, positive perirectal lymph nodes, or treatment were not predictive of recurrence. Anorectal melanoma was found incidentally after hemorrhoidectomy or polypectomy in five patients. Three other patients underwent an excisional biopsy of a lesion measuring less than 2 cm. Of these eight patients, five underwent APR and three underwent wide local excision with no microscopic residual tumor at pathology. All developed regional or systemic recurrence at a mean of 21 (range, 4-88) months, and all died of their disease at a mean of 29 (range, 5-98) months.

CONCLUSION

Prognosis for anorectal melanoma is poor, irrespective of surgical treatment performed. No predictive factors for recurrence were identified in this series. Wide local excision with a negative margin of a least 1 cm is suggested as the treatment of choice. APR should be reserved for tumor not amenable to local excision or for palliative treatment of large obstructive lesion until effective adjuvant therapies are available.

Risk-adjusted analysis of surgeon performance: a 1-year study

A 1-year prospective analysis was undertaken of all non-day-case general surgery in a district general hospital. Using the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) scoring system 3004 patients were assessed. From the predictions of mortality and morbidity so obtained, a quality measure, the ratio of observed to expected numbers of deaths and complications (O:E ratio) was determined for each surgeon, both overall and within specialty zones. The present study demonstrates the serious hazard in using 'raw' uncorrected mortality and morbidity statistics to compare surgeon performance. Mortality rates varied from 1.0 to 4.9 per cent whereas O:E ratios ranged from 0.83 to 1.06; morbidity rates varied from 5.3 to 12.6 per cent with O:E ratios 0.86-1.02. Great misunderstanding may result from the publication of surgeon or hospital 'league tables'. The present study demonstrates a technique that might allow surgeon performance to be monitored adequately and accurately.

The effects of major abdominal surgery, enteral and parenteral nutrition on pancreatic function and morphology

The effects of major abdominal surgery and nutritional support upon pancreatic function and morphology were studied in similar groups of patients who underwent major abdominal surgery (n = 18), received parenteral nutritional support (n = 18) or received enteral nutritional support (n = 16). The exocrine function of the pancreas was measured by means of an oral pancreatic function test (using 1 g of N-benzoyl-L-tyrosyl para-aminobenzoic acid) with measurement of serum para-aminobenzoic acid at 3 h and the Pancreatic Excretion Index. Pancreatic morphology was assessed by real time ultrasound and a pancreatic size index was calculated (maximum diameter of head x body). Serial measurements of function and morphology were carried out in each patient at entry into the study and at 7 and 14 days after operation or start of nutritional support. Serum PABA levels were similar in the 3 groups at the start of the study. Although the levels remained unchanged in the enteral and parenteral groups, a significant and progressive decrease was observed in the surgical group (serum PABA = 27.5 nmol/l (24.0-30.6) before operation, 10.5 nmol/l (5.5-13.4) 14 days after operation, P < 0.01). No significant changes in pancreatic size were seen. Parenteral and enteral nutrition preserves pancreatic exocrine function. A dramatic reduction in pancreatic exocrine function is seen after major abdominal surgery.

The prevalence of gut translocation in humans

BACKGROUND/AIMS

Gut translocation of enteric organisms across the intact intestinal mucosa has been postulated as a potential source of sepsis in susceptible patients. However, little is known of its occurrence or significance in humans. The aim of this study was to determine the prevalence of gut translocation of bacteria in humans and attempt to identify any predisposing factors to its occurrence.

METHODS

A consecutive series of 267 general surgical patients were examined for evidence of bacterial translocation by bacterial analysis of intestinal serosa and mesenteric lymph nodes taken at the time of surgery.

RESULTS

Translocation occurred in 10.3% of patients overall. Both aerobic and anaerobic bacteria translocated. Excluding patients with distal intestinal obstruction and those with inflammatory bowel disease in whom translocation was more common, the prevalence was 5%. Neither jaundice, nutritional status, nor total parenteral nutrition predisposed to translocation. Similarly, mucosal atrophy did not predispose to this phenomenon. The development of postoperative septic complications was twice as common in patients with translocation as in those without, but mortality was unaffected.

CONCLUSIONS

Translocation occurs as a spontaneous event in humans, but its clinical significance remains to be defined.