Clinical outcomes and inflammatory response to single-incision laparoscopic (SIL) colorectal surgery: a single-blinded randomized controlled pilot study

AIM

Single-incision laparoscopic (SIL) surgery is expanding, but its benefits, efficacy and safety compared with conventional laparoscopic (CL) surgery remain unclear. This pilot study examined clinical outcomes and biochemical markers of inflammation for colorectal resections by SIL and CL in a randomized controlled pilot trial.

METHOD

Fifty patients undergoing elective colorectal resection were randomized to either SIL or CL. Primary outcomes were operating time and length of stay (LoS); secondary outcomes included combined length of scars, pain scores, complications, Quality of Life EQ5D-VAS and the inflammatory markers interleukin-6 (IL-6), IL-8 and C-reactive protein (CRP) at baseline, 2, 6, 24 and 72 h.

RESULTS

There was no difference in age, gender, body mass index, indications and site of surgery, American Society of Anesthesiologists grade or incidence of previous surgery between the groups. Except for one conversion from SIL to open surgery, surgery was completed as intended. No difference between SIL and CL was found for operating time [median 130 (72-220) vs 130 (90-317) min, respectively, P = 0.528], LoS [median 4 (3-8) vs 4 (2-19)days, P = 0.888] and time to first flatus [2 (1-4) vs 2 (1-5) days, P = 0.374]. The combined length of scars was significantly shorter for SIL [4 (2-18) vs 7 (5-8) cm, P < 0.001]; in each group, four postoperative complications occurred (16%). Postoperative pain scores were similar [mean 7.67 (interquartile range 4) vs 7.25 (interquartile range 3.75), P = 0.835] to day 3. EQ5D-VAS was no different for both groups at discharge [72.5 (40-90) vs 70 (30-100), P = 0.673] but slightly higher for CL at 3 months [79 (45-100) vs 90 (50-100), P = 0.033].The IL-6, IL-8 and CRP levels between both groups showed similar peaks and no significant differences.

CONCLUSION

SIL colorectal surgery by experienced laparoscopic surgeons appears to be safe and equivalent to CL, with no discernible difference in its effect on the physiological response to surgical trauma.

Intra-arterial methylene blue injection into ex vivo colorectal cancer specimens improves lymph node staging accuracy: a randomized controlled trial

AIM

A randomized controlled trial was carried out to study the effect of a recently proposed technique of ex vivo intra-arterial methylene blue injection of the surgical specimen removed for colorectal cancer on lymph node harvest and staging.

METHOD

Between May 2012 and February 2013, 100 consecutive colorectal cancer resection specimens in a single institution were randomly assigned to intervention (methylene blue injection) and control (standard manual palpation technique) groups before formalin fixation. The specimen was then examined by the histopathologist for lymph nodes.

RESULTS

Both groups were similar for age, sex, site of tumour, operation and tumour stage. In the intervention group, a higher number of nodes was found [median 23 (5-92) vs. 15 (5-37), P < 0.001], with only one specimen not achieving the recommended minimum standard of 12 nodes [1/50 (2%) vs. 8/50 (16%), P = 0.014]. However, there was no upstaging effect in the intervention group [23/50 (46.0%) vs. 20/50 (40.0%); P = 0.686]. With a significantly lower number of nodes harvested in rectal cancer, the positive effect of the intervention was particularly observed in the patients who underwent preoperative neoadjuvant radiotherapy [median 30 nodes (12-57) vs. 11 (7-15); P = 0.011; proportion of cases with < 12 nodes 0/5 vs. 5/8 (62.5%), P = 0.024].

CONCLUSION

Ex vivo intra-arterial methylene blue injection increases lymph node yield and can help to reduce the number of cases with a lower-than-recommended number of nodes, particularly in patients with rectal cancer having neoadjuvant treatment. The technique is easy to perform, cheap and saves time.

Comparative assessment of pesticide residues in grain, soil, and water from IPM and non-IPM trials of basmati rice

The integrated pest management (IPM) modules of pesticide schedule on Basmati rice were validated at field experiments conducted in Northern India for consecutive 3 years (2005-2008). The pesticide residues were found below the detectable limit (<0.01-0.001 mg/kg) in soil and irrigation water samples of Kaithal region. In Dehra Dun region of Uttrakhand, the residues of carbendazim in rice grains and soil were detected below <0.01 mg/kg level. In second year experiments (2006-2007), only four non-IPM soil samples indicated the presence of chlorpyrifos and endosulfan in the range of ND <0.001 to 0.07 mg/kg, out of 45 samples analyzed. Carbendazim applied as seed treatment at Dehradun and Kaithal field trials was found below detectable limit in both IPM and non-IPM rice grains (<0.01 mg/kg) and irrigation water (0.01 μl/ml). Chlorpyrifos was detected in five water samples from Kaithal and one from Pant Nagar in the range of 0.003-0.006 μl/L, α- and β-isomer of endosulfan in the range of 0.005-0.03, and 0.005-0.02 μl/ml, respectively, in one sample from Pant Nagar and two from Kaithal, out of a total of 22 samples. In the region of Uttrakhand and Uttar Pradesh during 2007-2008, four non-IPM samples of soil indicated trace levels of endosulfan, out of 16 samples analyzed. The residues were detected below detection limit for carbendazim (<0.01 mg/kg) in soil samples of Dehradun IPM fields and for endosulfan and carbendazim (0.001-0.01 μl/L) in water samples each from IPM and non-IPM fields of Uttar Pradesh. The results of 3-year trials of IPM module indicated basmati rice as safe and economical with pesticide residue-free rice grains.

Stage and treatment variation with age in postmenopausal women with breast cancer: compliance with guidelines

Breast cancer-specific mortality is static in older women despite having fallen in younger age groups, possibly due to lack of screening and differences in treatment. This study compared stage and treatment between two cohorts of postmenopausal women (55–69 vs >70 years) in a single cancer network over 6 months. A total of 378 patients were studied (>70: N=167, 55–69 years: N=210). Older women presented with more advanced disease (>70: metastatic/locally advanced 12%, 55–69 years: 3%, P<0.01). Those with operable cancer had a worse prognosis (Nottingham Prognostic Index (NPI) >70: median NPI 4.4, 55–69 years: 4.25, P<0.03). These stage differences were partially explained by higher screening rates in the younger cohort. Primary endocrine therapy was used in 42% of older patients compared with 3% in the younger group (P<0.001). Older women with cancers suitable for breast conservation were more likely to choose mastectomy (>70: 57.5% mastectomy rate vs 55–69 years: 20.6%, P<0.01). Nodal surgery was less frequent in older patients (>70: 6.7% no nodal surgery, 55–69 years: 0.5%, P<0.01) and was more likely to be inadequate (>70: 10.7% <4 nodes excised, 55–69 years: 3.4%, P<0.02). In summary, older women presented with more advanced breast cancer, than younger postmenopausal women and were treated less comprehensively.

Comparison of seropositivity of HIV, HBV, HCV and syphilis in replacement and voluntary blood donors in western India

A 5 year retrospective study from June, 1994 to May, 1999 was conducted at Zonal Blood Transfusion Centre, Umaid Hospital and Department of Pathology, Dr. SN Medical College and Associated Group of Hospitals, Jodhpur (Rajastha, Western India. Donors were evaluated for seroprevalence of HIV, HBV, HCV and Syphilis. A Total 46,957 donors were tested, out of which 42,291 (90.1%) were replacement donors and 4666 (9.0%) were voluntary donors. The incidence of HIV was 0.44% in total donors, more in replacement (0.461%) as compare to voluntary (0.279%). The seroprevalence of HBV in total donor was 3.44%. The replacement donors had high incidence (3.52%) as compared to voluntary donors (2.57%). The incidence of HCV seropositivity was 0.285% (5 month data), all were replacement donors (0.328%). The seroprevalence of VDRL in total donor was 0.22%, more in replacement donor (0.239%) as compare to voluntary donors (0.129%). Hence forth, it has been observed that voluntary blood donation is more safe and advocated as compare to replacement donation, as high incidence of HIV, HBV, HCV and Syphilis are observed in replacement donors.

Reactive oxygen species modified polyguanylic acid: immunogenicity and implications for systemic autoimmunity

The effect of the hydroxyl radical on polyguanylic acid [poly(G)] was investigated with regard to progressive increase of autoantibodies against it in systemic lupus erythematosus (SLE) and progressive systemic sclerosis (PSS). Rabbits immunized with both native and ROS-poly(G) induced high titre antibodies. Immune IgG exhibited a high degree of specificity towards the immunogen, reiterated visually by a gel retardation assay. The induced antibodies showed a wide range of cross-reactivity with various synthetic polynucleotides exhibiting B-, A-, and allied conformations. The specificity of induced antibodies resembled the diverse binding characteristics of lupus anti-DNA autoantibodies. Moreover, sera from scleroderma patients showed binding to native and ROS-poly(G). SLE and PSS autoantibodies showed preferential recognition of ROS-poly(G) over native poly(G). These results demonstrate that the hydroxyl modified guanine residues in DNA and RNA can induce circulating SLE and PSS autoantibodies.

Effect of 3-[p-(N-2-pyrimidylsulfamoyl)phenyl hydrazono]pentane-2,4-dione on blood parameters of albino rats

Intramuscular injection of 3-[p-(N-2-pyrimidylsulfamoyl)phenylhydrazono]pentane-2,4-dio ne (compound I) resulted in decrease in haemoglobin and alanine transaminase (ALT) and increase in aspartate transaminase (AST) values in albino rats. The serum glucose was found to decrease and after administration of 14 doses of 5.4 mg kg-1 body wt glucose level also declined significantly. It is concluded that the compound I is a better hypoglycemic than sulfonamide or hydrazone alone.

Haematological and hepatotoxic effects of silken styles of corn in albino rats

The alterations of haematological parameters in albino rats were studied after oral administration of an aqueous extract of silken styles of corn (Zea maize Linn.) at 50, 100 and 150 mg kg-1 daily for 21 days. The following haematological values were significantly reduced on the 7th and 21st day following extract administration: haemoglobin (Hb), red blood corpuscles (RBC), clotting time (CT), mean corpuscular volume (MCV), haematocrit (Ht), serum glucose, blood urea nitrogen (BUN), cholesterol, aspartate transaminase (AST), alanine transaminase (ALT), calcium, total protein, total albumin and total acid phosphatase; and white blood corpuscles (WBC), mean corpuscular haemoglobin (MCH), mean corpuscular haemoglobin concentration (MCHC), alkaline phosphatase and creatinine increased. The remaining parameters were not significantly affected, except body weight parameters at the two highest doses. The results emphasize that the biochemical changes caused through aqueous extract of silken styles of corn (Zea maize Linn.) are not significantly toxic at low and medium doses (50 and 100 mg kg-1).

Effect of graded mechanical ischemia on oxygen tension and electrical potential in the canine gastric mucosa. A new experimental model

Oxygen tension and potential difference were measured in the gastric mucosa of anesthetized dogs with an ultramicroelectrode technqiue while total blood flow and arteriovenous oxygen content difference were measured. In the control period, measurements were: gastric blood flow, 102.4 +/- 3.0 ml per min per 100 g of tissue; calculated oxygen consumption, 2.4 +/- 0.1 ml per min per 100 g of tissue; intracellular oxygen tension, 15.0 +/- 0.6 mm Hg; and intracellular potential difference, -50.8 +/- 1.5 mv. When gastric blood flow was reduced 50% by tourniquet ischemia, oxygen tension decreased 20% (P less than 0.05) but electrical potential and oxygen consumption did not change. When blood flow was reduced 75%, oxygen tension and potential difference decreased significantly, 60% and 35%, respectively, but oxygen consumption was unchanged. Zero blood flow reduced oxygen tension, electrical potential, and total oxygen consumption to zero; release of the arterial tourniquet allowed them to return to control levels. The critical oxygen tension at which the electromotive force generated by the gastric mucosal cells was reduced averaged 9 mm Hg. This suggests that safety factors exist in the gastric circulation which permit a 60% reduction in total gastric blood flow to occur before an insufficiency of intracellular oxygen begins to limit cellular metabolism within the mucosa.

The effect of stored blood on mesenteric oxygen extraction during exdotoxin shock

Storage of blood in acid-citrate-dextrose (ACD) solution gradually depletes red cell 2,3-diphosphoglycerate (DPG) and increases the affinity of hemoglobin for oxygen. We examined the effect of exchange transfusion of DPG-depleted blood on mesenteric blood flow and oxygen consumption in dogs subjected to endotoxin shock. Two groups of 6 dogs each were anesthetized and subjected to exchange transfusion with either fresh ACD blood or 21-day-old ACD blood prior to administration of Escherichia coli endotoxin (2 mg/kg). Mesenteric blood flow, arteriovenous oxygen content difference and systemic arterial blood pressure were monitored continuously before and for 60 min after endotoxin. Mesenteric blood flow was reduced from 250 +/- 21 ml/min before endotoxin to 114 +/- 15 ml/min at 5 min, 157 +/- 29 ml/min at 30 min, and 112 +/- 17 ml/min at 60 min after endotoxin in the dogs exchanged with fresh blood. Corresponding values for intestinal oxygen consumption were 10.4 +/- 1.0, 7.5 +/- 0.8, 8.4 +/- 1.0, and 6.8 +/- 0.7 ml/min. In dogs transfused with 21-day-old blood, pre-endotoxin blood flow was 208 +/- 2ml/min and declined to 115 +/- 12, 93 +/- 5, and 80 +/- 8 ml/min at 5, 30, and 60 min post-endotoxin. Corresponding values for intestinal oxygen consumption were 8.1 +/- 0.9, 6.6 +/- 0.7, 6.2 +/-0.5, and 5.5 +/- 0.7 ml/min. There was no significant difference (p greater than 0.1) in responses of blood flow or oxygen consumption to endotoxin shock between the two groups of dogs. These findings indicate that exchange transfusion with DPG-depleted blood does not impair oxygen extraction by the ischemic intestine.