The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

A comparison of surgical techniques for perineal wound closure following perineal excision: a systematic review and network meta-analysis

BACKGROUND

To mitigate pelvic wound issues following perineal excision of rectal or anal cancer, a number of techniques have been suggested as an alternative to primary closure. These methods include the use of a biological/dual mesh, omentoplasty, muscle flap, and/or pelvic peritoneum closure. The aim of this network analysis was to compare all the available surgical techniques used in the attempt to mitigate issues associated with an empty pelvis.

METHODS

An electronic systematic search using MEDLINE databases (PubMed), EMBASE, and Web of Science was performed (Last date of research was March 15th, 2023). Studies comparing at least two of the aforementioned surgical techniques for perineal wound reconstruction during abdominoperineal resection, pelvic exenteration, or extra levator abdominoperineal excision were included. The incidence of primary healing, complication, and/or reintervention for perineal wound were evaluated. In addition, the overall incidence of perineal hernia was assessed.

RESULTS

Forty-five observational studies and five randomized controlled trials were eligible for inclusion reporting on 146,398 patients. All the surgical techniques had a comparable risk ratio (RR) in terms of primary outcomes. The pooled network analysis showed a lower RR for perineal wound infection when comparing primary closure (RR 0.53; Crl 0.33, 0.89) to muscle flap. The perineal wound dehiscence RR was lower when comparing both omentoplasty (RR 0.59; Crl 0.38, 0.95) and primary closure (RR 0.58; Crl 0.46, 0.77) to muscle flap.

CONCLUSIONS

Surgical options for perineal wound closure have evolved significantly over the last few decades. There remains no clear consensus on the "best" option, and tailoring to the individual remains a critical factor.

Outcomes of endoscopic full thickness resection in the colon rectum at an Italian tertiary center

PURPOSE

Endoscopic full-thickness resection (EFTR) is an innovative technique for the treatment of colonic lesions not feasible by conventional endoscopic resection. Here, we aimed to evaluate the efficacy and safety of a Full-Thickness Resection Device (FTRD) for colonic lesions in a high-volume tertiary referral center.

METHODS

A review of a prospectively collected database on patients that underwent EFTR with FTRD for colonic lesions from June 2016 to January 2021 at our institution was performed. Data regarding the clinical history, previous endoscopic treatments, pathological examination, technical and histological success, and follow-up were evaluated.

RESULTS

Thirty-five patients (26 males, median age 69 years) underwent FTRD for colonic lesion. Eighteen lesions were in the left colon, three in the transverse, and 12 in the right colon. The median size of the lesions was 13 (range 10-40) mm. Resection was technically successful in 94% of patients. The mean hospital stay was 3.2 (SD ± 1.2) days. Adverse events were reported in four cases (11.4%). Histological complete resection (R0) was achieved in 93.9% of cases. Endoscopic follow-up was available in 96.8% of patients, at a median duration of 14.6 months (3-46 months). Recurrence was observed in 19.4% of cases at a median time of 3 months (3-7 months). Five patients had multiple FTRD performed, with R0 resection in three cases. In this subset, adverse events were observed in 40% of cases.

CONCLUSIONS

FTRD is safe and feasible for standard indication. The non-negligible rate of recurrence observed suggests the need for close endoscopic follow-up in these patients. Multiple EFTR could help achieve complete resection in selected cases; however, in this setting, a higher risk of adverse events was observed.

Efficacy of laparoscopic Toupet fundoplication compared to endoscopic and surgical procedures for GERD treatment: a randomized trials network meta-analysis

PURPOSE

We aim to review and quantitatively compare laparoscopic Toupet fundoplication (LTF), Nissen fundoplication (LNF), anterior partial fundoplication (APF), magnetic augmentation sphincter (MSA), radiofrequency ablation (RFA), transoral incisionless fundoplication (TIF), proton pump inhibitor (PPI), and placebo for the treatment of GERD. A number of meta-analyses compared the efficacy of surgical and endoscopic procedures for recalcitrant GERD, but considerable debate on the effectiveness of operative strategies remains.

METHODS

A systematic review of MEDLINE databases, EMBASE, and Web of Science for randomized controlled trials (RCTs) comparing the aforementioned surgical and endoscopic GERD treatments was performed. Risk ratio and weighted mean difference were used as pooled effect size measures, whereas 95% credible intervals (CrI) were used to assess relative inference.

RESULTS

Thirty-three RCTs were included. Surgical and endoscopic treatments have similar RR for heartburn, regurgitation, bloating. LTF has a lower RR of post-operative dysphagia when compared to APF (RR 3.3; Crl 1.4-7.1) and LNF (RR 2.5; Crl 1.3-4.4). The pooled network meta-analysis did not observe any significant improvement regarding LES pressure and pH < from baseline. LTF, APF, LNF, MSA, RFA, and TIF had have a similar post-operative PPI discontinuation rate.

CONCLUSION

LTF has a lower rate of post-operative dysphagia when compared to APF and LNF. The pre-post effects, such as GERD-HQRL, LES pressure, and pH <4, should be avoided in meta-analyses because results may be biased. Last, a consensus about the evaluation of GERD treatments' efficacy and their outcomes is needed.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.

Multimodal imaging of hemorrhagic transformation biomarkers in an ischemic stroke model

Hemorrhagic transformation of ischemic stroke has devastating consequences, with high mortality and poor functional outcomes. Animal models of ischemic stroke also demonstrate the potential for hemorrhagic transformation, which complicates biochemical characterization, treatment studies, and hinders poststroke functional outcomes in affected subjects. The incidence of hemorrhagic transformation of ischemic stroke in animal model research is not commonly reported. The postmortem brain of such cases presents a complex milieu of biomarkers due to the presence of healthy cells, regions of varying degrees of ischemia, dead and dying cells, dysregulated metabolites, and blood components (especially reactive Fe species released from lysed erythrocytes). To improve the characterization of hemorrhage biomarkers on an ischemic stroke background, we have employed a combination of histology, X-ray fluorescence imaging (XFI), and Fourier transform infrared (FTIR) spectroscopic imaging to assess 122 photothrombotic (ischemic) stroke brains. Rapid freezing preserves brain biomarkers in situ and minimizes metabolic artifacts due to postmortem ischemia. Analysis revealed that 25% of the photothrombotic models had clear signs of hemorrhagic transformation. The XFI and FTIR metabolites provided a quantitative method to differentiate key metabolic regions in these models. Across all hemorrhage cases, it was possible to consistently differentiate otherwise healthy tissue from other metabolically distinct regions, including the ischemic infarct, the ischemic penumbra, blood vessels, sites of hemorrhage, and a region surrounding the hemorrhage core that contained elevated lipid oxidation. Chemical speciation of deposited Fe demonstrates the presence of heme-Fe and accumulation of ferritin.

Prehabilitation in rectal surgery: a narrative review

AIM

Neoadjuvant chemotherapy (NACRT) can make decompensated patients more vulnerable prior to rectal surgery. Prehabilitation is an intervention which enhances functional capacity to withstand the stress of surgery. The aim of this review was to evaluate the impact of prehabilitation for patients undergoing rectal surgery on physical fitness and clinical outcomes and to establish feasibility of prehabilitation.

METHODS

An analysis of the literature was conducted of PubMed, the Cochrane Library, MEDLINE, EMBASE and ScienceDirect. Articles were initially included based on their title and abstracts reviewed. Full-text copies of those selected were obtained for confirmation of inclusion.

RESULTS

Eight studies were included. Heterogenicity was observed in the structure of exercise programmes. Improvements in physical fitness were observed in six studies. One study demonstrated a statistically significant improvement in quality of life. The prehabilitation programmes were shown to be feasible, with high completion rates. No adverse events were reported. There was limited data regarding the impact of prehabilitation on postoperative outcomes.

CONCLUSION

Current evidence on prehabilitation in rectal surgery has considerable heterogenicity in both structure of programmes and outcome measures. Standardisation is required for future evaluation of the impact on outcomes. A trimodal approach of exercise, nutritional and psychological interventions has been employed in similar programmes, and should be used in rectal surgery. The intervention should be tailored to the patient and environment. This review highlights the benefits, safety and feasibility of prehabilitation and provides a platform for consensus-building for international trials.

Oncological outcomes of laparoscopic versus open rectal cancer resections: meta-analysis of randomized clinical trials

BACKGROUND

The role of laparoscopic rectal cancer surgery has been questioned owing to conflicting reports on pathological outcomes from recent RCTs. However, it is unclear whether these pathological markers and the surgical approach have an impact on oncological outcomes. This study assessed oncological outcomes of laparoscopic and open rectal cancer resections.

METHODS

A meta-analysis of RCTs was performed. Primary endpoints included oncological outcomes (disease-free survival (DFS), overall survival (OS), local recurrence). Secondary endpoints included surrogate markers for the quality of surgical resection.

RESULTS

Twelve RCTs including 3744 patients (2133 laparoscopic, 1611 open) were included. There was no significant difference in OS (hazard ratio (HR) 0.87, 95 per cent c.i. 0.73 to 1.04; P = 0.12; I2 = 0 per cent) and DFS (HR 0.95, 0.81 to 1.11; P = 0.52; I2 = 0 per cent) between laparoscopic and open rectal resections. There was no significant difference in locoregional (odds ratio (OR) 1.03, 95 per cent c.i. 0.72 to 1.48; P = 0.86; I2 = 0 per cent) or distant (OR 0.87, 0.70 to 1.08; P = 0.20; I2 = 7 per cent) recurrence between the groups. Achieving a successful composite score (intact mesorectal excision, clear circumferential resection margin and distal margin) was significantly associated with improved DFS (OR 0.55, 0.33 to 0.74; P < 0.001; I2 = 0 per cent). An intact or acceptable mesorectal excision (intact mesorectal excision with or without superficial defects) had no impact on DFS. Finally, a positive CRM was associated with worse DFS.

CONCLUSION

Well performed surgery (laparoscopic or open) achieves excellent oncological outcomes with very little difference between the two modalities. The advantage and benefit of minimally invasive surgery should be assessed on an individual basis.

Lateral pelvic lymphadenectomy for low rectal cancer: a META-analysis of recurrence rates

BACKGROUND

Locoregional recurrence (LR) remains a problem for patients with lower rectal cancer despite standardized surgery and improved neoadjuvant treatment regimens. Lateral pelvic lymph node dissection (LPLND) has been routine practice for some time in the Orient/East, but other regions have concerns about morbidity. As perioperative care and surgical approaches are refined, this has been revisited for selected patients. The question as to whether LPLND improves oncological outcomes was explored here.

METHODS

A systematic review of patients who underwent TME with or without LPLND from 2000 to 2020 was performed. The primary endpoint was the rate of LR between the two groups.

RESULTS

Seven papers met the predefined search criteria in which 2000 patients underwent TME alone, while 1563 patients had TME and LPLND. The rate of LR was marginally higher with TME alone when compared with TME plus LPLND, but this result was not statistically significant (9.8 vs 9.4%, odds ratio 0.75, 95% CI 0.41-1.38, *p = 0.35). In addition, four studies reported on distant recurrence rates, with TME and LPLND showing a slight reduction in overall rates (27.3 vs 29.9%, respectively, OR 0.65, 95% CI 0.45-0.92, *p = 0.02).

CONCLUSION

The addition of LPLND to TME is not associated with a significantly lower risk of LR in patients who undergo surgery for lower rectal cancer.

Management of anal intraepithelial neoplasia and anal squamous cell carcinoma at a tertiary referral centre with a dedicated infectious diseases unit: an 18-year review

INTRODUCTION

Anal squamous cell carcinoma (ASCC) is a rare malignancy with rising incidence rates. Risk factors include human immunodeficiency virus (HIV) infection, high-risk sexual activity and HPV-related genitourinary dysplasia/neoplasia. There is an overlap between high-risk patients and those attending HIV Medicine/Sexual Health (HMSH) services. We hypothesised that HMSH involvement may facilitate earlier referral to colorectal surgeons, with better outcomes.

METHODS

Retrospective review of all ASCC and anal intraepithelial neoplasia (AIN) treated at a tertiary-referral hospital with a dedicated HMSH clinic between 2000 and 2018. Comparative analysis was performed of demographics, management and outcomes between HMSH and non-HMSH patients.

RESULTS

One hundred and nine patients had anal pathology, eighty-five with ASCC (78%) and twenty-four with AIN (22%). Seventy (64%) were male. Median (range) age at ASCC diagnosis was 51 years (26-88). Thirty-six percent of all patients attended HMSH services, 28% were HIV positive, and 41% of males were men-who-have-sex-with-men (MSM). Eighty-one ASCC patients (97.5%) were treated with curative intent. Sixty-seven (80%) had primary chemoradiation therapy. Fifteen (17.5%) had primary surgical excision. Twelve (14%) developed recurrent disease. Ultimately, seven required salvage APR. Overall 3-year survival (3YS) was 76%. HMSH patients were significantly younger at ASCC diagnosis (p < 0.001), with a higher prevalence of HIV, HPV and MSM. HMSH attenders also tended to be diagnosed at earlier stages, were less likely to develop recurrence and achieved better overall outcomes, with a superior overall 3YS than non-HMSH patients (92% vs 72%, p = 0.037).

CONCLUSION

ASCC incidence is increasing worldwide. The HMSH cohort has emerged as a distinct subpopulation of younger, high-risk, male patients. Collaboration between HMSH and colorectal surgeons offers an opportunity for risk reduction strategies and earlier intervention.

Management options for chronic anal fissure: a systematic review of randomised controlled trials

INTRODUCTION

Anal fissure is the most common cause of severe anorectal pain in adults, contributing significantly to coloproctology workloads. There are a wide variety of management options available, including topical nitrites, calcium channel blockers, botulinum toxin injection and sphincterotomy. The aim of this study was to review current options for the treatment of chronic anal fissure.

METHODS

A comprehensive search identifying randomized controlled trials comparing treatment options for anal fissure published between January 2000 and February 2020 was performed. The primary outcome assessed was healing at 8 weeks post commencing treatment. Secondary outcomes included recurrence, intolerance of treatment and complications.

RESULTS

A total of 2822 studies were identified. After removal of duplicates and non-relevant studies, we identified nine randomized controlled trials which met pre-defined criteria. There was a total of 775 patients. At 8 weeks, healing rates were 95.13% in those treated with sphincterotomy, 66.7% in the botulinum toxin group, 63.8% in the nitrate group, 52.3% for topical diltiazem and 50% for topical minoxidil. Recurrence was highest amongst those treated with botulinum toxin injection (41.7%) and lowest for sphincterotomy (6.9%). Although the absolute number is low, there was a risk of permanent incontinence with sphincterotomy.

CONCLUSION

This review of the randomized control data demonstrates that healing was significantly higher amongst those treated with sphincterotomy versus more conservative modalities. Topical nitrites had similar outcomes to botulinum toxin injection but were poorly tolerated in comparison to other treatments. The benefit of sphincterotomy was at a cost of increased complications, notably permanent incontinence.

The Potential of a Relational Training Intervention to Improve Older Adults' Cognition

Behavioral gerontology rarely focuses on improving older adults' cognitive function. This gap in the literature should be addressed, as our aging population means that greater numbers of older adults are experiencing cognitive decline and reduced functional independence. If cognitive training interventions are to be socially significant, they should target improvements in core executive functions (EFs) that are critical for everyday cognition and functioning independence. Evidence from the cognitive sciences suggests that a cognitive training intervention targeting "relational knowledge" and "cognitive flexibility," which are core EFs, could translate to improvements in cognition and functioning for older adults. Behavioral researchers, interested in the effects of relational training on cognition, have shown a relationship between complex and flexible arbitrarily applicable relational responding (AARRing) and improved performance on measures of intelligence in children and young adults. However, data examining the impact of AARRing on the cognition of older adults are lacking. This article suggests that complex and flexible AARRing may be synonymous with the aforementioned EFs of relational knowledge and cognitive flexibility, and that a behaviorally oriented relational training intervention might improve cognition and functioning for healthy older adults or those experiencing cognitive decline. The article initially presents a brief overview of research in behavioral gerontology and older adult cognition, followed by a detailed explanation of how training complexity and flexibility in AARRing could result in improvements in core EFs. Specific suggestions for designing a relational training intervention and assessing relevant outcomes are provided.

Should MRI Be the Imaging Modality of Choice in Suspected Appendicitis During Pregnancy?

Aim The aim of this review was to evaluate the efficacy of magnetic resonance imaging (MRI) in determining appendicitis during pregnancy. Methods We retrospectively reviewed the clinical course for all pregnant patients with suspected appendicitis from 2013-2018. We evaluated the efficacy of MRI and Alvarado scoring and its impact on management. Results Twenty-nine pregnant patients with suspected appendicitis had an MRI. The majority (90%, n=26/29) had normal diagnostics with two patients (10.3%) having findings consistent with acute appendicitis. Two other patients proceeded to laparoscopy, one with an inconclusive MRI, and one patient with clinical appendicitis. We found no accurate correlation between pregnancy and Alvarado scoring. Conclusion MRI is a safe adjunct in accurately diagnosing appendicitis in pregnancy. Its routine use could help reduce rates of negative appendectomies and the potential risk to maternal and fetal health.

Minimally invasive approaches to the management of anastomotic leakage following restorative rectal cancer resection

AIM

Management of anastomotic leakage (AL) following rectal resection has evolved with increasing use of less invasive techniques. The aim of this study was to review the management of AL following restorative rectal cancer resection in a tertiary referral centre.

METHOD

A retrospective review of a prospectively maintained database was performed. The primary outcome was successful management of AL. The secondary outcome was the impact of AL on oncological outcome.

RESULTS

Five hundred and two restorative rectal cancer resections were performed during the study period. The incidence of AL was 9.9% (n = 50). AL occurred more commonly following neoadjuvant chemoradiotherapy (n = 31/252, 12.3%) than in those who did not receive neoadjuvant chemoradiotherapy (n = 19/250, 7.6%; P = 0.107); however, this was not statistically significant. Successful minimally invasive drainage was achieved in 28 patients (56%, radiological n = 24, surgical n = 4). Trans-rectal drainage was the most common drainage method (n = 14). The median duration of drainage was longer in the neoadjuvant group (27 vs 18 days). Surgical intervention was required in 11 patients, with anastomotic takedown and end-colostomy formation was most commonly required. Successful management of AL with drainage (maintenance of the anastomosis without the need for further intervention) was achieved in 26 of the 28 patients. There were no significant differences in overall or disease-free survival when patients with AL were compared with patients without AL (69.4% vs 72.6%, P = 0.99 and 78.7% vs 71.3%, P = 0.45, respectively).

CONCLUSION

In selected patients, AL following restorative rectal resection can be effectively controlled using minimally invasive radiological or surgical drainage without the need for further intervention.

Prophylactic negative wound therapy in laparotomy wounds (PROPEL trial): randomized controlled trial

BACKGROUND

Superficial surgical site infections are a common post-operative complication. They also place a considerable financial burden on healthcare. The use of prophylactic negative pressure wound therapy has been advocated to reduce wound infection rates. However, there is debate around its routine use. The purpose of this trial is to determine if prophylactic negative pressure wound therapy reduces post-operative wound complications in patients undergoing laparotomy.

METHODS/DESIGN

This multi-centre randomised controlled trial will compare standard surgical dressings (control) to two competing negative pressure wound therapy dressings (Prevena™ and PICO™). All patients will be over 18 years, who are undergoing an emergency or elective laparotomy. It is intended to enrol a total of 271 patients for the trial.

DISCUSSION

The PROPEL trial is a multi-centre randomised controlled trial of patients undergoing laparotomy. The comparison of standard treatment to two commercially available NPWT will help provide consensus on the routine management of laparotomy wounds.

TRIAL REGISTRATION

This study is registered with ClinicalTrials.gov (NCT number NCT03871023).

A standardized use of intraoperative anastomotic testing in colorectal surgery in the new millennium: is technology taking over? A systematic review and network meta-analysis

BACKGROUND

Anastomotic leakage (AL) remains the most challenging complication following colorectal resection. There are several tests that can be used to test anastomotic integrity intraoperatively including air leak testing (ALT) and intraoperative colonoscopy (IOC). Indocyanine green (ICG) can be used to visualise blood supply to the bowel used in the anastomosis. However, there is no consensus internationally regarding routine use and which technique is superior. The aim of this study was to determine which intraoperative anastomotoic leak test (IALT) was most effective in reducing AL.

METHODS

A systematic review and network meta-analysis were performed. An electronic systematic search was performed using Pubmed, CENTRAL, and Web of Science, of studies comparing ALT, IOC, and ICG. The inclusion criteria were as follows: (a) patients must have had colorectal surgery with formation of an anastomosis; (b) studies must have compared one or more IALTs; (c) and studies must have clear research methodology.

RESULTS

Eleven articles totalling 3844 patients met the inclusion criteria and were included in this meta-analysis. Point estimation showed that the AL rate in the control group (no IALT) was significantly higher when compared to the ICG group (RR 0.44; Crl 0.14-0.87) and higher, but without reaching statistical significance, when compared to ALT (RR 0.53; Crl 0.21-1.30) and IOC (RR 0.49; Crl 0.10-1.80). Indirect comparison showed that the AL rate in the ICG group was lower, when compared to both ALT (RR 0.44; Crl 0.14-0.87) and IOC (RR 0.44; Crl 0.14-0.87).

CONCLUSIONS

This study suggests that intraoperative testing for a good blood supply using ICG may reduce the AL rate following colorectal surgery.

Meta-analysis of the effect of extending the interval after long-course chemoradiotherapy before surgery in locally advanced rectal cancer

BACKGROUND

The current standard of care in locally advanced rectal cancer (LARC) is neoadjuvant long-course chemoradiotherapy (nCRT) followed by total mesorectal excision (TME). Surgery is conventionally performed approximately 6-8 weeks after nCRT. This study aimed to determine the effect on outcomes of extending this interval.

METHODS

A systematic search was performed for studies reporting oncological results that compared the classical interval (less than 8 weeks) from the end of nCRT to TME with a minimum 8-week interval in patients with LARC. The primary endpoint was the rate of pathological complete response (pCR). Secondary endpoints were recurrence-free survival, local recurrence and distant metastasis rates, R0 resection rates, completeness of TME, margin positivity, sphincter preservation, stoma formation, anastomotic leak and other complications. A meta-analysis was performed using the Mantel-Haenszel method.

RESULTS

Twenty-six publications, including four RCTs, with 25 445 patients were identified. A minimum 8-week interval was associated with increased odds of pCR (odds ratio (OR) 1·41, 95 per cent c.i. 1·30 to 1·52; P < 0·001) and tumour downstaging (OR 1·18, 1·05 to 1·32; P = 0·004). R0 resection rates, TME completeness, lymph node yield, sphincter preservation, stoma formation and complication rates were similar between the two groups. The increased rate of pCR translated to reduced distant metastasis (OR 0·71, 0·54 to 0·93; P = 0·01) and overall recurrence (OR 0·76, 0·58 to 0·98; P = 0·04), but not local recurrence (OR 0·83, 0·49 to 1·42; P = 0·50).

CONCLUSION

A minimum 8-week interval from the end of nCRT to TME increases pCR and downstaging rates, and improves recurrence-free survival without compromising surgical morbidity.

Direct label-free imaging of brain tissue using synchrotron light: a review of new spectroscopic tools for the modern neuroscientist

The incidence of brain disease and brain disorders is increasing on a global scale. Unfortunately, development of new therapeutic strategies has not increased at the same rate, and brain diseases and brain disorders now inflict substantial health and economic impacts. A greater understanding of the fundamental neurochemistry that underlies healthy brain function, and the chemical pathways that manifest in brain damage or malfunction, are required to enable and accelerate therapeutic development. A previous limitation to the study of brain function and malfunction has been the limited number of techniques that provide both a wealth of biochemical information, and spatially resolved information (i.e., there was a previous lack of techniques that provided direct biochemical or elemental imaging at the cellular level). In recent times, a suite of direct spectroscopic imaging techniques, such as Fourier transform infrared spectroscopy (FTIR), X-ray fluorescence microscopy (XFM), and X-ray absorption spectroscopy (XAS) have been adapted, optimized and integrated into the field of neuroscience, to fill the above mentioned capability-gap. Advancements at synchrotron light sources, such as improved light intensity/flux, increased detector sensitivities and new capabilities of imaging/optics, has pushed the above suite of techniques beyond "proof-of-concept" studies, to routine application to study complex research problems in the field of neuroscience (and other scientific disciplines). This review examines several of the major advancements that have occurred over the last several years, with respect to FTIR, XFM and XAS capabilities at synchrotron facilities, and how the increases in technical capabilities have being integrated and used in the field of neuroscience.

Colonic stenting as a bridge to surgery in malignant large bowel obstruction: oncological outcomes

INTRODUCTION

Stenting of obstructing colorectal cancers obviates the need for emergency surgery, reducing initial morbidity and mortality rate associated with emergency surgery and facilitates full staging of the neoplastic process with an opportunity to optimize the patient for surgery. Some recent publications have suggested however that this approach may be associated with higher local recurrence rates. We examined our outcomes following colonic stenting as a bridge to resection.

METHODS

A database was reviewed (2006-2018) of patients presenting with acute colorectal obstruction that proceeded to endoscopic stenting. We assessed the bridge to surgery strategy, its success, complication rate, and impact on recurrence and survival.

RESULTS

Of a total of 103 patients who presented with acute malignant large bowel obstruction over this time period, 26 patients had potentially curable disease at presentation and underwent stenting as a bridge to surgery. The technical success rate for stenting in those managed as a bridge to surgery was 92% (n = 24/26) with 7.69% (n = 2/26) having a complication. There was one stent-related perforation. Median follow-up of this cohort was 31 months, with a 5-year overall survival of 53.5%.

CONCLUSION

Colorectal stenting as a bridge to resection is a successful management strategy for those presenting with obstructing colorectal obstruction. Selective use is associated with lower rates of stoma formation, greater rates of laparoscopic resections with low complication rates, and acceptable oncological outcomes.

Meta-analysis of the cost-effectiveness of early versus delayed cholecystectomy for acute cholecystitis

Background

Acute calculous cholecystitis (ACC) is a common disease across the world and is associated with significant socioeconomic costs. Although contemporary guidelines support the role of early laparoscopic cholecystectomy (ELC), there is significant variation among units adopting it as standard practice. There are many resource implications of providing a service whereby cholecystectomies for acute cholecystitis can be performed safely.

Methods

Studies that incorporated an economic analysis comparing early with delayed laparoscopic cholecystectomy (DLC) for acute cholecystitis were identified by means of a systematic review. A meta‐analysis was performed on those cost evaluations. The quality of economic valuations contained therein was evaluated using the Quality of Health Economic Studies (QHES) analysis score.

Results

Six studies containing cost analyses were included in the meta‐analysis with 1128 patients. The median healthcare cost of ELC versus DLC was €4400 and €6004 respectively. Five studies had adequate data for pooled analysis. The standardized mean difference between ELC and DLC was −2·18 (95 per cent c.i. −3·86 to −0·51; P = 0·011; I² = 98·7 per cent) in favour of ELC. The median QHES score for the included studies was 52·17 (range 41–72), indicating overall poor‐to‐fair quality.

Conclusion

Economic evaluations within clinical trials favour ELC for ACC. The limited number and poor quality of economic evaluations are noteworthy.

Quality of life following ostomy reversal with purse-string vs linear skin closure: a systematic review

BACKGROUND

The importance of the defunctioning stoma on minimizing anastomotic leak in colorectal surgery is well established. However, a defunctioning stoma can substantially impact on quality of life (QoL). Circumferential purse-string approximation (PSA) and linear skin closure (LSC) are the most commonly performed surgical technique for reversal of stoma. The aim of this review was to systemically review and meta-analyze available randomized controlled trials (RCTs) comparing PSA and LSC.

METHODS

An electronic systematic search using MEDLINE databases (PubMed, EMBASE, and Web of Science) of RCTs comparing PSA and LSC was performed. Eight RCTs totalling 647 patients met the inclusion criteria and were included in this meta-analysis.

RESULTS

Patient's satisfaction is significantly lower in PSA group during the first postoperative week, but it sharply improves afterwards and no difference were noted at 1 and 6 months between the two groups. Relative risk (RR) of developing a SSI is significantly lower in PSA compared to LSC group (RR 0.16 95% CI 0.09; 0.30; p = 0.0001), whereas incisional hernia (RR 0.53 95% CI 0.08; 3.53; p = 0.512), operative time (MD - 0.06 95% CI - 0.30; 0.17; p = 0.593), and hospital stay (MD - 0.09 (95% CI - 0.29-0.11; p = 0.401) remain similar.

DISCUSSION

QoL was similar in both patients groups after the first postoperative week. PSA significantly reduced SSI rate. No difference was observed in incisional hernia rate, operative time, or length of hospital stay.

Effects of CDX2 on prognosis and chemotherapy responsiveness in mismatch repair-deficient colorectal cancer

Background

Caudal‐related homeobox transcription factor 2 (CDX2) is an intestine‐specific transcription factor implicated in tumour differentiation, proliferation, cell adhesion and migration. Negative CDX2 status (CDX2−) is associated with worse prognosis in colorectal cancer and may identify high‐risk stage II disease that benefits from adjuvant chemotherapy. This observational study investigated whether CDX2− is associated with prognosis or response to chemotherapy in the mismatch repair‐deficient (dMMR) phenotype of colorectal cancer.

Methods

Patients with resectable dMMR colorectal cancer were eligible for inclusion. The prognostic and predictive value of CDX2 expression on the presence of lymph node metastasis (LNM) and survival was investigated. CDX2 status was determined via immunohistochemistry using the Leica Bond™ CDX2 (clone EP25) ready‐to‐use primary antibody.

Results

Some 235 of 238 consecutive dMMR tumours were assessed for CDX2 status. CDX2− was observed in 15·7 per cent of colorectal cancer. Interobserver agreement was excellent (κ = 0·863; P < 0·001). CDX2− was significantly associated with female sex, increased size, advanced stage, worse conventional and poorly differentiated cluster (PDC) grade, mucinous morphology, perineural and lymphovascular invasion, and pN status (all P ≤ 0·038). CDX2− was not associated with LNM or survival in multivariable analysis. Independent predictors of LNM were PDC grade (odds ratio (OR) 4·12, 95 per cent c.i. 1·76 to 9·63; P = 0·001) and extramural venous invasion (OR 3·79, 1·62 to 8·85; P = 0·002). Budding (hazard ratio (HR) 2·79, 95 per cent c.i. 1·60 to 4·87; P < 0·001), pT status (HR 3·59, 1·29 to 10·01; P = 0·015) and adjuvant chemotherapy (HR 2·07, 1·15 to 3·74; P = 0·016) were independently associated with worse disease‐free survival.

Conclusion

CDX2− does not confer a worse prognosis in the dMMR phenotype of colorectal cancer. The MMR status of patients with colorectal cancer should be determined before assessing CDX2 status.

Curative cerebrovascular reconstruction with the Pipeline embolization device: the emergence of definitive endovascular therapy for intracranial aneurysms

Endovascular, endosaccular, coil embolization has emerged as an established therapy for both ruptured and unruptured cerebral aneurysms. However, many aneurysms are not cured using conventional endovascular techniques. Coil embolization often results in incomplete aneurysm occlusion or recanalization in the ensuing months after treatment. The Pipeline embolization device (PED; Chestnut Medical) represents a new generation endoluminal implant which is designed to treat aneurysms by reconstructing the diseased parent artery. Immediately after implantation, the PED functions to divert flow from the aneurysm, creating an environment conducive to thrombosis. With time, the PED is incorporated into the vessel wall as neointimal–endothelial overgrowth occurs along the construct. Ultimately, this process results in the durable complete exclusion of the aneurysm from the cerebrovasculature and a definitive endoluminal reconstruction of the diseased parent artery.

Correction to: A systematic review of stakeholder views of selection methods for medical schools admission

Following publication of the original article [1], the author report typographical errors in the.

Association of Age-Related Hearing Loss With Cognitive Function, Cognitive Impairment, and Dementia: A Systematic Review and Meta-analysis

Importance

Epidemiologic research on the possible link between age-related hearing loss (ARHL) and cognitive decline and dementia has produced inconsistent results. Clarifying this association is of interest because ARHL may be a risk factor for outcomes of clinical dementia.

Objectives

To examine and estimate the association between ARHL and cognitive function, cognitive impairment, and dementia through a systematic review and meta-analysis.

Data Sources and Study Selection

A search of PubMed, the Cochrane Library, EMBASE, and SCOPUS from inception to April 15, 2016, with cross-referencing of retrieved studies and personal files for potentially eligible studies was performed. Keywords included hearing, cognition, dementia, and Alzheimer disease. Cohort and cross-sectional studies published in peer-reviewed literature and using objective outcome measures were included. Case-control studies were excluded.

Data Extraction and Synthesis

One reviewer extracted and another verified data. Both reviewers independently assessed study quality. Estimates were pooled using random-effects meta-analysis. Subgroup and meta-regression analyses of study-level characteristics were performed.

Main Outcomes and Measures

Hearing loss measured by pure-tone audiometry only and objective assessment measures of cognitive function, cognitive impairment, and dementia. Cognitive function outcomes were converted to correlation coefficients (r value); cognitive impairment and dementia outcomes, to odds ratios (ORs).

Results

Forty studies from 12 countries met our inclusion criteria. Of these, 36 unique studies with an estimated 20 264 unique participants were included in the meta-analyses. Based on the pooled maximally adjusted effect sizes using random-effects models, a small but significant association was found for ARHL within all domains of cognitive function. Among cross-sectional studies, a significant association was found for cognitive impairment (OR, 2.00; 95% CI, 1.39-2.89) and dementia (OR, 2.42; 95% CI, 1.24-4.72). Among prospective cohort studies, a significant association was found for cognitive impairment (OR, 1.22; 95% CI, 1.09-1.36) and dementia (OR, 1.28; 95% CI, 1.02-1.59) but not for Alzheimer disease (OR, 1.69; 95% CI, 0.72-4.00). In further analyses, study, demographic, audiometric, and analyses factors were associated with cognitive function. Vascular dysfunction and impaired verbal communication may contribute to the association between hearing loss and cognitive decline.

Conclusions and Relevance

Age-related hearing loss is a possible biomarker and modifiable risk factor for cognitive decline, cognitive impairment, and dementia. Additional research and randomized clinical trials are warranted to examine implications of treatment for cognition and to explore possible causal mechanisms underlying this relationship.

The impact of social activities, social networks, social support and social relationships on the cognitive functioning of healthy older adults: a systematic review

BACKGROUND

Social relationships, which are contingent on access to social networks, promote engagement in social activities and provide access to social support. These social factors have been shown to positively impact health outcomes. In the current systematic review, we offer a comprehensive overview of the impact of social activities, social networks and social support on the cognitive functioning of healthy older adults (50+) and examine the differential effects of aspects of social relationships on various cognitive domains.

METHODS

We followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines, and collated data from randomised controlled trials (RCTs), genetic and observational studies. Independent variables of interest included subjective measures of social activities, social networks, and social support, and composite measures of social relationships (CMSR). The primary outcome of interest was cognitive function divided into domains of episodic memory, semantic memory, overall memory ability, working memory, verbal fluency, reasoning, attention, processing speed, visuospatial abilities, overall executive functioning and global cognition.

RESULTS

Thirty-nine studies were included in the review; three RCTs, 34 observational studies, and two genetic studies. Evidence suggests a relationship between (1) social activity and global cognition and overall executive functioning, working memory, visuospatial abilities and processing speed but not episodic memory, verbal fluency, reasoning or attention; (2) social networks and global cognition but not episodic memory, attention or processing speed; (3) social support and global cognition and episodic memory but not attention or processing speed; and (4) CMSR and episodic memory and verbal fluency but not global cognition.

CONCLUSIONS

The results support prior conclusions that there is an association between social relationships and cognitive function but the exact nature of this association remains unclear. Implications of the findings are discussed and suggestions for future research provided.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2012: CRD42012003248 .

Meta-analysis of the impact of surgical approach on the grade of mesorectal excision in rectal cancer

BACKGROUND

The subspecialization of colorectal surgeons, and improvements in the quality of mesorectal excision have revolutionized rectal cancer surgery. With the increasing use of minimally invasive techniques, the completeness of the mesorectal excision has been questioned. This study aimed to assess the pathological outcomes of open versus laparoscopic rectal resection.

METHODS

A meta-analysis of RCTs was undertaken. The primary endpoint was the adequacy of the mesorectal excision. Secondary endpoints included circumferential resection margin and distance to resection margins.

RESULTS

Four studies were included, reporting on 2319 patients; 972 (41·9 per cent) had open and 1347 (58·1 per cent) had laparoscopic resections. Meta-analysis of adequacy of the mesorectal excision showed a small difference in achieving an intact mesorectum in favour of open surgery (risk ratio (RR) 1·06, 95 per cent c.i. 1·02 to 1·10; P = 0·001). Superficial defects were more common in laparoscopic surgery (RR 0·70, 0·54 to 0·89; P = 0·004). Deep mesorectal defects (RR 0·78, 0·51 to 1·20; P = 0·256), circumferential margin (CRM) positivity (RR 0·85, 0·62 to 1·16; P = 0·310), and distance to radial (mean difference (MD) -0·06, 95 per cent c.i. -0·10 to 0·23; P = 0·443) and distal (MD 0·03, -0·06 to 0·12; P = 0·497) margins were all similar. A complete resection (intact mesorectum, negative CRM and distal margin) was achieved in 350 of 478 patients (73·2 per cent) in the laparoscopic group and 372 of 457 (81·4 per cent) in the open group (risk difference (RD) 8 (95 per cent c.i. 3 to 13) per cent; P = 0·003). However, an acceptable mesorectum (intact or superficial defects only) was present in 1254 of 1308 (95·9 per cent) and 916 of 949 (96·5 per cent) in the laparoscopic and open groups respectively (RD 1 (-1 to 3) per cent; P = 0·263).

CONCLUSION

Small differences in mesorectal quality were evident between open and laparoscopic rectal resections. This may be attributable to use of laparoscopic instruments; however, to date minor defects have not affected oncological outcomes.

Surgical management of splenic marginal zone lymphoma

OBJECTIVES

Splenic marginal zone lymphoma (SMZL) is a rare indolent B-cell lymphoma with variable prognosis. As a result, there is sparse knowledge on the role of splenectomy and best management approaches. We aim to explore management strategies and outcomes amongst the cohort of SMZL patients at our centre.

METHOD

A retrospective review of all splenectomies performed at a tertiary referral unit over a 23-year period was assessed. Immunohistochemical and pathological results of splenic samples, bone marrow biopsies, and peripheral blood were compiled. Operative management, surgical, and survival outcomes were assessed. Prognostic stratifications were applied and survival rates were calculated.

RESULTS

Eight cases of SMZL from a database of 693 splenectomies were identified. All patients had intermediate/high-risk disease. All patients underwent splenectomy with one patient receiving preoperative rituximab. All patients had progression-free survival and resolution of disease.

CONCLUSION

Based on the data obtained, current practice requires defined guidelines and centralised care.

Antenatal Pertussis Vaccination: Why are General Practitioners Reluctant? A Mixed Methods StudySetting

Pertussis has a disproportionately higher morbidity and mortality in infants less than 3 months of age. International and national guidelines recommend pertussis vaccination during pregnancy, as a safe and effective way to protect these infants. Antenatal pertussis vaccination uptake rates remain suboptimal, with many health care professionals (HCPs) still not recommending it. The reasons underlying this reluctance on behalf of HCPs have not been fully established. This study aims to evaluate the current practice and attitudes of General Practitioners (GPs) with regard to antenatal pertussis vaccination. An embedded mixed method design was used. The response rate was 41% (n=109). 54% of GPs who responded (n=59) routinely recommend antenatal pertussis vaccination. Safety concerns and a sense of isolation emerged as the major qualitative themes. More safety data, adequate funding from the Health Service Executive (HSE) and support from secondary care may help to increase the GP recommendation rate and enhance vaccination uptake in pregnancy.

Science or popular media: What drives breast cancer online activity?

Google Trends is reflective of international awareness. Since its launch in 2004, there have been several landmark publications, international awareness campaigns, and mainstream-media events that involve breast cancer. The aim of this study was to assess the impact of landmark academic publications vs mainstream-media announcements in driving online breast cancer activity via Google Trends. Ten breast cancer-related themes or landmark publications (five academic publications and five media-related events) were used to compare the impact of online search activity. This activity was determined by retrospectively analyzing Google Trends data over a 12-year period (2004-2016) and calculating the relative search volume. Breast cancer searches showed a slight decrease in the twelve-year period. Since 2004, eight of top 10 Breast Cancer searches were in October. This coincides with breast cancer awareness month. The major five academic publications were all published in the New England Journal of Medicine or the Lancet. Interestingly, only one publication (Tailor-X trial) made the top 10 spikes in relative search volume. Academic publications as expected generate lower rates of public awareness and Internet searching. However, if academic publications are coupled with media releases, there is considerable potential for achieving increased public awareness.

The Impact of the Mediterranean Diet on the Cognitive Functioning of Healthy Older Adults: A Systematic Review and Meta-Analysis

Evidence from epidemiologic studies suggests a relation between the Mediterranean diet (MeDi) and cognitive function, but results are inconsistent. Prior reviews have not provided pooled data from meta-analysis of longitudinal studies and randomized controlled trials (RCTs), or they included younger adult participants. This systematic review and meta-analysis examines the impact of the MeDi on the cognitive functioning of healthy older adults. Fifteen cohort studies with 41,492 participants and 2 RCTs with 309 and 162 participants in intervention and control groups, respectively, were included. The primary outcome of interest was cognitive function, divided into domains of memory and executive function. Meta-analysis of cohort studies revealed a significant association between MeDi and older adults' episodic memory (n = 25,369, r = 0.01, P = 0.03) and global cognition (n = 41,492, r = 0.05, P ≤ 0.001), but not working memory (n = 1487, r = 0.007, P = 0.93) or semantic memory (n = 1487, r = 0.08, P = 0.28). Meta-analysis of RCTs revealed that compared with controls, the MeDi improved delayed recall (n = 429, P = 0.01), working memory (n = 566, P = 0.03), and global cognition (n = 429, P = 0.047), but not episodic memory (n = 566, P = 0.15), immediate recall (n = 566, P = 0.17), paired associates (n = 429, P = 0.20), attention (n = 566, P = 0.69), processing speed (n = 566, P = 0.35), or verbal fluency (n = 566, P = 0.12). The strongest evidence suggests a beneficial effect of the MeDi on older adults' global cognition. This article discusses the influence of study design and components of the MeDi on cognitive function and considers possible mechanisms.

A systematic review examining quality of life following pelvic exenteration for locally advanced and recurrent rectal cancer

AIM

Pelvic exenteration is a complex surgical procedure associated with considerable morbidity. Quality of life (QoL) is a crucial metric of surgical outcome. The aim of this review was to assess the QoL following pelvic exenteration for locally advanced rectal cancer (LARC) and local recurrent rectal cancer (LRRC).

METHOD

A comprehensive search of studies published between 2000 and 2016 that examined QoL outcome following pelvic exenteration was performed. Functional Assessment of Cancer Therapy - Colorectal (FACT-C), SF-36 version 2, European Organization for Research and Treatment of Cancer QLQ-C30, and Brief Pain Inventory assessments from these studies were reviewed.

RESULTS

Seven studies reporting on 382 patients were included. Baseline QoL was the strongest predictor of postoperative QoL. Female gender, total pelvic exenteration with or without bone resection, and positive surgical margins were associated with a reduced QoL. In the majority of patients, QoL gradually improved between 2 and 9 months post-operation.

CONCLUSION

QoL is an important patient-reported outcome. This review highlights factors associated with reduced postoperative QoL that should be borne in mind when surgical resection is being considered.

Satisfaction rates with the current Special Type Consultation (STC) reimbursement scheme among General Practitioners - A Mixed Methods Study

The Special Type Consultation (STC) scheme is a fee-for-service reimbursement scheme for General Practitioners (GPs) in Ireland. Introduced in 1989, the scheme includes specified patient services involving the application of a learned skill, e.g. suturing. This study aims to establish the extent to which GPs believe this scheme is appropriate for current General Practice. This is an embedded mixed-methods study combining quantitative data on GPs working experience of and qualitative data on GPs attitudes towards the scheme. Data were collected by means of an anonymous postal questionnaire. The response rate was 60.4% (n=159.) Twenty-nine percent (n=46) disagreed and 65% (n=104) strongly disagreed that the current list of special items is satisfactory. Two overriding themes were identified: economics and advancement of the STC process. This study demonstrates an overwhelming consensus among GPs that the current STC scheme is outdated and in urgent need of revision to reflect modern General Practice.

Chronic Disease Management - The Patient's Perspective

A paucity of data exists on Irish patients' perspective of chronic disease management. This study explores patients' views on what is the most appropriate setting for their chronic disease management, the advantages and disadvantages of these settings, and where they get information on their condition. Semi-structured qualitative interviews were carried out with 24 patients. Three main themes emerged: Current Care Model, Health Literacy and Treatment Burden. Patients believe that the GP-patient relationship plays a pivotal role in the provision of chronic disease management. Health literacy and psychosocial burden were found to impact significantly on the lives of patients with chronic disease(s).

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Incidental findings detected on emergency abdominal CT scans: a 1-year review

INTRODUCTION

In recent years, there has been a substantial rise in the use of computed tomography (CT) in the emergency medicine setting. Accordingly, with increased CT usage there has been an upsurge in incidental pathology detection.

METHODS

A retrospective review of all emergency CT abdominal scans performed at a university teaching hospital was examined. The frequency of incidental findings, their clinical significance and workload effect for the radiology department was assessed.

RESULTS

1155 patients had an emergency abdominal CT scan of which 700 had incidental findings detected. Of the incidental findings, 143 were deemed indeterminate requiring urgent investigations. Twenty-four occult neoplasms were confirmed subsequently. Additionally, 259 patients were recommended for additional diagnostics. The cumulative effect of the initial emergency abdominal CT was 15,015 relative value units (RVU). Subsequent imaging of incidental findings resulted in another 1674 RVU workload for radiology.

CONCLUSION

Incidental findings cause considerable debate and concern over which patients require significant follow-up, investigations, and/or surveillance. This exerts significant pressures on sub-specialties for their expert input, with increased workload and implications on healthcare service provision.

Problems and solutions in delivering global surgery in the 21st century

BACKGROUND

Surgery has had low priority in global health planning, so the delivery of surgical care in low- and middle-income countries is often poorly resourced. A recent Lancet Commission on Global Surgery has highlighted the need for change.

METHODS

A consensus view of the problems and solutions was identified by individual surgeons from high-income countries, familiar with surgical care in remote and poorer environments, based on recent publications related to global surgery.

RESULTS

The major issues identified were: the perceived unimportance of surgery, shortage of personnel, lack of appropriate training and failure to establish surgical standards, failure to appreciate local needs and poor coordination of service delivery.

CONCLUSION

Surgery deserves a higher priority in global health resource allocation. Lessons learned from participation in humanitarian crises should be considered in surgical developments.

Patterns of retroperitoneal trauma following gunshot violence: A case series

Introduction

Abdominal trauma is defined as any injury to the abdomen and its containing viscera. Common penetrating injuries including gunshot or stab injuries are increasing worldwide. However, retroperitoneal gunshot injuries have a lower incidence than trans-abdominal trauma and can have substantially different outcomes.

Case report

We report a series of three family members involved in gunshot violence over an18-month period. Each sustained retroperitoneal gunshot injuries with varying injuries patterns and treatment courses. Interestingly, one patient had a delayed small bowel perforation on day 6 post injury.

Discussion

Retroperitoneal trauma following gun violence has a lower incidence than trans-abdominal trauma. There is a paucity of literature describing injury patterns following this type of injury and their subsequent management. In the context of penetrating retroperitoneal trauma, the retroperitoneal organs are at risk and therefore serial clinical and/or radiological assessment is necessary. Delayed small bowel injury as a consequence of retroperitoneal gunshot is an unusual finding, with no reports to our knowledge in the literature.

Conclusion

this case series highlight that penetrating retroperitoneal trauma can produce a variety of injury patterns. Therefore a wide clinical acumen is needed to ensure a successful outcome. The trajectory of the bullet may help ascertain potential injuries, but serial assessment and observation are also important. Ultimately, individual cases must be treated accordingly, based on clinical stability, severity of injury and radiological findings. Despite initial stability, patients should always be observed for delayed complications.

Postoperative outcomes following mechanical bowel preparation before proctectomy: a meta-analysis

AIM

Previous meta-analyses of mechanical bowel preparation (MBP) before colorectal surgery have grouped colon and rectal resection together. An increased postoperative morbidity has been suggested in the absence of MBP following proctectomy. The current study used meta-analytical techniques to evaluate the comparative outcome of patients who received MBP prior to proctectomy.

METHOD

A comprehensive search was performed for published studies examining the effect of MBP before proctectomy on patient outcome. Random effects methods were used to combine data.

RESULTS

Eleven studies including 1258 patients were identified. There was no significant difference in overall morbidity (OR 1.062, 95% CI 0.584-1.933, P = 0.844), anastomotic leakage (OR 1.144, 95% CI 0.767-1.708, P = 0.509), surgical site infection (OR 0.946, 95% CI 0.549-1.498, P = 0.812) or mortality (OR 1.377, 95% CI 0.549-3.455, P = 0.495) between those who did not and those who did receive MBP prior to proctectomy.

CONCLUSION

The current study did not demonstrate a beneficial effect of MBP prior to proctectomy, but the data were limited. Decision-making as to its use should be made on a case-by-case basis.

Sedation for gastroscopy: Is it an adequately understood and informed choice?

INTRODUCTION

Sedation uptake rates for oesophagogastroduodenoscopy (OGD) vary greatly. Issues concerning adequate information and consent have been raised. Additionally, patient comprehension of sedation options is inconsistent.

METHODS

A closed ended questionnaire was created and delivered to assess patient understanding regarding sedation prior to OGD. The questionnaire was based on British Society of Gastroenterology guidelines.

RESULTS

One hundred and eleven patients were recruited. 90 % of the sedated and 73 % of the unsedated patients were satisfied with their respective decisions (OR 0.283, *p = 0.01). 65 % were unaware of basic differences between conscious sedation and general anesthesia, and 37 % were unaware that driving is permitted after having throat spray alone. The most informed of the age groups had the lowest uptake of sedation and the least informed had the highest uptake.

CONCLUSION

The decision to undergo gastroscopy with or without sedation is not a sufficiently informed one. This study highlights the need for the widespread dissemination of good quality information to inform patients better regarding sedation prior to OGD.

Investigation of the mechanisms mediating MDMA "Ecstasy"-induced increases in cerebro-cortical perfusion determined by btASL MRI

RATIONALE

Acute administration of the recreational drug of abuse 3,4-methylenedioxymethamphetamine (MDMA; Ecstasy) has previously been shown to increase cerebro-cortical perfusion as determined by bolus-tracking arterial spin labelling (btASL) MRI.

OBJECTIVES

The purpose of the current study was to assess the mechanisms mediating these changes following systemic administration of MDMA to rats.

METHODS

Pharmacological manipulation of serotonergic, dopaminergic and nitrergic transmission was carried out to determine the mechanism of action of MDMA-induced increases in cortical perfusion using btASL MRI.

RESULTS

Fenfluramine (10 mg/kg), like MDMA (20 mg/kg), increased cortical perfusion. Increased cortical perfusion was not obtained with the 5-HT2 receptor agonist 2,5-dimethoxy-4-iodophenyl-aminopropane hydrochloride (DOI) (1 mg/kg). Depletion of central 5-HT following systemic administration of the tryptophan hydroxylase inhibitor para-chlorophenylalanine (pCPA) produced effects similar to those observed with MDMA. Pre-treatment with the 5-HT receptor antagonist metergoline (4 mg/kg) or with the 5-HT reuptake inhibitor citalopram (30 mg/kg), however, failed to produce any effect alone or influence the response to MDMA. Pre-treatment with the dopamine D1 receptor antagonist SCH 23390 (1 mg/kg) failed to influence the changes in cortical perfusion obtained with MDMA. Treatment with the neuronal nitric oxide (NO) synthase inhibitor 7-nitroindazole (7-NI) (25 mg/kg) provoked no change in cerebral perfusion alone yet attenuated the MDMA-related increase in cortical perfusion.

CONCLUSIONS

Cortical 5-HT depletion is associated with increases in perfusion although this mechanism alone does not account for MDMA-related changes. A role for NO, a key regulator of cerebrovascular perfusion, is implicated in MDMA-induced increases in cortical perfusion.

An unusual cause for massive inflation

Chagas disease is a rare condition but with an increasing incidence. Megacolon is a known sequelae. Surgical management remains the only disease modifying treatment option; with variable long-term success. We highlight an interesting case to emphasize attention to this rare condition as a differential diagnosis in any patient presenting with massive intestinal dilatation.