Robotic Heller's cardiomyotomy for achalasia: early outcomes for a high-volume UK centre

INTRODUCTION

Heller's cardiomyotomy (HCM) is the gold standard treatment for achalasia. Laparoscopic HCM has been shown to be effective with low rates of symptom recurrence, though oesophageal mucosal perforation rates remain high. The aim of this prospective case series is to assess the short-term complication rates and perioperative outcomes for the first cohort of patients undergoing robotic-assisted HCM for achalasia in a single high-volume UK centre.

METHODS

Data were collected from a prospective cohort of patients who underwent robotic HCM at a single high-volume UK centre. Outcomes were assessed using the Eckhard score, which was calculated after their routine postoperative clinic appointments.

RESULTS

Thirteen patients underwent robotic HCM during the study period; this is the second largest reported case series in the European literature. There were no intraoperative oesophageal perforations. Six patients were discharged as day cases, six patients were discharged on the first postoperative day and one patient's hospital stay was two nights. There was a single perioperative complication of urinary retention. All patients reported improvement of symptoms following their operation, and all had a postoperative Eckhard score of less than 3, indicating their achalasia was in remission.

CONCLUSIONS

This cohort has demonstrated that robotic HCM has an exceptional safety profile and results in high levels of symptom resolution, even early in the learning curve. The robotic approach may be superior to laparoscopy as it allows more precise identification and dissection of the oesophageal muscle fibres, which likely reduces the risk of inadvertent mucosal damage or incomplete myotomy.

AB0633 REAL WORLD EXPERIENCE OF THE IMPACT OF SECUKINUMAB ON DISEASE ACTIVITY AND FATIGUE IN PATIENTS WITH ANKYLOSING SPONDYLITIS

Background:

Fatigue is one of the most commonly reported symptom of ankylosing spondylitis (AS). It impacts functional ability, quality of life, and ability to maintain employment1. Secukinumab, a fully human monoclonal IgG1 antibody that neutralizes IL-17A, has shown significant and sustained improvement in the signs and symptoms of active AS in the MEASURE 2 study2. It has also shown to improve fatigue scores. Despite this, the published literature on real life experience is scarce. We report our experience of Secukinumab use at Gartnavel General Hospital, Glasgow, UK.

Objectives:

We performed a retrospective review to assess the response of our AS patients to Secukinumab. We also reviewed the impact of treatment on fatigue.

Methods:

AS patients commenced on Secukinumab 150mg subcutaneously from mid-2016 to September 2019 were identified using the clinical records on our database. Response using Bath AS disease activity index (BASDAI) and Bath AS function index (BASFI) were recorded. Impact on fatigue and pain was measured using single-item fatigue and pain visual analogue scale (VAS) within the BASDAI questionnaire.

Results:

30 AS patients, 11 anti-TNF naïve and 19 anti-TNF inadequate responders (IR), on Secukinumab were identified. Retention rate was 76.66% (23/30). Sustained improvement was observed across all outcome measures over 3.5 years. Fatigue and pain improvement were somewhat lower than expected but did show slow improvement. Responses were greater in anti-TNF naïve patients. There was no significant difference in response between smokers (33.34%, 10/30) and non-smokers (36.67%, 11/30). There were 4 patients with inflammatory bowel disease, none of whom flared. No new safety signals were identified.

Table.

Clinical response to Secukinumab in patients with active AS

TimeBASADIBASFIFatigueAS painMean%changeMean%changeMean%changeMean%changeBaseline7.097.37.67.993M6.71-5%7.24-8%6.9-9%6.89-14%6M5.4-24%5.8-20%6.29-17%6.06-24%9M6.01-15%6.56-10%6.41-16%6.1-24%12M5.04-29%5.42-26%6.35-16%5.55-30%18M4.98-30%3.73-49%6.38-16%4.91-38%24M5.52-22%5.72-22%6.79-11%5.6-30%%Change from baselineAnti-TNF naïveAnti-TNF IRAnti-TNF naïveAnti-TNF IRAnti-TNF naïveAnti-TNF IRAnti-TNF naïveAnti-TNF IR3M-37%-9%-44%6%-10%-14%-53%-14%6M-34%-27%-38%-29%-28%-6%-43%-6%9M-27%-4%-30%1%-23%-6%-41%-6%12M-41%-22%-31%-29%-31%0%-44%0%18M-32%-11%-57%-22%-35%5%-34%5%24M-26%-12%-32%-1%-16%3%-32%3%

There were <3 patients in >2 years follow up group therefore results were omitted from analysis

Conclusion:

In our real-life cohort of AS patients, significant improvement was seen over 3.5 years in both BASDAI and BASFI. Fatigue was significantly improved in anti-TNF naïve group, but results were disappointing in anti-TNF IR group. This may be explained by the fact that there are older patients with established disease and background degenerative changes in anti-TNF IR group. Although fatigue data had slightly discordant results compared with the MEASURE 2 study2, considering the use of single item VAS rather than multidimensional measures such as FACEIT fatigue scale, clear improvement has been observed.

References:

[1]E. E. Schneeberger, M. F. Marengo, F. Dal Pra, J. A. Maldonado Cocco, and G. Citera, “Fatigue assessment and its impact in the quality of life of patients with ankylosing spondylitis,” Clin Rheumatol, vol. 34, no. 3, pp. 497–501, 2015.

[2]H. Marzo-Ortega, J. Sieper, A. Kivitz, R. Blanco, M. Cohen, R. Martin, A. Readie, H. B. Richards, and B. Porter, (2017) ‘Secukinumab and Sustained Improvement in Signs and Symptoms of Patients With Active Ankylosing Spondylitis Through Two Years: Results From a Phase III Study’, Arthritis Care & Research, Vol. 69, No. 7, July 2017,(DOI 10.1002/acr.23233), pp. 1020–1029.

Acknowledgments:

S. Kerr, K. Anderson and Rheumatology department, Gartnavel General Hospital, Glasgow, UK

Disclosure of Interests:

None declared

Evaluation of 4-methyl-2-[(2-methylbenzyl) amino]-1,3-thiazole-5-carboxylic acid against hyperglycemia, insulin sensitivity, and oxidative stress-induced inflammatory responses and β-cell damage in the pancreas of streptozotocin-induced diabetic rats

4-Methyl-2-[(2-methylbenzyl) amino]-1,3-thiazole-5-carboxylic acid (bioactive compound (BAC)), a novel thiazole derivative, is a xanthine oxidase inhibitor and free radical scavenging agent. Effects of BAC on hyperglycemia, insulin sensitivity, oxidative stress, and inflammatory mediators were evaluated in streptozotocin (STZ)-induced neonatal models of non-insulin-dependent diabetes mellitus (NIDDM) rats where NIDDM was induced in neonatal pups with single intraperitoneal injection of STZ (100 mg/kg). The effect of BAC (10 and 20 mg/kg, p.o.) for 3 weeks was evaluated by the determination of blood glucose, oral glucose tolerance test (OGTT), HbA1c level, insulin level, insulin sensitivity, and insulin resistance (IR). Furthermore, inflammatory mediators (tumor necrosis factor-alpha and interleukin-6) and oxidative stress were estimated in serum and pancreatic tissue, respectively. Significant alteration in the level of blood glucose, OGTT, HbA1c, insulin level, insulin sensitivity, in addition variation in the antioxidant status and inflammatory mediators, and alteration in histoarchitecture of pancreatic tissue confirmed the potential of BAC in STZ-induced neonatal models of NIDDM rats. Pretreatment with BAC restored the level of glucose by decreasing the IR and increasing the insulin sensitivity. Furthermore, BAC balanced the antioxidant status and preserved the inflammatory mediators. Histological studies of pancreatic tissues showed normal architecture after BAC administration to diabetic rats. Altogether, our results suggest that BAC successfully reduces the blood glucose level and possesses antioxidant as well as anti-inflammatory activities. This leads to decreased histological damage in diabetic pancreatic tissues, suggesting the possibility of future diabetes treatments.

Outcomes of an innovative training course in laparoscopic hernia repair

Introduction The Ethicon™ laparoscopic inguinal groin hernia training (LIGHT) course is an educational course based on three days of teaching on laparoscopic hernia surgery. The first day involves didactic lectures with tutorials. The second day involves practical cadaveric procedures in laparoscopic hernia surgery. The third day involves direct supervision by a consultant surgeon during laparoscopic hernia surgery on a real patient. We reviewed our outcomes for procedures performed on real patients on the final day of the course for early complications and outcomes. Methods A retrospective study was undertaken of patients who had laparoscopic hernia surgery as part of the LIGHT course from 2013 to 2015. A matched control cohort of patients who had elective laparoscopic hernia surgery over the study period was identified. These patients had their surgery performed by the same consultant general surgeons involved in delivering the course. All patients were followed up at 6 weeks postoperatively. Results A total of 60 patients had a laparoscopic inguinal hernia repair and 23 patients had a laparoscopic ventral hernia repair during the course. The mean operative time for laparoscopic inguinal hernia repair was 48 minutes for trainees (range 22-90 minutes) and 35 minutes for consultant surgeons (range 18-80 minutes). There were no intraoperative injuries or returns to theatre in either group. All the patients operated on during the course were successfully performed as daycase procedures. The mean operative time for laparoscopic ventral hernia repair was 64 minutes for trainees (range 40-120 minutes) and 51 minutes for consultant surgeons (range 30-130 minutes). Conclusions The outcomes of patients operated on during the LIGHT course are comparable to procedures performed by a consultant. Supervised operating by trainees is a safe and effective educational model in hernia surgery.

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.

Radiological and clinical examination in the diagnosis of Spigelian hernias

INTRODUCTION

Spigelian hernia are rarely reported lateral abdominal wall hernias. Clinical diagnosis of a suspected hernia can be challenging owing to vague presenting symptoms and signs. This study aimed to investigate the accuracy of preoperative imaging and clinical examination in the diagnosis of Spigelian hernias.

METHODS

A retrospective analysis was performed of patients who presented to North Tyneside and Wansbeck General Hospitals between 1998 and 2010. All patients were assessed by a consultant general surgeon in the outpatient clinic or on the surgical admissions ward. Patients were included who presented with a history suggestive of a Spigelian hernia and a palpable lump or equivocal clinical examination. All patients proceeded to surgery, which was used as the reference standard.

RESULTS

Overall, correlation with operative findings showed computed tomography (CT) to have a sensitivity of 100% and a positive predictive value (PPV) of 100%. Ultrasonography had a sensitivity of 90% and a PPV of 100%. Clinical assessment alone had a sensitivity of 100% and a PPV of 36%.

CONCLUSIONS

This study shows that ultrasonography and CT have a high sensitivity and PPV in relation to occult Spigelian hernias. When no obvious Spigelian hernia is present, patients should be evaluated with radiological investigation to establish a diagnosis. Owing to diagnostic uncertainty, a laparoscopic approach should be favoured.

Outcome of patients in laparoscopic training courses compared to standard patients

BACKGROUND & AIM

Current Laparoscopic simulators have limited usefulness and patients have been used for training since the dawn of surgery. NUGITS (Northumbrian Upper Gastro Intestinal Team of Surgeons) Laparoscopic Skills courses utilise hands-on experience with simulators moving to live operating on volunteer patients. It is vital to know that the volunteer patient is not disadvantaged by greater surgical risk.

METHODS

This was a case-controlled prospective comparison of patients undergoing both Laparoscopic Cholecystectomy (LC) [n=51] and Laparoscopic Inguinal Hernia (LIH) [n=62] during NUGITS training courses. They are compared with a matched (age, sex and ASA grade) control group LC (n=51) and LIH (n=62) operated on by consultants. The outcome measures were surgical peri-and post-operative complications, post-operative hospital stay, readmission and early recurrence of inguinal hernia (<6 months).

RESULTS

In the LC cohort, there was no significant difference in the length of hospital stay (p=0.07) or readmission (p=0.16) in both the groups. The mean operating time was higher in the trainee compared to the control group (p=0.001). There was no difference in the post-operative morbidity or mortality in either group. In LIH cohort, the mean operating time was higher in the trainee compared with the control group. There was no significant difference in post-operative complications (p>0.05) and early post-operative recurrence of hernia (p>0.05).

CONCLUSION

The post-operative outcomes of patients undergoing laparoscopic surgery during laparoscopic training courses are similar to consultant-operated patients. Thus, it is acceptable and safe to encourage patients to volunteer for laparoscopic training courses.

REV3 is required for spontaneous but not methylation damage-induced mutagenesis of Saccharomyces cerevisiae cells lacking O6-methylguanine DNA methyltransferase

O6-methylguanine (O6-MeG) DNA methyltransferase (MTase) removes the methyl group from a DNA lesion and directly restores DNA structure. It has been shown previously that bacterial and yeast cells lacking such MTase activity are not only sensitive to killing and mutagenesis by DNA methylating agents, but also exhibit an increased spontaneous mutation rate. In order to understand molecular mechanisms of endogenous DNA alkylation damage and its effects on mutagenesis, we determined the spontaneous mutational spectra of the SUP4-o gene in various Saccharomyces cerevisiae strains. To our surprise, the mgt1 mutant deficient in DNA repair MTase activity exhibited a significant increase in G:C-->C:G transversions instead of the expected G:C-->A:T transition. Its mutational distribution strongly resembles that of the rad52 mutant defective in DNA recombinational repair. The rad52 mutational spectrum has been shown to be dependent on a mutagenesis pathway mediated by REV3. We demonstrate here that the mgt1 mutational spectrum is also REV3-dependent and that the rev3 deletion offsets the increase of the spontaneous mutation rate seen in the mgt1 strains. These results indicate that the eukaryotic mutagenesis pathway is directly involved in cellular processing of endogenous DNA alkylation damage possibly by the translesion bypass of lesions at the cost of G:C-->C:G transversion mutations. However, the rev3 deletion does not affect methylation damage-induced killing and mutagenesis of the mgt1 mutant, suggesting that endogenous alkyl lesions may be different from O6-MeG.

Methionine reduces spontaneous and alkylation-induced mutagenesis in Saccharomyces cerevisiae cells deficient in O6-methylguanine-DNA methyltransferase

The exposure of DNA to reactive intracellular metabolites is thought to be a major cause of spontaneous mutagenesis. DNA alkylation is implicated in the above process by the fact that bacterial and yeast cells lacking DNA alkylation-specific repair genes exhibit elevated spontaneous mutation rates. The origin of the intracellular alkylating molecules is not clear; however, S-adenosylmethionine (SAM) has been proposed as one source because it has a reactive methyl group known to methylate proteins and DNA. We supplemented yeast cultures with excess methionine and examined the effects of increased endogenous SAM concentration on spontaneous and alkylation-induced mutagenesis in the absence of various DNA repair pathways. Our results show that either the excess methionine, or the increased SAM produced as a result of this treatment, is able to protect yeast cells from mutagenesis, and that this effect is alkylation-damage-specific. The protective effect was observed only in the mgt1 mutant deficient in the O(6)-methylguanine-DNA repair methyltransferase, but not in the wild type or other DNA repair-deficient strains, indicating that the protection is specific for O-methyl lesions. Thus, our results may lend support to the recently reported chemopreventive effect of SAM in rodents and further suggest that the observed tumor prevention by SAM may be, in part, due to its suppression of spontaneous mutagenesis in mammals. Given that a strong correlation has been established between O(6)-methylguanine and carcinogenicity, this study may offer a novel approach to preventing carcinogenesis.

A mutation in the MSH5 gene results in alkylation tolerance

DNA methylating agents such as N-methyl-N'-nitro-N-nitrosoguanidine (MNNG) are potent carcinogens; their carcinogenic effect is mainly due to the effect of production of O6-methylguanine (O6 MeG) on DNA. O6 MeG is not only mutagenic but also toxic to the cell because Mer-/Mex- cells unable to remove O6 MeG are very sensitive to killing by MNNG. It has been proposed that repeated futile mismatch correction of O6 MeG-containing bp is responsible for the genotoxicity of the O6 MeG lesion and that loss of mismatch repair activity results in cellular tolerance to O6 MeG, but the hypothesis has not been proved. We used yeast as a model to test this hypothesis and found that chromosome deletion of any known nuclear mitotic mismatch repair genes, including MLH1, MSH2, MSH3, MSH6, and PMS1, did not rescue mgt1delta O6 MeG DNA repair methyltransferase-deficient cells from killing by MNNG. A large number of mgt1delta, MNNG-tolerant revertants were isolated, among which one cell line, XS-14, has been found to carry a mutated allele of the MSH5 gene. The mutation also affected spore survival but did not increase the spontaneous mutation rate. We further demonstrated that a mutated form of the MSH5 gene, msh5-14, not the msh5delta-null mutation, is responsible for the cellular tolerance to MNNG in XS-14 cells. This observation offers an alternative model that may reconcile seemingly contradictory observations of yeast and mammalian cells.

DNA mismatch repair mutants do not increase N-methyl-N'-nitro-N-nitrosoguanidine tolerance in O6-methylguanine DNA methyltransferase-deficient yeast cells

Treatment of cells with N-methyl-N'-nitro-N-nitrosoguanidine (MNNG) produces, among other lesions, mutagenic and carcinogenic lesions such as O6-methylguanine (O6MeG) and O4-methylthymine in DNA. An O6MeG DNA methyl-transferase (MTase) specifically and efficiently repairs such lesions. MTase-deficient bacterial, yeast and mammalian cells exhibit increased sensitivity not only to MNNG-induced mutagenesis, but also to MNNG-induced killing, suggesting that O6MeG-type lesions are also lethal to the cells. The lethal effect caused by O6MeG is not clear. Results from several recent experiments indicate that some MNNG-tolerant cell lines exhibit a loss of DNA mismatch binding/repair activity, suggesting that functional mismatch repair is probably responsible for the cellular sensitivity to DNA methylating agents. We tested this abortive O6MeG-T mismatch repair hypothesis in a well-defined lower eukaryote, Saccharomyces cerevisiae. We found that while mgt1-deleted MTase-deficient yeast strains are hypersensitive to MNNG-induced killing, combination of this mutation with any of the mlh1, msh2 or pms1 mutations did not render cells more tolerant to killing. msh3 mutation also did not rescue MNNG-induced genotoxicity. Furthermore, through the isolation and characterization of MNNG-tolerant cell lines from the MTase-deficient mutants we demonstrated that a DNA mismatch repair defect is neither sufficient nor required for this process. Since both DNA repair MTases and mismatch repair proteins are highly conserved between yeast and mammalian cells, our results could suggest alternative mechanisms in the cellular tolerance to O6MeG-induced killing.

Relationship Between the Systems Responsible for Uptake of 5-hydroxytryptamine and of Noradrenaline by Human Blood Platelets

Human blood platelets carry a high affinity, but low capacity, saturable system for the uptake of noradrenalhe. The uptake is partially Na(+) dependent but cannot be categorised as uptake. It is distinct from the uptake system responsible for 5-hydroxytryptamine transport into the platelet since the selective inhibitors of the platelet uptake system for 5-hydroxytryptamine (citalopram, paroxetine) Wer from those for the uptake system for noradrenaline (normetanephrine, methylisoprenaline). 5-hydroxytryptamine inhibits noradrenaline uptake but with properties inconsistent with competition for the same uptake system while noradrenaline does not inhibit 5-hydroxytryptamine uptake. Neither noradrenaline nor 5-hydroxytryptamine uptake by human platelets is inhibited by dopamine.

Post-discharge follow-up of stroke patients at Groote Schuur Hospital--a prospective study

A survey of 59 stroke patients was undertaken between 3 and 6 months after the event to determine whether a weekly stroke round would improve the rate of referral for rehabilitation. Comparison with a previous survey at Groote Schuur Hospital showed a marked improvement (40% for physiotherapy and 10% for occupational therapy v. 76% and 50% respectively). A comparison of referral rates between younger (< 65 years old) and older patients (> 65 years old) revealed a significantly higher rate of referral among the younger patients. Attendance for both groups was low (approx. 7 sessions per 3 months). Social work was an important requirement and 60% of all patients expressed a need for more help. Social needs of older and younger patients differ. Despite the improved referral rate the rehabilitation of stroke patients is unsatisfactory, mainly because of transport difficulties. Methods should be investigated to establish rehabilitation centres in the community to overcome this impasse.