Johan Forceps As a Knot Pusher for Extracorporeal Roeder Knot: An Inexpensive Alternative to an Endoloop Ligature in Laparoscopic Appendicectomy.

Background: Securing of the appendix stump is one of the key steps in performing laparoscopic appendicectomy (LA). This can be achieved by a variety of methods including endoloops, stapler, and clips. An alternative technique, previously described by authors, is the use of Johan forceps as a knot pusher, to deploy an extracorporeal Roeder knot at the base of appendix. We aimed to evaluate the safety and cost-effectiveness of our technique. Patients and Methods: A single surgeon's, prospective cohort, and multicenter study was undertaken at three different hospitals in the United Kingdom. We collected data of all patients, who underwent LA by this technique between 2014 and 2019. Demographics, operative findings, postoperative complications and readmissions were recorded and analyzed. Results: In total, 227 appendicectomies were performed. Median age was 24 years (interquartile range [IQR]: 16-58) with 58% male preponderance. Operative findings were 57% (n = 130) acutely inflammatory appendicitis, 16.74% (n = 38) were complicated appendicitis (perforated, gangrenous). Rest of the operative findings were macroscopically normal appendix (with no other pathology in 18.06% (n = 41), and macroscopically normal appendix but with gynecological pathologies in 7.9% (n = 18). Postoperatively, there were no cases to report complication of blow out stumps neither clinically nor radiologically. Surgical site infections rate has been 3.5% (n = 8). One patient had small intra-abdominal abscess (0.4%), treated by IV antibiotics. Mean hospital stay was 1.89 days (standard deviation [SD] 1-5 days). Thirty days readmissions rate was 4.8%. None of the complications or readmissions was related to the surgical technique. There were no deaths recorded in this series. Cost of handmade endoloop was $0.69. Conclusion: Use of Johan forceps as knot pusher for extracorporeal Roeder knot is a safe, feasible, cost-effective, and easily reproducible technique for carrying out LA.

Validation of a cost-effective appendicectomy model for surgical training.

BACKGROUND: Appendicitis is a commonly occurring condition worldwide. The gold standard treatment is appendicectomy. Although training models are commercially available for this procedure, they are often associated with high cost. Here we present a cost-effective model. AIM: To establish construct validity of a cost-effective laparoscopic appendicectomy simulation model. METHODS: Three groups of surgeons were recruited; novices (n = 31), of intermediate expertise (n = 13) and experts (n = 5) and asked to perform a simulated laparoscopic appendicectomy using the new model. Their performance was assessed by a faculty member and compared between the three groups using a validated scoring system (Global Operative Assessment of Laparoscopic Skills [GOALS] score). RESULTS: One-way ANOVA test showed a significant difference in task performance between groups (p < 0.0001). Post-hoc comparisons after the application of Bonferroni correction (statistically significant p value <0.017) demonstrate a significant difference in performance between all groups for all GOALS categories as well as the total score. Effect size calculations showed that experience level had moderate (Eta-squared >0.5 and <0.8) and significant (>0.8) impact on the performance of the simulated procedure. CONCLUSION: The model described in this study is cost-effective, valid and can adequately simulate appendicectomy. The authors recommend inclusion of this model to postgraduate surgical training.

Polymorphisms in the glutathione S-transferase mu cluster are associated with tumour progression and patient outcome in colorectal cancer.

Glutathione S-transferase (GST) enzymes catalyse the detoxification of by-products of reactive oxygen species and are thus important in cellular defence mechanisms. The GSTs are polymorphic with allelic variants encoding isoforms with functional differences. GST polymorphism has been associated with susceptibility and clinical outcome in patients with cancer. In this retrospective cohort, we have investigated associations between common GSTM1, GSTM3 and GSTP1 polymorphisms with factors known to influence clinical out-come and patient survival in colorectal cancer. Significant linkage disequilibrium was demonstrated between GSTM1 and GSTM3 alleles (P< or =0.001). We identified no significant associations between the GSTP1(Ile105Val105) polymorphism and any clinical outcome parameters or patient survival. However significant associations were demonstrated with mu class GSTs. Those patients who were GSTM1 null presented less frequently with poorly-differentiated tumours (P=0.038). Furthermore, patients who were GSTM3 AA were less likely to present with advanced stage tumours (T-stage, P=0.036 and Dukes' classifications, P=0.012) or distant metastases (P=0.017) when examined alone. Upon further examination of the effect of linkage disequilibrium, we found that, in GSTM1 null individuals, GSTM3 AA (compared with other GSTM3 genotypes combined) had longer disease-free survival (HR=0.54, 95% CI 0.30-0.98, P=0.044). Thus, the GSTM3 AA genotype is associated with improved prognosis especially in those with GSTM1 null. Our findings suggest that the GST mu gene cluster mediates tumour characteristics and survival in patients with colorectal cancer.

Loss of heterozygosity on chromosome 10q is associated with earlier onset sporadic colorectal adenocarcinoma.

Recent studies have shown that loss of heterozygosity (LOH) on chromosome 10q is a frequent event in a number of tumour types including colorectal cancers. Because previous studies have used markers located mainly distally on chromosome 10, we have examined 114 sporadic colorectal adenocarcinomas for LOH using a panel of 9 highly polymorphic microsatellite markers spanning the long arm of chromosome 10. Using microdissected tumour material, LOH of one or more chromosome 10q markers was a frequent event (75 of 114; 66%). The highest frequency of loss (42 of 96; 44%) was observed at the marker D10S1790 located at 10q21.1. The mean age of presentation, of patients with LOH of D10S1790 was significantly (p = 0.0006) lower (67.1 years) compared to patients with retention of this marker (73.5 years). When we compared frequency of loss at this marker in patients presenting before 70 years of age (68%) to those above 70 years (23%) we observed a significant difference (p < 0.0001). Statistical analysis between loss, or instability at other markers and clinicopathological features did not show any significant associations. In addition LOH at D10S1790 was infrequent in adenomas (2 of 20; 10%) compared to adenocarcinomas (42 of 96; 44%) (p = 0.0047), suggesting that loss within this region is a late event in colorectal tumorigenesis. The association of loss at D10S1790 and an earlier age of presentation in adenocarcinomas suggests that this locus may harbor a tumour suppressor gene(s), which affects the rate of colorectal tumour progression. Identification of this region of genetic loss further refines our understanding of the paradigm in this tumour type of multiple-steps responsible for initiation and progression.