Meta-analysis of biomarkers predicting risk of malignant progression in Barrett's oesophagus.

BACKGROUND: Barrett's oesophagus is a precursor to the development of oesophageal adenocarcinoma. This study sought to clarify the role of genetic, chromosomal and proliferation biomarkers that have been the subjects of multiple studies through meta-analysis. METHODS: MEDLINE, Embase, PubMed and the Cochrane Library were searched for clinical studies assessing the value of p53, p16, Ki-67 and DNA content abnormalities in Barrett's oesophagus. The main outcome measure was the risk of development of high-grade dysplasia (HGD) or oesophageal adenocarcinoma. RESULTS: Some 102 studies, with 12 353 samples, were identified. Mutation (diagnostic odds ratio (DOR) 10·91, sensitivity 47 per cent, specificity 92 per cent, positive likelihood ratio (PLR) 4·71, negative likelihood ratio (NLR) 0·65, area under the curve (AUC) 0·792) and loss (DOR 16·16, sensitivity 31 per cent, specificity 98 per cent, PLR 6·66, NLR 0·41, AUC 0·923) of p53 were found to be superior to the other p53 abnormalities (loss of heterozygosity (LOH) and overexpression). Ki-67 had high sensitivity in identifying high-risk patients (DOR 5·54, sensitivity 82 per cent, specificity 48 per cent, PLR 1·59, NLR 0·42, AUC 0·761). Aneuploidy (DOR 12·08, sensitivity 53 per cent, specificity 87 per cent, PLR 4·26, NLR 0·42, AUC 0·846), tetraploidy (DOR 5·87, sensitivity 46 per cent, specificity 85 per cent, PLR 3·47, NLR 0·65, AUC 0·793) and loss of Y chromosome (DOR 9·23, sensitivity 68 per cent, specificity 80 per cent, PLR 2·67, NLR 0·49, AUC 0·807) also predicted malignant development, but p16 aberrations (hypermethylation, LOH, mutation and loss) failed to demonstrate any advantage over the other biomarkers studied. CONCLUSION: Loss and mutation of p53, and raised level of Ki-67 predicted malignant progression in Barrett's oesophagus.

Mid-Term Remission of Type 2 Diabetes Mellitus After Laparoscopic Roux En-Y Gastric Bypass.

BACKGROUND: Laparoscopic Roux en-Y gastric bypass (LRYGB) is an established therapeutic modality for type 2 diabetes mellitus (T2DM). However, there is paucity of data on the outcomes of LRYGB on T2DM beyond 2 years. This study aimed to examine the medium-term effects of LRYGB on T2DM and determine the predictors of T2DM resolution. METHODS: Prospective data were collected for all consecutive LRYGB performed from September 2009 to November 2010. The American Diabetes Association guidelines were used to define complete (CR) or partial (PR) remission of diabetes. Diabetes status was considered improved when there was >50 % reduction in the dose of medications or when glycaemic control was achieved after stopping insulin. The effects of baseline characteristics, diabetes data and weight loss data at 4 years on T2DM remission were studied. RESULTS: Forty-six patients with T2DM underwent LRYGB with mean ± SD age and body mass index (BMI) of 48.6 ± 9.6 years and 50.4 ± 6.5 kg/m2, respectively. Median (IQR, interquartile range) duration of T2DM preoperatively was 60 (36-126) months. Median (IQR) follow-up was 52 (50-57) months. T2DM remission was achieved in 64 % of patients (44 % CR, 20 % PR), and a further 28 % of patients had improvement in their diabetes status. Multivariate analyses demonstrated significant excess weight loss (EWL) [P = 0.008] and lower BMI [P = 0.04] at 4 years to be the only independent predictors of T2DM medium-term outcomes. CONCLUSION: The medium-term effects of LRYGB on T2DM remission/improvement were maintained in 92 % of patients. EWL and lower BMI at 4 years were independent predictors of T2DM remission.

A cross-sectional retrospective study comparing handwritten operation notes with electronic operation notes.

INTRODUCTION: Electronically completed medical notes have been shown to be superior in legibility and completeness to handwritten ones. Despite this, surgeons continue to use handwritten operation notes. This paper aims to compare the quality of handwritten versus electronic operation notes. METHODS: This is a retrospective cross-sectional single-centre study done at Darent Valley Hospital, a district general hospital at Dartford, UK. We looked at 405 operation notes of patients who had general surgery procedures between 1 January 2020 to 31 January 2021 checking for legibility and completeness of operation note criteria as given by the Royal College of Surgeons of England's Good Surgical Practice. Data were collated using an app that populates comparison criteria in an Excel sheet and were analysed using SPSS (Statistical Package for the Social Sciences). The results are presented in bar graphs and frequency table. RESULTS: In 17 out of the 18 criteria in RCS England's Good Surgical Practice, electronic notes were better completed than handwritten ones (p<0.001). Signature as a criterion had comparable level of completeness in both handwritten and electronic notes, 95% versus 91% respectively. There was 8.3% illegibility in the handwritten note and none in the electronic ones. CONCLUSIONS: Electronic notes are far better completed than handwritten notes in 17 out of the 18 criteria of a good operation note by RCS England. The difference between both forms of notes is far too much; we propose a complete shift in practice from handwritten to electronic format.

Snake Venom: A Promising Source of Neurotoxins Targeting Voltage-Gated Potassium Channels.

The venom derived from various sources of snakes represents a vast collection of predominantly protein-based toxins that exhibit a wide range of biological actions, including but not limited to inflammation, pain, cytotoxicity, cardiotoxicity, and neurotoxicity. The venom of a particular snake species is composed of several toxins, while the venoms of around 600 venomous snake species collectively encompass a substantial reservoir of pharmacologically intriguing compounds. Despite extensive research efforts, a significant portion of snake venoms remains uncharacterized. Recent findings have demonstrated the potential application of neurotoxins derived from snake venom in selectively targeting voltage-gated potassium channels (Kv). These neurotoxins include BPTI-Kunitz polypeptides, PLA2 neurotoxins, CRISPs, SVSPs, and various others. This study provides a comprehensive analysis of the existing literature on the significance of Kv channels in various tissues, highlighting their crucial role as proteins susceptible to modulation by diverse snake venoms. These toxins have demonstrated potential as valuable pharmacological resources and research tools for investigating the structural and functional characteristics of Kv channels.

Systematic review and meta-analysis of outcomes after intraoperative pancreatic duct stent placement during pancreaticoduodenectomy.

BACKGROUND: Postoperative pancreatic leakage after pancreaticoduodenectomy is often serious. Although some studies have suggested that stenting the anastomosis can reduce the incidence of this complication, the value of stenting in the setting of pancreaticoduodenectomy remains unclear. METHODS: Studies comparing outcomes of stent versus no stent, and internal versus external stent placement for pancreaticoduodenectomy were eligible for inclusion. Pooled odds ratios (ORs) with 95 per cent confidence intervals were calculated using fixed- or random-effects models. RESULTS: From a search of the literature published between January 1973 and September 2011, five randomized clinical trials (RCTs) and 11 non-randomized observational clinical studies (OCS) involving 1726 patients were selected for inclusion in this review. Meta-analysis of RCTs revealed that placing a stent in the pancreatic duct did not reduce the incidence of postoperative pancreatic fistula. External stents had no advantage over internal stents in terms of clinical outcome. Subgroup analyses revealed that use of an external stent significantly reduced the incidence of pancreatic fistula (RCTs: OR 0·42, 0·24 to 0·76, P = 0·004; OCS: OR 0·43, 0·27 to 0·68, P < 0·001), delayed gastric emptying (RCTs: OR 0·41, 0·19 to 0·87, P = 0·02) and postoperative morbidity (RCTs: OR 0·55, 0·34 to 0·89, P = 0·02) compared with no stent. CONCLUSION: Pancreatic duct stenting did not reduce the incidence of pancreatic fistula and other complications in pancreaticoduodenectomy compared with no stenting. Although no difference was found between external and internal stents in terms of efficacy, external stents seemed to reduce the incidence of pancreatic fistula compared with control.

Effective implementation and adaptation of structured robotic colorectal programme in a busy tertiary unit.

BACKGROUND: Safety and feasibility of robotic colorectal surgery has been reported as increasing over the last decade. However safe implementation and adaptation of such a programme with comparable morbidities and acceptable oncological outcomes remains a challenge in a busy tertiary unit. We present our experience of implementation and adaptation of a structured robotic colorectal programme in a high-volume center in the United Kingdom. METHODS: Two colorectal surgeons underwent a structured robotic colorectal training programme consisting of time on simulation console, dry and wet laboratory courses, case observation, and initial mentoring. Data were collected on consecutive robotic colorectal cancer resections over a period of 12 months and compared with colorectal cancer resections data of the same surgeons' record prior to the adaptation of the new technique. Patient demographics including age, gender, American Society of Anesthesiologist score (ASA), Clavien-Dindo grading, previous abdominal surgeries, and BMI were included. Short-term outcomes including conversion to open, length of stay, return to theatre, 30- and 90-days mortality, blood loss, and post-operative analgesia were recorded. Tumour site, TNM staging, diverting stoma, neo-adjuvant therapy, total mesorectal excision (TME) grading and positive resection margins (R1) were compared. p values less than or equal to 0.05 were considered statistically significant. RESULTS: Ninety colorectal cancer resections were performed with curative intent from June 2018 to June 2020. Thirty robotic colorectal cancer resections (RCcR) were performed after adaption of programme and were compared with 60 non-robotic colorectal cancer resections (N-RCcR) prior to implementation of technique. There was no conversion in the RCcR group; however, in N-RCcR group, five had open resection from start and the rest had laparoscopic surgery. In laparoscopic group, there were six (10.9%) conversions to open (two adhesions, three multi-visceral involvements, one intra-operative bleed). Male-to-female ratio was 20:09 in RCcR group and 33:20 in N-RCcR groups. No significant differences in gender (p = 0.5), median age (p = 0.47), BMI (p = 0.64) and ASA scores (p = 0.72) were present in either groups. Patient characteristics between the two groups were comparable aside from an increased proportion of rectal and sigmoid cancers in RCcR group. Mean operating time, and returns to theaters were comparable in both groups. Complications were fewer in RCcR group as compared to N-RCcR (16.6% vs 25%). RCcR group patients have reduced length of stay (5 days vs 7 days) but this is not statistically significant. Estimated blood loss and conversion to open surgery was significantly lesser in the robotic group (p < 0.01). The oncological outcomes from surgery including TNM, resection margin status, lymph node yield and circumferential resection margin (for rectal cancers) were all comparable. There was no 30-day mortality in either group. CONCLUSION: Implementation and integration of robotic colorectal surgery is safe and effective in a busy tertiary center through a structured training programme with comparable short-term survival and oncological outcomes during learning curve.

Lymph node ratio versus number of affected lymph nodes as predictors of survival for resected pancreatic adenocarcinoma.

BACKGROUND: The objective of this study was to compare the prognostic significance of the lymph node ratio (LNR) with the absolute number of affected lymph nodes for resected pancreatic ductal adenocarcinoma. METHODS: Data were collected from 84 patients who had undergone pancreatoduodenectomy for pancreatic ductal adenocarcinoma over a 10-year period. Patients were categorized into four groups according to the absolute LNR (0, 0-0.199, 0.2-0.299, > or =0.3). Kaplan-Meier and Cox proportional hazard models were used to evaluate the prognostic effect. RESULTS: An LNR of > or =0.2 (median survival 8.1 vs. 35.7 months with LNR < 0.2; p < 0.001) and > or =0.3 (median survival 5.9 vs. 29.6 months with LNR < 0.3; p < 0.001), tumor size (p < 0.017), positive resection margin (p < 0.001), and nodal involvement (p < 0.001) were found to be significant prognostic markers following univariate analysis. Following multivariate analysis, only LNR at both levels [> or =0.2 (p = 0.05; HR 1.8) and LNR of > or =0.3 (p = 0.01; HR 2.7)] were independent predictors of a poor outcome. The number of lymph nodes examined had no effect on overall survival in either node-positive patients (p = 0.339) or node-negative patients (p = 0.473). CONCLUSIONS: The LNR represents a stronger independent prognostic indicator than the absolute number of affected lymph nodes in patients with resected pancreatic ductal adenocarcinoma.

Surgical site infection rate and associated risk factors in elective general surgery at a public sector medical university in Pakistan.

This prospective study aimed to determine the surgical site infection (SSI) rate and associated risk factors was carried in a general surgical ward at Liaquat University Hospital Jamshoro. A total of 460 patients requiring elective general surgery from July 2005 to June 2006 were included in this study. All four surgical wound categories were included. Primary closure was employed in all cases. Patients were followed up to 30th day postoperatively. All cases were evaluated for postoperative fever, redness, swelling of wound margins and collection of pus. Cultures were taken from all the cases with any of the above finding. Mean +/- SD age of the patients was 38.8 +/- 17.4 years with male to female ratio of 1.5:1. The overall rate of surgical site infection was 13.0%. The rate of wound infection was 5.3% in clean operations, 12.4% in clean-contaminated, 36.3% in contaminated and 40% in dirt-infected cases. Age, use of surgical drain, duration of operation and wound class were significant risk factors for increased surgical site infection (P < 0.05). Postoperative hospital stay was double in cases who had surgical site infection. Sex, haemoglobin level and diabetes were not statistically significant risk factors (P > 0.05). In conclusion, surgical site infection causes considerable morbidity and economic burden. The routine reporting of SSI rates stratified by potential risk factors associated with increased risk of infection is highly recommended.

Are we meeting the British Society of Gastroenterology guidelines for cholecystectomy post-gallstone pancreatitis?

BACKGROUND: The aim of this study was to audit the current management of patients suffering with gallstone pancreatitis (GSP) at a university teaching hospital for compliance with the British Society of Gastroenterology (BSG) guidelines regarding cholecystectomy post-GSP. METHODS: Data were collected on all patients identified via the hospital coding department that presented with GSP between January 2011 and November 2013. Patients with alcoholic pancreatitis were excluded. The primary outcome was the length of time in days from diagnosis of GSP to cholecystectomy. Secondary outcomes included readmission with gallstone-related disease prior to definitive management and admitting speciality. RESULTS: One hundred and fifty-eight patients were identified with a presentation of GSP during the study period. Thirty-nine patients were treated conservatively. One hundred and six patients underwent laparoscopic cholecystectomy a median (interquartile range) interval of 33.5 days (64 days) post-admission. Patients with a severe attack as classified by the Glasgow severity score (n = 16) waited a median of 79.5 days (71.5) for cholecystectomy. Only 32% (n = 34) of patients with mild disease underwent cholecystectomy during the index admission or within 2 weeks. When grouped by admitting speciality, patients admitted initially under hepatobiliary surgery waited significantly fewer days for definitive treatment compared with other specialities (P < 0.0001). Twenty-one patients (19.8%) re-presented with gallstone-related pathology prior to undergoing cholecystectomy. CONCLUSIONS: Only 32.1% were treated as per BSG guidelines. About 19.8% (n = 21) of the patients suffered further morbidity as a result of a delayed operation and there is a clear difference between admitting speciality and the median time to operation.

Frequency of intestinal parasitic infestation in children of 5-12 years of age in Abbottabad.

BACKGROUND: Worm infestation is a major problem in children from developing countries due to bad hygienic conditions. It produces nutritional deficiencies and anaemia in children, especially when hookworm infestation is present. METHODS: This cross-sectional study deals with investigation of the frequency of intestinal parasitic infestation in children between the ages 5-12 years. A total of 283 subjects were tested and screened for different intestinal parasites at of Department of Physiology, Ayub Medical College, Abbottabad. Negative cases were re-examined and if found free of intestinal pathogenic parasites were labelled as negative. RESULTS: Of the 283 children examined, 230 tested positive for various intestinal parasites. The frequency of helminthic infestation was found to be above 81%. There were 8 different species of helminths and protozoa found in the specimens. By far the highest frequency of 48% was noted for Ascaris lumbricoides while 6.9% (16 cases) of the specimens examined had mixed infestation. The mean Haemoglobin (Hb) level was found to be 9.82 g/dl in males and 9.0 g/dl in females. Virtually no Hookworm infestation was found which may be the reason of not so low Hb level of the subjects. CONCLUSIONS: A very high percentage (81%) of children from suburbs of Abbottabad have intestinal worm infestation and majority of them (48% of positive cases) have Ascaris lumbricoides. Children were not very severely anaemic because of virtually no hook worm cases.