Pilonidal sinus laser-assisted closure (PiLAC) - a low-morbidity alternative to excision with excellent long-term outcomes.

INTRODUCTION: Recurrence after surgery for pilonidal sinus disease is a recognised problem and patients often re-present months after discharge. We routinely treat primary and recurrent pilonidal sinus disease with Pilonidal sinus Laser-Assisted Closure (PiLAC). Long-term outcomes following PiLAC surgery was examined following clinical and telephone review. METHODS: All patients undergoing PiLAC as a day-case between April 2016 and July 2019 were included. Patients were followed up in a nurse-led clinic until complete healing or recurrence. A prospective database and retrospective audit of notes combined with longer-term follow-up by telephone were used. RESULTS: A total of 35 patients underwent PiLAC, median age 28 (18-53 years), 28 males:7 females. A total of 28 patients had long-term (>60 days) follow-up, mean 407 days (range 67-887 days); 25/28 patients (89.3%) had healed with no recurrence on long-term follow-up. Of these 28 patients, 11 were first presentation of pilonidal disease and underwent PiLAC as their first treatment, with a 91% heal rate long term. A total of 15 patients had seton drainage prior to PiLAC, with a 93% heal rate versus no seton (83%). Fisher's exact test showed no significant difference between sex, new/recurrent pilonidal disease and seton placement (p>0.05). CONCLUSIONS: Healing after PiLAC for the treatment of primary and recurrent pilonidal sinus disease is preserved with excellent long-term outcomes. We recommend it as an alternative to surgical excision.

A comparative multicentre study evaluating gluteal turnover flap for wound closure after abdominoperineal resection for rectal cancer.

BACKGROUND: The aim of this study was to compare perineal wound healing between gluteal turnover flap and primary closure in patients undergoing abdominoperineal resection (APR) for rectal cancer. METHODS: Patients who underwent APR for primary or recurrent rectal cancer with gluteal turnover flap in two university hospitals (2016-2021) were compared to a multicentre cohort of primary closure (2000-2017). The primary endpoint was uncomplicated perineal wound healing within 30 days. Secondary endpoints were long-term wound healing, related re-interventions, and perineal herniation. The perineal hernia rate was assessed using Kaplan Meier analysis. RESULTS: Twenty-five patients had a gluteal turnover flap and 194 had primary closure. The uncomplicated perineal wound-healing rate within 30 days was 68% (17/25) after gluteal turnover flap versus 64% (124/194) after primary closure, OR 2.246; 95% CI 0.734-6.876; p = 0.156 in multivariable analysis. No major wound complications requiring surgical re-intervention occurred after flap closure. Eighteen patients with gluteal turnover flap completed 12-month follow-up, and none of them had chronic perineal sinus, compared to 6% (11/173) after primary closure (p = 0.604). The symptomatic 18-month perineal hernia rate after flap closure was 0%, compared to 9% after primary closure (p = 0.184). CONCLUSIONS: The uncomplicated perineal wound-healing rate after the gluteal turnover flap and primary closure after APR is similar, and no chronic perineal sinus or perineal hernia occurred after flap closure. Future studies have to confirm potential benefits of the gluteal turnover flap.

CK2 abrogates the inhibitory effects of PRH/HHEX on prostate cancer cell migration and invasion and acts through PRH to control cell proliferation.

PRH/HHEX (proline-rich homeodomain protein/haematopoietically expressed homeobox protein) is a transcription factor that controls cell proliferation, cell differentiation and cell migration. Our previous work has shown that in haematopoietic cells, Protein Kinase CK2-dependent phosphorylation of PRH results in the inhibition of PRH DNA-binding activity, increased cleavage of PRH by the proteasome and the misregulation of PRH target genes. Here we show that PRH and hyper-phosphorylated PRH are present in normal prostate epithelial cells, and that hyper-phosphorylated PRH levels are elevated in benign prostatic hyperplasia, prostatic adenocarcinoma, and prostate cancer cell lines. A reduction in PRH protein levels increases the motility of normal prostate epithelial cells and conversely, PRH over-expression inhibits prostate cancer cell migration and blocks the ability of these cells to invade an extracellular matrix. We show that CK2 over-expression blocks the repression of prostate cancer cell migration and invasion by PRH. In addition, we show that PRH knockdown in normal immortalised prostate cells results in an increase in the population of cells capable of colony formation in Matrigel, as well as increased cell invasion and decreased E-cadherin expression. Inhibition of CK2 reduces PRH phosphorylation and reduces prostate cell proliferation but the effects of CK2 inhibition on cell proliferation are abrogated in PRH knockdown cells. These data suggest that the increased phosphorylation of PRH in prostate cancer cells increases both cell proliferation and tumour cell migration/invasion.

Comparison of analgesic efficacy of four-quadrant transversus abdominis plane (TAP) block and continuous posterior TAP analgesia with epidural analgesia in patients undergoing laparoscopic colorectal surgery: an open-label, randomised, non-inferiority trial.

Posterior transversus abdominis plane blocks have been reported to be an effective method of providing analgesia after lower abdominal surgery. We compared the efficacy of a novel technique of providing continuous transversus abdominis plane analgesia with epidural analgesia in patients on an enhanced recovery programme following laparoscopic colorectal surgery. A non-inferiority comparison was used. Adult patients undergoing elective laparoscopic colorectal surgery were randomly assigned to receive continuous transversus abdominis plane analgesia (n = 35) vs epidural analgesia (n = 35), in addition to a postoperative analgesic regimen comprising regular paracetamol, regular diclofenac and tramadol as required. Sixty-one patients completed the study. The transversus group received four-quadrant transversus abdominis plane blocks and bilateral posterior transversus abdominis plane catheters that were infused with levobupivacaine 0.25% for 48 h. The epidural group received an infusion of bupivacaine and fentanyl. The primary outcome measure was visual analogue scale pain score on coughing at 24 h after surgery. We found no significant difference in median (IQR [range]) visual analogue scores during coughing at 24 h between the transversus group 2.5 (1.0-3.0 [0-5.5]) and the epidural group 2.5 (1.0-5.0 [0-6.0]). The one-sided 97.5% CI was a 0.0 (∞-1.0) difference in means, establishing non-inferiority. There were no significant differences between the groups for tramadol consumption. Success rate was 28/30 (93%) in the transversus group vs 27/31 (87%) in the epidural group. Continuous transversus abdominis plane infusion was non-inferior to epidural infusion in providing analgesia after laparoscopic colorectal surgery.

Concordance between vacuum assisted biopsy and postoperative histology: implications for the proposed Low Risk DCIS Trial (LORIS).

AIM: The recent Breast Cancer Screening Review has estimated that for one life saved three patients are overtreated. The dramatic increase in the diagnosis of Ductal carcinoma in-situ (DCIS) has not lead to the expected decrease in the incidence of invasive cancer. It is not clear if all DCIS progress to invasive cancer if untreated. The Low Risk DCIS Trial (LORIS) intends to compare the current treatment of low risk DCIS i.e. surgery, with active monitoring. For effective implementation, concordance between diagnostic biopsy using large volume vacuum assisted biopsy (VAB) and excision histology is vital. A two-centre UK audit was done to assess concordance in patients diagnosed with low grade DCIS diagnosed using VAB. METHODS: Data of DCIS diagnosed with VAB from year 2001-2010 in University Hospital Birmingham and Leeds Teaching Hospitals was retrospectively collected and concordance between diagnostic and excision histology was assessed. Low Grade DCIS diagnoses were further evaluated retrospectively with regard to their eligibility for LORIS. RESULTS: Of 225 DCIS diagnoses 128 (57%) were high grade, 66 (29%) intermediate grade and 31 (14%) low grade. Overall 18% were upgraded to invasive cancer. The upgrade rate to invasive cancer for high grade was 23% and for low grade DCIS was 10%. In the low grade group eligible for LORIS, there were no upgrades to invasive cancer. CONCLUSION: The upgrade rates to invasive cancer are comparable to series published in literature. The concordance for the low risk DCIS with zero upgrade to invasive cancer supports the stringent LORIS eligibility criteria for trial selection.

Patient education videos for elective colorectal surgery: results of a randomized controlled trial.

AIM: Recent advances in surgery have focused on peri-operative care and interventions to improve outcome following surgery. Psychological preparation has a positive impact on recovery and incorporates a range of strategies with dissemination of information as one of the key elements. Information can be given verbally, through printed information or through use of a video. Traditionally, reliance has been on the use of written material as an adjunct to patient education in clinic. The current study is a randomized trial on the use of video education in patients undergoing elective colorectal resection within an enhanced recovery programme. METHOD: Sixty-five eligible patients undergoing elective colorectal surgery were identified and 61 were randomized between August 2010 and August 2011 to either video and information leaflets or information leaflets alone. A fast track protocol was established for all the patients. Clinicians in charge of postoperative recovery were blinded. Standard discharge criteria were employed for all patients. RESULTS: Of 61 patients randomized, one dropped out and outcomes on 60 were analysed. There was no difference in baseline characteristics between the groups (age, P = 0.964; body mass index, P = 0.829). Twenty-eight (91%) patients in the video group had left sided resections while two (6%) had right sided resections. Nineteen (66%) in the non-video group had left sided resections while nine (31%) had right sided resections. One (3%) patient in the non-video group and one (3%) in the video group had a total colectomy. Fourteen (45%) patients in the video group and 12 (41%) in the non-video group had surgery completed laparoscopically. There was no difference in the primary (median hospital stay 5 vs 5 days; P = 0.239) or the secondary outcome measures (pain score on movement, P = 0.338; pain score at rest, P = 0.989; nausea score, P = 0.74; epidural use, P = 0.984; paracetamol use, P = 0.44; voltarol use, P = 0.506) between the groups. CONCLUSION: Use of video education in the psychological preparation of patients undergoing elective colorectal surgery does not improve short-term outcomes.

The sensitivity of needle core biopsy in combination with other investigations for the diagnosis of phyllodes tumours of the breast.

BACKGROUND: The sensitivity of needle-core biopsy (NCB) in diagnosing phyllodes tumours has only been addressed by a handful of small studies. The aim of this study was to analyse the sensitivity of NCB in the diagnosis of phyllodes tumours and to compare this to the sensitivity of other commonly performed investigations. A secondary aim was to assess the effect of various patient and disease factors on the rate of false negative test results. METHODS: Pathology databases were interrogated to identify all patients with the SNOMED term M-9020 or the word phyllodes in specimen reports. Excisional specimen reports were matched to prior FNAC reports, NCB reports and imaging reports. RESULTS: Ninety-one patients had a confirmed phyllodes tumour on excision. The sensitivity of FNAC, NCB and imaging for diagnosing phyllodes tumours was 40%, 63% and 65% respectively. The sensitivity of imaging and NCB was greater for borderline and malignant lesions. Combining cytohistological and radiological tests improved sensitivity to 76%. A younger age was associated with a greater false negative rate for all tests. Borderline and malignant phyllodes tumours were significantly associated with advancing age and greater lesion size on imaging and histology. CONCLUSIONS: This is the largest report to date assessing the sensitivity of NCB in the diagnosis of phyllodes tumours. Increased sensitivity in the diagnosis of phyllodes tumours can be achieved by combining cytohistological and radiological test results. The novel association between younger age and false negative results warrants further investigation. The most likely explanation is a reluctance to diagnose phyllodes tumours in young women given the increased prevalence of cellular fibroadenomas in this age group.

Preparation for elective colorectal surgery using a video: a questionnaire-based observational study.

OBJECTIVE: Every patient has a perception about surgery and psychological preparation of the patient has an important impact on their postoperative recovery and outcome. In this study we looked at impact of a visual educational aid, in the form of a patient DVD on outcome following colorectal surgery within an enhanced recovery programme (ERP). DESIGN: We carried out a prospective analysis of a consecutive series of patients undergoing elective colorectal resection. All patients were given information about their operation in a clinic setting. Our intervention included a 15 minute patient educational video describing the preoperative assessment, post-operative recovery and advice on discharge. A questionnaire on patients' views of ERP and video education was given on discharge. SETTING: University teaching hospital PARTICIPANTS: Patients undergoing elective colorectal resection MAIN OUTCOME MEASURES: Outcomes studied included length of hospital stay, patient perception of ERP, postoperative complications and readmissions: RESULTS: Thirty-two patients underwent elective colorectal surgery over a 3 month period. Median length of stay in hospital was 5 days. The questionnaire response rate was 100%. All patients thought they were well informed of the enhanced recovery programme. Eighty-eight percent responded that the video information provided about their operation was adequate, with 28% finding the video very helpful and more useful than other forms of patient information. There were no major postoperative complications and no readmissions. CONCLUSION: Audiovisual presentation in the form of a patient video is a useful tool in the psychological preparation of patients undergoing colorectal surgery.

Laparoscopic extralevator abdominal perineal excision of the rectum: the best of both worlds.

We report a combined laparoscopic and open technique for extralevator abdominal perineal excision of the rectum. The key steps are a laparoscopic rectal dissection limited distally by the coccyx. The open, prone, perineal dissection affords excellent views and allows a cylindrical specimen to be obtained. The resulting perineal defect is closed by a biological mesh. Extralevator abdominal perineal excision of the rectum offers a superior oncological specimen with reduced circumferential resection margin involvement compared to traditional techniques. Combined with a laparoscopic approach, this also has the potential to improve postoperative recovery and reduce morbidity.

Management of obstetric anal sphincter injuries--a role for the colorectal surgeon.

AIM: To determine if surgical repair of third and fourth degree obstetric perineal tears by an experienced colorectal surgeon produces satisfactory functional results in the short and long term. METHOD: Consecutive deliveries were studied prospectively over a 32-month period. All patients with suspected third or fourth degree tears were referred to the colorectal team. Following confirmation of the injury, patients underwent surgical repair using a standard overlapped technique according to an established protocol. The patients were reviewed 2 months later. Long-term continence was determined, by postal and telephone follow up, after a minimum of 3 years. RESULTS: Fifty-nine sphincter injuries were identified and repaired by the colorectal team. Two months following repair 51 (86%) of patients had normal continence, four (7%) had urgency, and five (8%) had occasional incontinence of flatus. All patients with any degree of incontinence underwent endoanal ultrasound at which no sphincter defects were noted, and all improved symptomatically following pelvic floor physiotherapy. Long-term follow up data was obtained in 45 women. Thirty-nine (87%) had normal continence scores, 11 (24%) described urgency, but only three (7%) were often incontinent of liquid stool. Seven (15%) were occasionally incontinent of flatus. CONCLUSION: Excellent short and long-term functional results were obtained in the repair of third and fourth degree tears when performed by experienced colorectal surgeons. Since the protocol was established, obstetricians in North Cheshire have adopted the double overlapped technique, and now manage the majority of these injuries themselves.

Small, flat colorectal cancers in the UK population: an analysis of resected specimens.

OBJECTIVES: To establish the prevalence of small, flat carcinomas in surgically resected colon. To determine whether tumour morphology influences stage at presentation. METHOD: 1763 surgically resected colorectal cancers from one UK centre excised between 1995 and 2004 were examined. Age 69 years, (42-90), M:F equal. Sixty-one tumours < or =20 mm across were identified. Slides were reviewed by a consultant histopathologist and classified using Japanese Research Society Classification, JRSC and TNM staging. Fisher's exact test was used for analysis. RESULTS: In 61 small cancers, 64% (39/61) showed flat morphology and 33% (20/61) polypoid. Two lesions were unclassifiable. Prevalence was 2.2% of all resected colorectal cancers. More T1 tumours at presentation were polypoid, (30% vs. 8%; P = 0.033). T3 tumours were more likely to be flat than polypoid, (49% vs. 20%; P = 0.016). Infiltration into musclaris mucosa occurred in 77% (30/39) flat tumours. Rates of metastases were high in both groups, (30% polypoid vs. 39% flat, not significant). CONCLUSIONS: The prevalence of small, flat cancers in resected specimens in the UK concurs with that of Japanese studies. Small, flat cancers should be staged carefully because of high rates of T3/4 disease. The results support the theory of accelerated carcinogenesis in flat cancers.

Evolution of the two-week rule pathway--direct access colonoscopy vs outpatient appointments: one year's experience and patient satisfaction survey.

Abstract Objectives The aim of this study was to compare the effectiveness of Direct access colonoscopy (DAC) vs outpatient appointments for two-week rule colorectal cancer referrals and to evaluate the satisfaction of patients referred through these routes. Patients and methods Data were collected prospectively from January 2003 to December 2003 on patients who were referred for DAC or outpatient appointments at the discretion of the referring General practitioner via the Lower GI two-week rule pathway. A postal questionnaire was used to survey patient satisfaction. Results Six hundred and thirty-nine patients were referred via the two-week rule pathway; 188 patients underwent colonoscopy at their initial hospital visit and 19 (10.1%) colorectal cancers were diagnosed; 442 patients had an outpatient appointment and 32 (7.2%) colorectal cancers were identified. There were 7 (1%) inappropriate referrals and 2 patients refused investigations. All outcome parameters measured were reduced for patients referred directly for colonoscopy including time to definitive investigations (Median 9 vs 52 days P < 0.0001), time to histological diagnosis (Median 14 vs 42 days P < 0.0001) and time to treatment (Median 55 vs 75 days P < 0.0483). One hundred and seventy patients were surveyed by the postal questionnaire of whom 127 (75%) responded. Ninety-eight percent of patients were satisfied with the service provided. Four (6.6%) of 60 patients who had undergone direct access colonoscopy expressed a desire to be seen at the outpatient department initially. Conclusions Direct access colonoscopy results in significantly reduced times to histological diagnosis and definitive treatment in patients with colorectal cancer. Patients can be directly admitted for investigations bypassing the outpatient clinic without affecting patient satisfaction.

Visceral schistosomiasis of domestic animals in India: humoral immune status of infected cattle, sheep and goats against major polypeptide antigens of Schistosoma indicum and S. spindale.

Polypeptide profiles of Schistosoma indicum and S. spindale adult worm homogenates were obtained by sodium dodecyl sulphate-polyacrylamide gel electrophoresis. Humoral immune status of infected cattle, sheep and goats against Schistosoma indicum and S. spindale Ags was determined by immunoblot analysis and by indirect ELISA using four major polypeptides of approximate molecular masses 45 kDa, 40 kDa, 28 kDa and 15 kDa electro-eluted from the gel slices. Cattle sera samples had higher levels of antibodies against Si/s40 and Si/s28 than against Si/s45 antigen. Reasons have been discussed for the absence of detectable levels of anti-Si/s28, -Si/s45 and -Si/s40 antibodies in a significant number of sera samples from S. indicum egg-positive sheep.

Co-expression of vascular endothelial growth factor C (VEGF-C) and c-erbB2 in human breast carcinoma.

Vascular endothelial growth factor C (VEGF-C) has angiogenic and lymphangiogenic properties and is associated with the development of lymphatic metastases in a number of epithelial malignancies. The aim of this study was to determine VEGF-C protein expression in a series of breast carcinomas and correlate this with axillary lymph node (LN) metastases, the presence of lympho-vascular invasion (LVI), bone marrow micro-metastases (BMM) and other clinico-pathological data including oestrogen receptor (ER) and c-erbB2 status. VEGF-C expression was determined by immunohistochemistry (IHC) in 51 tumours. ER and c-erbB2 were also assessed by IHC. Bone marrow analysis was performed using a combination of immunomagnetic separation and immunocytochemistry. Overall, 30/51 (59%) of the tumours were positive for VEGF-C. There was no significant correlation between VEGF-C expression and LN status, LVI, BMM, tumour size, grade or ER status. However, there was an association between c-erbB2 and VEGF-C expression (P=0.013). The correlation between VEGF-C and c-erbB2 suggests a functional relationship and may, in part, explain the aggressive phenotype associated with c-erbB2-positive tumours.

Evaluation of closed loop control of arterial pressure during hypotensive anaesthesia for local resection of intraocular melanoma.

We have studied 20 patients undergoing local resection of intraocular melanoma during hypotensive anaesthesia, allocated randomly to receive either manual control by an experienced anaesthetist or closed-loop computer control of an infusion of a 5:1 mixture of trimetaphan camsylate (TMP) and sodium nitroprusside (SNP). There were no significant differences in the smallest systolic and diastolic arterial pressures obtained, heart rate or infusion requirements between the two groups, but the duration of both the infusion and the operation were significantly longer in the computer-controlled group (P < 0.05). The quality of control of arterial pressure was assessed by the percentage of time spent at pressures greater and less than the prescribed target values, and was satisfactory in both groups during the critical period of profound hypotension. We conclude that the computer-controlled infusion performed satisfactorily during profound hypotension compared with an experienced anaesthetist.

Cell-mediated immune responses to sporozoites and macroschizonts of Theileria annulata.

The nature of cell-mediated immune (CMI) responses was studied in cross-bred bovine calves, immunised by attenuated and allogeneic macroschizonts of Theileria annulata. The CMI responses were also investigated in calves, destined to survive or die of tropical theileriosis (Theileria annulata) induced by a virulent dose of sporozoites or macroschizont-infected lymphoblasts. Calves suffering fatal theileriosis showed poor CMI response. Microcytotoxicity assay revealed an enhanced population of specific cytotoxic cells amongst the peripheral blood lymphocytes (PBL) of calves resolving the infection successfully. The E rosette assay showed proliferation of T cells and the assay for macrophage migration inhibition factor (MIF) demonstrated antigen sensitised cells in the PBL. Calves, immunised by allogeneic and attenuated macroschizont-infected lymphoblasts or those recovering from virulent macroschizont-induced infection, showed protective CMI responses with patterns similar to those appearing after non-fatal sporozoite infection.