Clinical outcomes and inflammatory response to single-incision laparoscopic (SIL) colorectal surgery: a single-blinded randomized controlled pilot study.

AIM: Single-incision laparoscopic (SIL) surgery is expanding, but its benefits, efficacy and safety compared with conventional laparoscopic (CL) surgery remain unclear. This pilot study examined clinical outcomes and biochemical markers of inflammation for colorectal resections by SIL and CL in a randomized controlled pilot trial. METHOD: Fifty patients undergoing elective colorectal resection were randomized to either SIL or CL. Primary outcomes were operating time and length of stay (LoS); secondary outcomes included combined length of scars, pain scores, complications, Quality of Life EQ5D-VAS and the inflammatory markers interleukin-6 (IL-6), IL-8 and C-reactive protein (CRP) at baseline, 2, 6, 24 and 72 h. RESULTS: There was no difference in age, gender, body mass index, indications and site of surgery, American Society of Anesthesiologists grade or incidence of previous surgery between the groups. Except for one conversion from SIL to open surgery, surgery was completed as intended. No difference between SIL and CL was found for operating time [median 130 (72-220) vs 130 (90-317) min, respectively, P = 0.528], LoS [median 4 (3-8) vs 4 (2-19)days, P = 0.888] and time to first flatus [2 (1-4) vs 2 (1-5) days, P = 0.374]. The combined length of scars was significantly shorter for SIL [4 (2-18) vs 7 (5-8) cm, P < 0.001]; in each group, four postoperative complications occurred (16%). Postoperative pain scores were similar [mean 7.67 (interquartile range 4) vs 7.25 (interquartile range 3.75), P = 0.835] to day 3. EQ5D-VAS was no different for both groups at discharge [72.5 (40-90) vs 70 (30-100), P = 0.673] but slightly higher for CL at 3 months [79 (45-100) vs 90 (50-100), P = 0.033].The IL-6, IL-8 and CRP levels between both groups showed similar peaks and no significant differences. CONCLUSION: SIL colorectal surgery by experienced laparoscopic surgeons appears to be safe and equivalent to CL, with no discernible difference in its effect on the physiological response to surgical trauma.

Single-incision laparoscopic reversal of Hartmann's operation through the stoma site: comparative outcomes with conventional laparoscopic and open surgery.

AIM: Restoration of bowel continuity after Hartmann's procedure (RoH) can be challenging and associated with considerable morbidity. A technique using single-incision laparoscopic surgery through the stoma site (SIL RoH) has been shown to be feasible and safe. In this study, we compared clinical outcomes of SIL RoH with conventional laparoscopic surgery (CL) and open surgery (OS). METHODS: This was a retrospective analysis of a prospectively maintained database between 2007 and 2017 in a UK colorectal unit. The access technique was decided by the surgeon on a case by case basis. RESULTS: A total of 106 patients underwent RoH. It was carried out for diverticular disease (n = 71, 67.6%), cancer (n = 19, 17.9%) and anastomotic leak (n = 4, 3.8%). The remainder (n = 12, 11.3%) were for miscellaneous reasons including trauma. Most RoHs were performed via OS (n = 87, 81.1%). The most common intended approaches for RoH were SIL (n = 56, 52.8%) and OS (n = 34, 32.1%) with fewer starting with CL (n = 16, 15.1%). Conversion to OS took place in five (8.9%) patients with SIL and six (37.5%) with CL (P = 0.005). Postoperative complications occurred in 17 (30.4%) for SIL, seven (43.8%) for CL and 17 (50.0%) for OS (P = 0.162). Median operating time for SIL was 146 min (range 44-389), 211 min (109-320) for CL and 211 min (85-420) for OS (P < 0.001). Median length of stay was 4 days (2-44) for SIL compared to 6 (3-34) for CL and 7 (4-34) for OS (P < 0.001). Discharge on or before day 5 was achieved in 41 (74.5%) patients for SIL compared to six (37.5%) for CL and seven (20.6%) for OS (P < 0.001). CONCLUSION: Compared to OS and CL, SIL RoH appears to have shorter operating times and hospitalization, with no discernible difference in morbidity; this finding requires further evaluation in a randomized setting.

Primary care referral practice, variability and socio-economic deprivation in colorectal cancer.

AIM: The reasons for pre-hospital delay of the diagnosis of cancer are multifactorial, but include a physician-related component. Urgent cancer pathways and direct-to-test approaches have been implemented, but the emergency presentation of colorectal cancer (CRC) remains little changed over recent years. We examined the variability between primary care providers in referral patterns and its effect on outcome. METHOD: A retrospective analysis was performed of a prospectively maintained database for 2009-2014 in a UK district hospital providing bowel cancer screening and tertiary rectal cancer services. RESULTS: Of 1145 CRC patients, 937 (81.8%) were diagnosed with a symptomatic cancer; 229/937 (24.4%) initially presented as an emergency. Between 44 primary care providers, emergency presentation varied between 8.3% and 57.1%. Patients of providers with high levels of emergency presentations (HV) had more advanced cancers than those of providers with medium (MV) or low levels (LV) [103/253 (40.7%), 154/461 (33.4%), 65/223 (29.1%); P = 0.025] and a lower 3-year overall survival (50.2%, 57.8%, 65.6%; P = 0.013), but with no difference in case-mix or deprivation levels. In adjusted analysis, this difference remained significant (advanced disease, OR 1.663, P = 0.011; 3-year hazard ratio 1.479, P = 0.010; comparing HV with LV). Conversely, elective suspected cancer referrals were less often used amongst diagnosed cancers [LV 136/223 (61.0%), MV 228/461 (49.5%), HV 114/253 (45.1%), P < 0.001] with limited evidence for a more selective approach in the use of the 2-week rule amongst all 2-week rule referrals [LV 136/2508 (5.4%); MV 228/4239 (5.4%); HV 115/1526 (7.8%); positive cancer diagnosis, P = 0.005]. CONCLUSION: Significant variability in emergency presentation of CRC requires local audit and examination of the reasons for delay in diagnosis and targeted measures to improve performance in non-emergency referral pathways.

Intra-arterial methylene blue injection into ex vivo colorectal cancer specimens improves lymph node staging accuracy: a randomized controlled trial.

AIM: A randomized controlled trial was carried out to study the effect of a recently proposed technique of ex vivo intra-arterial methylene blue injection of the surgical specimen removed for colorectal cancer on lymph node harvest and staging. METHOD: Between May 2012 and February 2013, 100 consecutive colorectal cancer resection specimens in a single institution were randomly assigned to intervention (methylene blue injection) and control (standard manual palpation technique) groups before formalin fixation. The specimen was then examined by the histopathologist for lymph nodes. RESULTS: Both groups were similar for age, sex, site of tumour, operation and tumour stage. In the intervention group, a higher number of nodes was found [median 23 (5-92) vs. 15 (5-37), P < 0.001], with only one specimen not achieving the recommended minimum standard of 12 nodes [1/50 (2%) vs. 8/50 (16%), P = 0.014]. However, there was no upstaging effect in the intervention group [23/50 (46.0%) vs. 20/50 (40.0%); P = 0.686]. With a significantly lower number of nodes harvested in rectal cancer, the positive effect of the intervention was particularly observed in the patients who underwent preoperative neoadjuvant radiotherapy [median 30 nodes (12-57) vs. 11 (7-15); P = 0.011; proportion of cases with < 12 nodes 0/5 vs. 5/8 (62.5%), P = 0.024]. CONCLUSION: Ex vivo intra-arterial methylene blue injection increases lymph node yield and can help to reduce the number of cases with a lower-than-recommended number of nodes, particularly in patients with rectal cancer having neoadjuvant treatment. The technique is easy to perform, cheap and saves time.

Comparative study of safety and outcomes of single-port access versus conventional laparoscopic colorectal surgery.

BACKGROUND: Single-port access (SPA) offers cosmetic advantages in addition to the well-recognised benefits of conventional multi-port laparoscopic (CL) surgery, and can be carried out using standard straight instruments. We report the outcomes of our early experience with SPA colorectal resections in comparison with CL surgery. METHODS: We compared the following data, patient characteristics, operating time, morbidity, operative mortality, length of hospital stay and tumour variables, of patients who underwent SPA right, left, sigmoid and total colon resections, as well as high anterior resections and panproctocolectomies, with that of patients who underwent equivalent conventional laparoscopic (CL) operations. The 40 SPA and 78 CL patients studied underwent surgery between February 2008 and September 2011. RESULTS: There was no difference between the SPA and CL operations, as regards the patient's sex (55.0 vs. 62.8% males, p = 0.411), comorbidity (ASA I 10.0 vs. 12.8%; ASA II 57.5 vs. 59.0%; ASA III 32.5 vs. 25.6%; ASA IV 0 vs. 2.6%, p = 0.722) and body mass index (26.2 vs. 28.0 kg/m(2), p = 0.073). However, SPA patients were younger (mean age 54.1 vs. 64.8 years, p = 0.001), and malignancy was a less common indication for surgery (25.0 vs. 71.8%, p < 0.001). There were no conversions to open surgery, and one death occurred in the CL group (1.3%). Mean operating time (162 vs. 170 min, p = 0.547), median post-operative hospital stay (4 vs. 4 days, p = 0.255) and morbidity (7.5 vs. 12.8%, p = 0.538) were comparable. CONCLUSIONS: SPA laparoscopic surgery appears safe in the hands of experienced laparoscopic surgeons, with no increase in operating time, length of stay, morbidity and mortality. Selection of patients with indications for surgery for benign disease may be of importance to ensure an oncologically safe initial uptake of SPA colorectal practice.

Single-port access laparoscopic reversal of Hartmann operation.

BACKGROUND: Single-port access offers cosmetic advantages in addition to the well-recognized benefits of standard multiport laparoscopic surgery, and can be performed with the use of standard straight instruments. We describe a technique of single-port access reversal of Hartmann colostomy by use of the colostomy site for access. METHODS: After routine skin preparation and laparoscopic setup, the colostomy is mobilized from its mucocutaneous border, and the anvil of a circular stapler is secured to the distal lumen. By the use of a GelPoint system with 3 or 4 trocars, the intra-abdominal adhesions are divided and the splenic flexure is mobilized to achieve sufficient access to the abdominal and pelvic cavities and proximal colonic mobility. The rectal stump is mobilized to the mid rectum, starting from the posterior mesorectal fascia around to the anterior rectal wall. A tension-free colorectal anastomosis is secured with a standard circular stapling device inserted transanally, and leak tested. The colostomy wound is closed in standard fashion. RESULTS: Five patients underwent single-port access reversal of Hartmann resection (4 diverticular perforations and 1 pT3N0 colon cancer), with a mean operating time of 155 (range, 137-187) minutes and a median length of stay of 3 (range, 2-11) days. There were no conversions, major surgical morbidity, or deaths. CONCLUSION: Single-port access reversal of Hartmann colostomy through the stoma site is safe, and it offers additional cosmetic advantages with no apparent additional morbidity in comparison with standard multiport surgery.

Changes in serum acute phase proteins in ovarian cancer patients receiving cis-diamminedichloroplatinum (CDDP) infusion therapy.

Nine patients with adenocarcinoma of the ovary were given a number of courses of Cisplatin, by I.V. infusion. In four patients a complete clinical response was observed and these patients are disease-free one year after treatment. There was no clinical response in the remaining five patients who have subsequently died. Serial determinations of three acute-phase reactant proteins (alpha 1-acid glycoprotein, haptoglobin, alpha 1-antitrypsin) were performed before every infusion and after therapy. Constantly high or rising serum levels of haptoglobin and alpha 1-acid glycoprotein were associated with progression of the cancer, whereas in patients who were disease-free after therapy, these glycoproteins remained essentially in the normal range. The results suggest that serial measurements of haptoglobin and alpha 1-acid glycoprotein may have clinical value as aids in deciding the effectiveness of drug therapy in these patients.

Comparative teratogenicity of chlordiazepoxide, amitriptyline, and a combination of the two compounds in the fetal hamster.

A combination of chlordiazepoxide and amitriptyline maternally administered as a single intraperitoneal injection on day 8 of gestation in the fetal hamster produced predominantly central nervous system anomalies including exencephaly and encephalocoele. In addition, omphalocoele, spinal flexion, and microcephaly were noted. A dose response relationship was found in which a maternal dose range of 13/33 mg/kg--33/83 mg/kg chlordiazepoxide/amitriptyline produced 7-92 percent fetal anomalies. Combination drug dose levels up to 23/58 mg/kg produced no maternal mortality. However, higher levels did result in a marked dose dependent mortality rate. The teratogenic potential of the combined drugs is much more pronounced than that of either drug administered alone since chlordiazepoxide at a maternal dose range of 280/3100 mg/kg produced 3-55 percent fetal anomalies, and amitriptyline at a maternal dose range of 60-100 mg/kg produced 6-45 percent fetal anomalies. The majority of these aberrant fetal developmental entities also were classifiable as exencephaly and encephalocoeles. Dose-dependent maternal mortality was observed at all dose levels for each drug administered separately.

Cadmium toxicity: inducement of changes in blood and tissue metabolites in fish.

The effects of acute (24 h) and chronic (90 days) cadmium (Cd) poisoning on blood and tissue metabolite levels of a teleost, Puntius conchonius were studied. Significant hyperglycemia with an increment in liver, kidney and ovary cholesterol occurred during acute Cd poisoning. By contrast, an enduring hypoglycemia and diminished levels of tissue cholesterol manifested the chronically intoxicated fish. Both acute and chronic Cd poisoning, however, caused marked hypocholesterolemia, glycogenolysis in liver and brain, and a concomitant rise in myocardium glycogen concentration. Testes cholesterol was found to be depleted after both acute and chronic (60 days) Cd poisoning.

Syndrome of primary ciliary dyskinesia: Kartagener's syndrome with empyema thoracis and azoospermia.

Primary ciliary dyskinesia is a genetically determined disorder with several pulmonary complications. A case of an 18-year-old male suffering from this entity and having empyema thoracis and azoospermia is presented here.

Individual and combined toxicity of common pesticides to teleost Puntius conchonius Hamilton.

Individual and combined toxicity of three pesticides, endosulfan, phosphamidon, and aldicarb was evaluated in P. conchonius. The 48 hr LC50 was 21.36 and 446.5 ppm respectively for endosulfan and phosphamidon. When tested jointly, 48 hr LC50 for different ratios of these pesticides were 0.332 (IE:3P), 0.224 (IE:1P), and 0.178 ppm (3E:1P). The cotoxicity coefficients for these combinations were 1793, 3986, and 10009, respectively. An equitoxic mixture of endosulfan, phosphamidon, and aldicarb yielded a 48 hr LC50 of 130.5 ppm. An enhanced toxic impact is indicated when the pesticides are present together rather than as individual compounds.

Effect of somatotropin upon a freshwater fish, Channa punctatus (Bloch).

The mammalian growth hormone was administered intramuscularly to a freshwater teleost, Channa punctatus. The hormone induced a mild hyperglycemia lasting 120 hours. The beta cells in the pancreatic islets showed degranulation due to exhaustion.

Cytoarchitecture of the corpuscles of Stannius in hillstream teleosts, Barilius bendelisis (Ham.) and Garra gotyla (Gray).

The teleosts, Barilius bendelisis and Garra gotyla possess corpuscles of Stannius (CS) which are discrete, encapsulated bodies lying in close proximity to the mesonephros. The corpuscular cells are arranged in anastomosing cords which are separated from each other by connective tissue septa and numerous sinusoids. Light microscopically, 2 types of secretory cells comprise the CS in these species. Majority of the corpuscular cells are stainable with AF and PAS in contrast to the nonstainable cells which evince little affinity for the dyes. The fine cytoplasmic granules contained in the stainable cells are polarized on the vascular face in Barilius bendelisis.

Effect of organomercurial poisoning on the peripheral blood and metabolite levels of a freshwater fish.

This work evaluated the hematological and biochemical changes in the fish, Puntius conchonius, under experimental organomercurial poisoning. Long-term (8 weeks) exposure to 3.63 and 6.03 mg/liter methoxyethyl mercuric chloride (MEMC) (0.2 and 0.33 fractions of 96-hr LC50) led to morphological aberrations in mature erythrocytes including nuclear and cytoplasmic deterioration, vacuolation, chromatin condensation, and hypochromia. Immature erythrocytes showing membrane leakage were also encountered. Erythrocyte count and hemoglobin (Hb) were significantly lowered after 1 and 3 weeks followed by a marginal rise persisting upto 8 weeks. Differential leucocyte counts revealed significant thrombocytopenia, lymphocytosis, and neutropenia. Collateral evaluation of blood glucose and tissue glycogen levels revealed significant hyperglycemia as well as glycogen depletion in liver and brain. Heart glycogen content evinced a substantial increase after 5 and 8 weeks exposure.