The effect of purse-string approximation versus linear approximation of ileostomy reversal wounds on morbidity rates and patient satisfaction: the 'STOMA' trial.

BACKGROUND: Ileostomy reversal is associated with surgical site infection (SSI) rates as high as 37%. Recent literature suggests that employing a purse-string approximation (PSA) of the reversal wound reduces this rate of SSI. Thus we wished to perform a randomised controlled trial to compare SSI rates in purse-string versus linear closure (PLC) wounds following ileostomy reversal. METHODS: A randomised, controlled trial was conducted at University Hospital Limerick. Sixty-one patients undergoing ileostomy reversal were included. Thirty-four patients were randomised to PSA and 27 patients to linear closure. The primary endpoint was incidence of SSI and secondary endpoints measured were quality of life and satisfaction with cosmesis. Statistical analysis was performed on a per protocol basis using SPSS version 22.0. RESULTS: Three patients in the PSA group developed an SSI compared to 8 in the PLC group at 30 days (8 vs 30%, p = 0.03). The mean time to SSI diagnosis was faster in the PSA group (3 vs 12.3 days, p = 0.08). Patients who developed SSI experienced a longer mean length of stay (6.8 vs 11.4 days, p = 0.012). On multivariate analysis, PLC was the only predictive factor of SSI formation (p < 0.001). There was no difference in patient satisfaction between the two study groups (p = 0.14). CONCLUSIONS: PSA of wounds following ileostomy reversal significantly reduces SSI formation compared to linear approximation without any effect on patient satisfaction.

Neoadjuvant therapy does not affect lymph node ratio in rectal cancer.

AIMS: Recently, lymph-node ratio (LNR) has emerged as a prognostic tool in staging rectal cancer. Studies to date have demonstrated threshold values above and below which survival is differentially altered. Neoadjuvant therapy significantly reduces the number of lymph node retrieved. The aim of the present study was to determine the effect of neoadjuvant therapy on LNR and its prognostic properties. METHODS: Consecutive patients who underwent curative rectal cancer resections in a single institution from 2007 to 2010 were reviewed. LNR was stratified into five subgroups of 0, 0.01-0.17, 0.18-0.41, 0.42-0.69 and 0.7-1.0 based on a previous study. The effect of neoadjuvant therapy on lymph node retrieval, LNR, locoregional (LR) and systemic recurrence (SR), disease-free (DFS) and overall survival (OS) was compared between patients who did (Neoadjuvant) and did not (Surgery Alone) receive neoadjuvant therapy. RESULTS: Neoadjuvant and Surgery Alone groups were comparable in gender, age and tumour stage. The number of lymph nodes retrieved were significantly lower in the Neoadjuvant group (p < 0.01). However, LNR remained similar in both groups (p = 0.36). There was no statistical difference in the DFS and OS between the Neoadjuvant and Surgery Alone groups at the various LNR cut off values in patients with AJCC Stage 3 tumours. CONCLUSIONS: LNR ratio remains unaltered despite reduced lymph node retrieval after neoadjuvant therapy in rectal cancer. LNR may therefore be a more reliable prognostic indicator in this subgroup of patients.

Overall survival is improved in mucinous adenocarcinoma of the colon.

INTRODUCTION: Debate persists regarding the relationship between mucin expression and outcome in colon cancer. This arises due to discrepancy in the definition of mucinous adenocarcinoma and the combination of both colon and rectal cancers in analyses. This study examines the relationship between increased mucin production and outcomes in colon cancer. METHODS: Cases were classified according to the World Health Organization classification of mucinous adenocarcinoma of the colon. Accordingly, tumors were categorized as either (a) mucinous adenocarcinoma of the colon (greater than 50% of the extracellular matrix occupied by mucin) or (b) non-mucinous adenocarcinoma of the colon. Overall survival and disease-free survival were calculated. A stepwise Cox proportional hazards regression model was employed to determine the risk of death/disease recurrence. Kaplan-Meier estimates of overall survival and disease-free survival were plotted for each group and compared using a log-rank test. RESULTS: On univariate analysis, mucinous adenocarcinoma was associated with reduced risk of death (P = 0.01). On multivariate analysis, mucinous adenocarcinoma was also associated with reduced risk of death (hazard ratio (HR) 0.33, 95% confidence interval (CI) 0.14-0.79, P = 0.01). Kaplan-Meier estimates confirmed improved rate of survival in the mucinous vs. non-mucinous group (P = 0.01). Mucinous adenocarcinoma did not affect disease-free survival (HR 0.75, 95% CI 0.46-1.21, P = 0.22). A comparison of Kaplan-Meier estimates for systemic recurrence demonstrated significant increases in systemic recurrence in the group with no mucin production (P = 0.04) but not for locoregional recurrence (P = 0.24). CONCLUSIONS: Histopathological evidence of mucinous adenocarcinoma in colon cancer is associated with improved outcomes.

Vertical rectus abdominis myocutaneous flap and quality of life following abdominoperineal excision for rectal cancer: a multi-institutional study.

BACKGROUND: To obtain a clear surgical margin, abdominoperineal excision (APE) for rectal cancer frequently leaves a large perineal defect surrounded by irradiated tissue. A vertical rectus abdominis myocutaneous (VRAM) flap may facilitate healing of this wound. The current study aims to determine the effect of VRAM flap perineal reconstruction following APE on patient quality of life (QOL). METHODS: This is a retrospective cohort study from a prospectively collected database. Data on QOL were assessed via telephone questionnaire using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ)-C30, EORTC QLQ-C29 and the Cleveland Clinic QOL questionnaires. RESULTS: Twenty-seven patients underwent primary perineal closure, and 12 patients underwent a VRAM flap perineal reconstruction. The mean duration of follow-up was 16.8 months. Overall, there was no significant difference in the Cleveland Clinic QOL score between groups (VRAM vs. no VRAM: 0.7 ± 0.2 vs. 0.7 ± 0.2, p 0.735). Patients in the VRAM group had lower levels of fatigue (5.5 ± 9.9 vs. 23.6 ± 19.2, p 0.004). Patients in the VRAM group had reduced sore skin scores around the stoma site (11.0 ± 16.2 vs. 31.8 ± 31.1, p 0.036). VRAM flap was associated with an increased incidence of abdominal wall hernia (VRAM vs. no VRAM: 25 % vs. 0 %, p 0.024). CONCLUSIONS: This study is limited by its non-randomized retrospective design and relatively small sample size. A significant difference in patient QOL was not demonstrated between VRAM flap and primary perineal closure after APE for rectal cancer. Further studies in this area are warranted.

Origin and spreading of canine morbillivirus in South America.

Canine distemper virus (CDV) is a Morbillivirus (Canine morbillivirus) that greatly impacts domestic and wildlife carnivores worldwide. The CDV RNA genome has high genetic variability, evidenced by several lineages that follow a global geographic pattern. The evolutionary trajectories and population dynamics of CDV lineages are still unclear and debatable, particularly in South America, where relatively few sequences are available. We performed phylogenetic and Bayesian analyses using an updated dataset of the highly variable hemagglutinin (H) gene, including seven South American countries. The time to the most recent common ancestor (tMRCA) of the current CDV lineages was dated to the early 1900s in North America. Maximum likelihood and Bayesian maximum clade credibility phylogenies showed similar topologies with two main branches (L1 and L2) corresponding to the NA1 lineage (L1) and the remaining lineages worldwide (L2). The four circulating lineages in South America (EU1/SA1, SA2, SA3, NA4/SA4) arose from independent migration events from North America and Europe. North American strains colonized most northern South American countries via Ecuador and then Colombia and Peru, originating the SA3 and NA4/SA4 lineages during their spread. The entry and expansion in the southern part of South America (Argentina, Brazil, Chile, and Uruguay) occurred through three independent migration events and gave rise to the EU1/SA1 and SA2 lineages. South American lineages have specific combinations of amino acids under positive selection that constitute signatures of taxonomic and evolutionary relevance. Our findings provide a comprehensive scenario for the origin and migration routes of Canine morbillivirus in South America and highlight the importance of phylodynamics in understanding the geographic patterns of modern genetic variability.

Single incision laparoscopic total proctocolectomy with ileopouch anal anastomosis.

AIM: We present our initial experience of a single port laparoscopic total proctocolectomy with ileoanal J pouch anastomosis. The single incision laparoscopic surgery (SIL), (Covidien, Norwalk, Connecticut, USA) device with a multichannel cannula and specially designed curved laparoscopic instrumentation were used. METHOD: A patient with familial adenomatous polyposis underwent restorative proctocoectomy. A colonoscopy had demonstrated nearly 1000 polyps in the colon with several 1-cm polyps in the rectum. The abdomen was entered through a 2.5 cm incision sited preoperatively for the temporary ileostomy. The single port device was inserted and a total proctocolectomy was performed. Ligation of the vessels was performed with the Ligasure (Covidien). The colon and rectum were extracted through the SIL site. An 18-cm ileoanal J pouch was created extracorporeally. The pouch anal anastomosis was performed intracorporeally and a diverting loop ileostomy created through the SIL port site. RESULTS: The operating time was 172 min. Blood loss was 100 ml and the hospital stay was 4 days without any complication. The patient had a virtually scar-less abdomen other than the site of the loop ileostomy. CONCLUSION: Single port laparoscopic surgery may allow complex colorectal surgery to be performed resulting in a virtually scar-less procedure.

Gaseous constituents in the plume from eruptions of mount st. Helens.

Measurements in the stratosphere of gaseous constituents in the plume of Mount St. Helens were obtained during five flights of the NASA U-2 aircraft between 19 May and 17 June 1980. Mixing ratios from gas chromatographic measurements on samples acquired about 24 hours after the initial eruption show considerable enhancement over nonvolcanic concentrations for sulfur dioxide (more than 1000 times), methyl chloride (about 10 times), and carbon disulfide (more than 3 times). The mixing ratio of carbonyl sulfide was comparable to nonvolcanic mixing ratios although 3 days later it was enhanced two to three times. Ion chromatography measurements on water-soluble constituents are also reported. Very large concentrations of chloride, nitrate, and sulfate ions were measured, implying large mixing ratios for the water-soluble gaseous constituents from which the anions are derived. Measurements of radon-222 present in the plume are also reported.

Mobilization of endothelial precursor cells: systemic vascular response to musculoskeletal trauma.

Postnatal vasculogenesis, the process by which vascular committed bone marrow stem cells or endothelial precursor cells (EPC) migrate, differentiate, and incorporate into the nacent endothelium contributing to physiological and pathological neovascularization, has stimulated much interest. Its contribution to tumor nonvascularization, wound healing, and revascularization associated with skeletal and cardiac muscles ischaemia is established. We evaluated the mobilization of EPCs in response to musculoskeletal trauma. Blood from patients (n = 15) following AO type 42a1 closed diaphyseal tibial fractures was analyzed for CD34 and AC133 cell surface marker expression. Immunomagnetically enriched CD34+ mononuclear cell (MNC(CD34+)) populations were cultured and examined for phenotypic and functional vascular endothelial differentiation. Circulating MNC(CD34+) levels increased sevenfold by day 3 postinjury. Circulating MNC(AC133+) increased 2.5-fold. Enriched MNC(CD34+) populations from day 3 samples in culture exhibited cell cluster formation with sprouting spindles. These cells bound UEA-1 and incorporated fluorescent DiI-Ac-LDL intracellularily. Our findings suggest a systemic provascular response is initiated in response to musculoskeletal trauma. Its therapeutic manipulation may have implications for the potential enhancement of fracture healing.

Laparoscopic surgery protects against the oncologic adverse effects of open surgery by attenuating endothelial progenitor cell mobilization.

BACKGROUND: Endothelial progenitor cells (EPCs) derived from bone marrow incorporate into foci of neovascularization to propagate tumor growth. These cells are mobilized in response to surgical injury. Laparoscopic surgery may protect against the oncologic adverse effects of open surgical tumor excision, and this may be related to attenuated mobilization of EPCs. METHODS: For this study, 132 C57BL/6 mice were randomized to standardized laparotomy, laparoscopy, or control groups. The animals were killed at 6, 24, 48, and 72 h. Femur bone marrow and peripheral blood were harvested. Bone marrow EPCs were detected by flow cytometric dual staining for the stem cell antigen-1/cKit phenotype. Circulating EPCs were characterized in blood by vascular endothelial growth factor receptor 2 positive/macrophage activating complement-1 negative staining. Separately, 12 C57/bl6 mice bearing 3LL Lewis lung tumors 12 days after laparotomy or laparoscopy had their tumors excised and examined for endothelial cell expression (marker P1H12). RESULTS: Laparoscopy decreased circulating EPCs and bone-marrow EPC levels, as compared with laparotomy, at all time points. Bone marrow EPC levels were 2.95% +/- 0.32% after laparotomy, as compared with 0.65 +/- 0.21 in the laparoscopy group (p < 0.05). The circulating EPC level in the laparotomy group was 35.2% +/- 6% of cells, as compared with 3.1% +/- 0.2% in the laparoscopy group (p < 0.05). In homogenized tumors, the percentage of P1H12 expression among laparoscopy-treated animals was 22.1% +/- 4.2%, as compared with 39% +/- 8% in the laparotomy group (p < 0.05). CONCLUSION: Laparoscopy decreased EPC levels in both bone marrow and circulation, resulting in decreased tumor endothelial cell burden. This may represent a novel mechanism by which laparoscopy protects against the oncologic adverse effects of open surgical tumor excision.

Cyproheptadine treatment of Nelson's syndrome: restoration of plasma ACTH circadian periodicity and reversal of response to TRF.

Administration of cyproheptadine for four months to a patient with Nelson's Syndrome was associated with evidence of skin lightening, decreased plasma ACTH concentrations, return of a normal circadian periodicity of plasma ACTH concentrations, and lack of responsiveness of plasma ACTH concentrations to TRF administration, in contrast to the response seen in the untreated state.

Surgical injury induces the mobilization of endothelial progenitor cells.

BACKGROUND: Endothelial progenitor cells (EPCs) are derived from the bone marrow and incorporate into the foci of tumor neovascularization to increase tumor growth. We hypothesized that surgery induces the mobilization of EPCs. METHODS: C57BL/6 mice were assigned randomly to standardized laparotomy or anesthesia-only treatment groups (n=102 mice). Animals were killed at 6, 24, 48, and 72 hours. Bone marrow EPCs were detected by blood flow cytometric dual staining for stem cell antigen-1/cKit. Circulating EPCs were characterized in blood by vascular endothelial growth factor receptor 2(+)/macrophage activating complement-1(-) staining. EPCs were detected in splenic homogenates by dual staining for lectin and acetylated low-density lipoprotein uptake. Plasma vascular endothelial growth factor was determined by enzyme-linked immunosorbent assay. RESULTS: Surgery induced increases in bone marrow and splenic EPC levels (0.2% +/- 0.01% vs 2.9% +/- 0.3%) at 24 hours and in circulating EPC levels (2.5% +/- 0.01% vs 35.2% +/- 6%) at 48 hours compared with control subjects (P <.001). Surgical injury also caused an increase in vascular endothelial growth factor release (81 +/- 8 vs 14 +/- 2 pg; P>.02). CONCLUSIONS: EPCs were mobilized by surgical injury, which may have implications for residual and metastatic tumor growth during the perioperative period.

Theory derivation: application to nursing.

This article demonstrates an application of the theory derivation strategy to concepts thought to contribute to the development of the caring perspective within professional nurse role development. A theoretical structure and relational statements are developed to describe and explain the phenomenon and to lay the groundwork for hypothesis testing.

Young widows' experience with an Internet self-help group.

1. Finding empathetic support is an important factor in coping for people with various needs. 2. Support group resources may be limited due to long travel distances, expense of child care, lack of transportation, or no available group for specific needs. 3. Nurses can guide their patients to Internet support groups for self-care when traditional groups are not accessible or applicable to their circumstances.

Early quality of life outcomes following Doppler guided transanal haemorrhoidal dearterialisation: a prospective observational study.

BACKGROUND AND AIMS: There are few studies examining the quality of life (QOL) of patients with haemorrhoidal disease. Transanal heamorrhoidal dearterialization (THD) is a treatment modality for heamorrhoidal disease in which a Doppler transducer is used to locate the supplying arteries that are subsequently ligated. The aim of this study was to assess symptoms and QOL changes following THD. PATIENTS AND METHODS: This was a prospective evaluation of QOL and symptom changes following THD. Patient symptoms, demographics and QOL were recorded preoperatively and 1-month post-operatively following THD using the medical outcomes study short-form-36 (SF-36). RESULTS: Thirteen patients undergoing THD were evaluated. One month following THD symptoms of haemorrhoid protrusion, bleeding, anal pain, painful defaecation, constipation and tenesmus, had all significantly reduced (P <0.05). Limitations in usual role activities because of physical health problems (53.8 +/- 10.5 Vs 90.4 +/-4.5, P = 0.004), vitality, energy and fatigue (45 +/- 6.9 Vs 73.5 +/- 5.0, P= 0.003), general mental health, psychologic distress and wellbeing (60.9 +/- 6.9 Vs 83.1 +/- 5.9, P= 0.023), limitations in social activities because of physical or emotional problems (58.7 +/- 8.8 Vs 84 +/- 5.9, P = 0.025), and physical pain (52.9 +/- 7.9 Vs 84.6 +/- 6.4, P= 0.005) scores had all improved 1-month following THD. CONCLUSIONS: THD significantly reduces symptoms of haemorrhoidal disease and improves specific aspects of QOL 1-month following surgery.

The benefits of a laparoscopic approach in ileal pouch anal anastomosis formation: a single institutional retrospective case-matched experience.

AIMS: A laparoscopic approach to ileoanal pouch formation is novel. By using prospectively gathered data, laparoscopic and open restorative proctocolectomy procedures in mucosal ulcerative colitis (UC) and familial adenomatous polyposis (FAP) patients were compared using a case-matched design. METHODS: Ten consecutive patients have had laparoscopic ileal pouch anal anastomosis (IPAA) since April 2005. Their intraoperative findings, immediate and early postoperative outcomes are compared with ten non-selected patients who had an open IPAA pre April 2005. RESULTS: Laparoscopic IPAA group had a shorter time to ileostomy function, a reduced mean time to regular diet and a mean shorter hospital stay. Their overall opioid analgesia requirements were 50% that of the open group. There were no re-operations or readmissions in either group. Mean operative time was longer for the laparoscopic group. CONCLUSIONS: Patients undergoing laparoscopic IPAA can expect faster postoperative gastrointestinal recovery, reduced blood loss, reduced opioid requirements and improved cosmesis.

Sustained weight loss and improvement of quality of life after laparoscopic adjustable gastric banding for morbid obesity: a single surgeon experience in Ireland.

BACKGROUND: Although substantial weight loss is the primary outcome following bariatric surgery, changes in obesity-related morbidity and quality of life (QoL) are equally important. This study reports on weight loss, QoL and health outcomes following laparoscopic adjustable gastric banding (LAGB). METHODS: Bariatric analysis and reporting outcome system questionnaire survey was carried out on patients who had LAGB. Patients' body weight, body mass index, QoL and co-morbidities were recorded. RESULTS: Twenty-three of 26 patients answered the questionnaire (response rate of 92%). Fifteen patients (60%) achieved over 50% excess weight loss. Twenty-two patients (84.6%) reported improvement in QoL. Co-morbidities in 18 patients (75%) resolved or improved. One patient had postoperative aspiration pneumonia and no other morbidity was recorded. CONCLUSIONS: Laparoscopic adjustable gastric banding is a safe and feasible method of bariatric surgery. It can achieve satisfactory weight loss with significant improvement in QoL and co-morbidity provided patients undergo thorough preoperative preparation and rigorous postoperative follow-up.

A novel technique for repair of iatrogenic tracheal tear complicating three-stage oesophagectomy.

We report a rare case of iatrogenic tracheal tear during a three-stage oesophagectomy in a 76-year-old woman and review current literature. The tear occurred due to trauma from a double lumen endotracheal tube. We used a novel technique of repairing the tear, which extended to the carina, avoiding a second thoracotomy or full sternotomy by using the laparoscopic suturing instruments.