Variation in esophageal anastomosis technique-the role of collaborative learning.

Centralization of care has improved outcomes in esophagogastric (EG) cancer surgery. However, specialist surgical centers often work within clinical silos, with little transfer of knowledge and experience. Although variation exists in multiple dimensions of perioperative care, the differences in operative technique are rarely studied. An esophageal anastomosis workshop was held to identify areas of common and differing practice within the operative technique. Surgeons showed videos of their anastomosis technique by open and minimally invasive surgery. Each video was followed by a discussion. Surgeons from 10 different EG cancer centers attended. Eight key technical differences and learning points were identified and discussed: the optimum diameter of the gastric conduit; avoiding ischemia in the gastric conduit; minimizing esophageal trauma; the use of an esophageal mucosal collar; omental wrapping; intraoperative leak testing; ideal diameter of the circular stapler and the growing use of linear stapled anastomoses. The workshop received positive feedback from participants and on 2 years follow-up, 40% stated that they believed that the learning of tips and techniques during the workshop has contributed to lowering their anastomotic leak rate. Many differences exist in surgical technique. The reasons for, and crucially the significance of, these differences must be discussed and examined. Workshops provide a forum for peer-to-peer collaborative learning to reflect on one's own practice and improve surgical technique. These changes can, in turn, generate incremental improvements in patient care and postoperative outcomes.

T staging esophageal tumors with x rays.

With histopathology results typically taking several days, the ability to stage tumors during interventions could provide a step change in various cancer interventions. X-ray technology has advanced significantly in recent years with the introduction of phase-based imaging methods. These have been adapted for use in standard labs rather than specialized facilities such as synchrotrons, and approaches that enable fast 3D scans with conventional x-ray sources have been developed. This opens the possibility to produce 3D images with enhanced soft tissue contrast at a level of detail comparable to histopathology, in times sufficiently short to be compatible with use during surgical interventions. In this paper we discuss the application of one such approach to human esophagi obtained from esophagectomy interventions. We demonstrate that the image quality is sufficiently high to enable tumor T staging based on the x-ray datasets alone. Alongside detection of involved margins with potentially life-saving implications, staging tumors intra-operatively has the potential to change patient pathways, facilitating optimization of therapeutic interventions during the procedure itself. Besides a prospective intra-operative use, the availability of high-quality 3D images of entire esophageal tumors can support histopathological characterization, from enabling "right slice first time" approaches to understanding the histopathology in the full 3D context of the surrounding tumor environment.

Microdissection TESE (mTESE) following adult orchidopexy for undescended intra-abdominal and inguinal testicles - surgical techniques and outcomes from a single-centre cohort.

INTRODUCTION AND OBJECTIVES: Adult undescended testicles (UDTs) often present to fertility specialists with subfertility or azoospermia and with either an intra-abdominal or inguinal testicle(s). Performing an orchidopexy followed by a surgical sperm retrieval (SSR) is a potential option to retrieve spermatozoa. A microdissection TESE (mTESE) procedure is performed to retrieve mature spermatozoa for use in ICSI. This paper reviews the outcomes of mTESE in adults following an orchidopexy. MATERIAL AND METHODS: A cohort of azoospermic patients underwent adult orchidopexy over a 10-year period at a single specialist centre. Data were collected retrospectively from the patient records retrieved from an institutional database. All patients underwent pre-operative imaging to localize the testicles, serum testosterone levels and a semen analysis. Separate intraoperative testicular biopsies were performed to exclude intratubular germ cell neoplasia (ITGCN) and to analyse the Johnsen score. RESULTS: Twelve patients (age range 18-36 years) underwent orchidopexy procedures for either intra-abdominal or inguinal testicles. Mean follow-up was 34 months (range 13-58). Ninety per cent of patients had bilateral UDT with azoospermia. Pre-operative testosterone levels were within the normal range (mean 13.9 nmol/L; range 9.1-24.2). Five pelvic testicles (from four patients) were brought down and underwent a delayed mTESE. A total of nine inguinal orchidopexy procedures were carried out in eight men, and spermatozoa were found and preserved in three patients. None of the men with intra-abdominal testicles had mature spermatozoa present following a delayed mTESE. Overall, SSR was successful in 37.5% of the patients. Histological analysis showed no cases of ITGCN and the Johnsen scores ranged from 1 to 3.3. CONCLUSIONS: Microdissection TESE following orchidopexy for inguinal testicles can result in a successful SSR in over 1/3rd of patients. Intra-abdominal testicles appear to lack spermatogonia although the testicles can still be preserved for endogenous hormone production. Adult orchidopexy allows preservation of endogenous testosterone, easier self-examination and an immediate or delayed mTESE in azoospermic patients.

Caustic ingestion injury of the upper aerodigestive tract in adults.

Adult ingestion of caustic substances is an unusual but serious surgical problem, with injuries likely to be more extensive than those in the corresponding paediatric population. After initial stabilisation and airway management, clinicians are presented with a complex multisystemic problem, frequently requiring a multidisciplinary approach involving several surgical disciplines and associated therapies. A new multidisciplinary team was convened to discuss complex ingestion injury in adults and established techniques were used to bring forward a proposed treatment algorithm. An algorithm may potentially improve clinical efficacy and risk in the management of these complex patients.

Angiogenesis in cancer: the role of endothelin-1.

This review summarises the process of angiogenesis, its role in tumourigenesis and suggests a mechanism by which endothelin-1 may influence these processes.

Mechanisms of endothelin 1-stimulated proliferation in colorectal cancer cell lines.

BACKGROUND: The peptide endothelin (ET) 1 promotes proliferation in a number of epithelial cancers. The aim of this study was to identify the mechanism of ET-1-stimulated proliferation in colorectal cancer cells in vitro. METHODS: The effects of ET-1 on colorectal cancer cell lines HT29, LIM1215 and SW620 were studied. Cells were cultured with ET-1 plus antagonists/inhibitors to ET(A) or ET(B) receptors, G protein subtypes, phosphoinositide 3-kinase (PI3K) or protein kinase C (PKC). DNA replication and apoptosis were investigated by 5-bromo-2'-deoxyuridine incorporation and Annexin V staining. Transactivation of the epidermal growth factor (EGF) receptor was investigated by blockade of the receptor in the presence of ET-1, measurement of levels of phosphorylated EGF receptor in the presence of ET-1, and comparing the effects of ET-1 and EGF on cell proliferation. RESULTS: ET-1 significantly stimulated growth of all cell lines via ET(A) receptors. ET-1 stimulated DNA replication, not apoptosis. ET-1-stimulated growth was inhibited by antagonism of pertussis toxin-sensitive G proteins, PI3K and PKC. Inhibition of the EGF receptor reduced the effect of ET-1. ET-1 increased levels of phosphorylated EGF receptor via the ET(A) receptor. CONCLUSION: ET-1 increased DNA replication in colorectal cancer cells via the ET(A) receptor. This mitogenic action was mediated via pertussis toxin-sensitive G proteins, PI3K, PKC and transactivation of the EGF receptor.

Endothelin receptor expression in colorectal cancer.

The distribution of endothelin-A- and B- (ET(A), ET(B)) receptor subtypes was compared in colorectal cancer to that in normal colon and their expression in the colorectal cancer cell lines LIM1215. HT29, SKCO1, SKCO17 and LoVo was determined, using gross and high resolution autoradiography and quantified by densitometry. ET(A) and ET(B) binding sites were expressed by all the cell lines. There was significantly (p = 0.008) higher expression of ET(A)-receptors by cancers (205.95 dpm x 1000/mm2) compared normal colon (129.19 dpm x 1000/mm2). However, for ET(B)-receptors, this was reversed, with significantly (p = 0.008) higher expression of ET(B) binding in normal colon (207.00 dpm x 1000/mm2) than in tumours (122.35 dpm x 1000/mm2).