Adipose tissue grafting for management of persistent anastomotic leak after low anterior resection.

BACKGROUND: An anastomotic leak is the most dreaded complication after low anterior resection. Adipose tissue grafting may induce healing in a persistent anastomotic defect. The aim of the present study was to report retrospectively reviewed outcomes for a series of patients who were managed with heterotopic grafted adipose tissue to facilitate anastomotic healing. METHODS: Patients with anastomotic leakage after low anterior resection sequentially treated with grafting of adipose tissue were included in the study. All patients had pelvic radiation during treatment and had a diverting ileostomy in situ. The cohort had a persistent defect despite being treated with available modalities such as suture repair, fibrin glue, Endo-Sponge and surgical debridement. The outcomes were reviewed and reported. RESULTS: There were 11 patients (8 males and 3 females) with a median age of 54 years (range 33-72 years). Five patients experienced complete healing of the anastomotic defect with successful reversal of the diverting ileostomy. The anastomotic defect of one other patient in the series appeared to have healed and hence his diverting ileostomy was reversed. However, he presented with a recurrent leak, which ultimately necessitated an abdominoperineal resection. Another patient had a persistent defect after an attempt at adipose tissue grafting and opted to proceed with a takedown of the anastomosis. In the remaining four patients, the outcome after adipose tissue grafting remains unknown, as two patients succumbed to metastatic disease, one was lost to follow-up and the remaining patient developed a recurrence which required pelvic exenteration. Procedural associated morbidity occurred in one patient who developed fat embolism, which was treated expectantly. CONCLUSIONS: Adipose tissue grafting is safe and feasible, though its effectiveness remains uncertain. It may be useful selectively in the management of persistent anastomotic leak after radiation and low anterior resection.

Frequency dependence of surface acoustic wave swimming.

Surface acoustic waves (SAWs) are elastic waves that can be excited directly on the surface of piezoelectric crystals using a transducer, leading to their exploitation for numerous technological applications, including for example microfluidics. Recently, the concept of SAW streaming, which underpins SAW microfluidics, was extended to make the first experimental demonstration of 'SAW swimming', where instead of moving water droplets on the surface of a device, SAWs are used as a propulsion mechanism. Using theoretical analysis and experiments, we show that the SAW swimming force can be controlled directly by changing the SAW frequency, due to attenuation and changing force distributions within each SAW streaming jet. Additionally, an optimum frequency exists which generates a maximum SAW swimming force. The SAW frequency can therefore be used to control the efficiency and forward force of these SAW swimming devices. The SAW swimming propulsion mechanism also mimics that used by many microorganisms, where propulsion is produced by a cyclic distortion of the body shape. This improved understanding of SAW swimming provides a test-bed for exploring the science of microorganism swimming, and could bring new insight to the evolutionary significance for the length and beating frequency of swimming microbial flagella.

Gate tunable graphene-integrated metasurface modulator for mid-infrared beam steering.

The ability to integrate graphene into metasurface devices has attracted enormous interest as a means of achieving dynamic electrical control of their electromagnetic response. In this manuscript, we experimentally demonstrate a graphene-integrated metasurface modulator that establishes the potential to actively control the amplitude and phase of mid-infrared light with high modulation depth and speed, in good agreement with simulation results. Our simulations also show it is possible to construct a reconfigurable surface with tunable phase profile by incorporating graphene-integrated metasurface modulators with specific geometric parameters. This reconfigurable surface is able to manipulate the orientation of the wave reflected from it, achieving a high-speed, switchable beam steering reflective interface. The results here could inspire research on dynamic reflective display and holograms.

Changes in the multidisciplinary management of rectal cancer from 2009 to 2015 and associated improvements in short-term outcomes.

AIM: Significant recent changes in management of locally advanced rectal cancer (LARC) include preoperative staging, use of extended neoadjuvant therapies and minimally invasive surgery (MIS). This study was aimed at characterizing these changes and associated short-term outcomes. METHOD: We retrospectively analysed treatment and outcome data from patients with T3/4 or N+ LARC ≤ 15 cm from the anal verge who were evaluated at a comprehensive cancer centre in 2009-2015. RESULTS: In total, 798 patients were identified and grouped into five cohorts based on treatment year: 2009-2010, 2011, 2012, 2013 and 2014-2015. Temporal changes included increased reliance on MRI staging, from 57% in 2009-2010 to 98% in 2014-2015 (P < 0.001); increased use of total neoadjuvant therapy, from 17% to 76% (P < 0.001); and increased use of MIS, from 33% to 70% (P < 0.001). Concurrently, median hospital stay decreased (from 7 to 5 days; P < 0.001), as did the rates of Grade III-V complications (from 13% to 7%; P < 0.05), surgical site infections (from 24% to 8%; P < 0.001), anastomotic leak (from 11% to 3%; P < 0.05) and positive circumferential resection margin (from 9% to 4%; P < 0.05). TNM downstaging increased from 62% to 74% (P = 0.002). CONCLUSION: Shifts toward MRI-based staging, total neoadjuvant therapy and MIS occurred between 2009 and 2015. Over the same period, treatment responses improved, and lengths of stay and the incidence of complications decreased.

Effectiveness of a multidisciplinary patient care bundle for reducing surgical-site infections.

BACKGROUND: Surgical-site infection (SSI) is associated with significant healthcare costs. To reduce the high rate of SSI among patients undergoing colorectal surgery at a cancer centre, a comprehensive care bundle was implemented and its efficacy tested. METHODS: A pragmatic study involving three phases (baseline, implementation and sustainability) was conducted on patients treated consecutively between 2013 and 2016. The intervention included 13 components related to: bowel preparation; oral and intravenous antibiotic selection and administration; skin preparation, disinfection and hygiene; maintenance of normothermia during surgery; and use of clean instruments for closure. SSI risk was evaluated by means of a preoperative calculator, and effectiveness was assessed using interrupted time-series regression. RESULTS: In a population with a mean BMI of 30 kg/m2 , diabetes mellitus in 17·5 per cent, and smoking history in 49·3 per cent, SSI rates declined from 11·0 to 4·1 per cent following implementation of the intervention bundle (P = 0·001). The greatest reductions in SSI rates occurred in patients at intermediate or high risk of SSI: from 10·3 to 4·7 per cent (P = 0·006) and from 19 to 2 per cent (P < 0·001) respectively. Wound care modifications were very different in the implementation phase (43·2 versus 24·9 per cent baseline), including use of an overlying surface vacuum dressing (17·2 from 1·4 per cent baseline) or leaving wounds partially open (13·2 from 6·7 per cent baseline). As a result, the biggest difference was in wound-related rather than organ-space SSI. The median length of hospital stay decreased from 7 (i.q.r. 5-10) to 6 (5-9) days (P = 0·002). The greatest reduction in hospital stay was seen in patients at high risk of SSI: from 8 to 6 days (P < 0·001). SSI rates remained low (4·5 per cent) in the sustainability phase. CONCLUSION: Meaningful reductions in SSI can be achieved by implementing a multidisciplinary care bundle at a hospital-wide level.

Zeta potentials of the rare earth element fluorcarbonate minerals focusing on bastnäsite and parisite.

Rare earth elements (REE) are critical to a wide range of technologies ranging from mobile phones to wind turbines. Processing and extraction of REE minerals from ore bodies is, however, both challenging and relatively poorly understood, as the majority of deposits contain only limited enrichment of REEs. An improved understanding of the surface properties of the minerals is important in informing and optimising their processing, in particular for separation by froth flotation. The measurement of zeta potential can be used to extract information regarding the electrical double layer, and hence surface properties of these minerals. There are over 34 REE fluorcarbonate minerals currently identified, however bastnäsite, synchysite and parisite are of most economic importance. Bastnäsite-(Ce), the most common REE fluorcarbonate, supplies over 50% of the world's REE. Previous studies of bastnäsite have showed a wide range of surface behaviour, with the iso-electric point (IEP), being measured between pH values of 4.6 and 9.3. In contrast, no values of IEP have been reported for parisite or synchysite. In this work, we review previous studies of the zeta potentials of bastnäsite to investigate the effects of different methodologies and sample preparation. In addition, measurements of zeta potentials of parisite under water, collector and supernatant conditions were conducted, the first to be reported. These results showed an iso-electric point for parisite of 5.6 under water, with a shift to a more negative zeta potential with both collector (hydroxamic and fatty acids) and supernatant conditions. The IEP with collectors and supernatant was <3.5. As zeta potential measurements in the presence of reagents and supernatants are the most rigorous way of determining the efficiency of a flotation reagent, the agreement between parisite zeta potentials obtained here and previous work on bastnäsite suggests that parisite may be processed using similar reagent schemes to bastnäsite. This is important for future processing of REE deposits, comprising of more complex REE mineralogy.

A highly attenuating and frequency tailorable annular hole phononic crystal for surface acoustic waves.

Surface acoustic wave (SAW) devices are widely used for signal processing, sensing and increasingly for lab-on-a-chip applications. Phononic crystals can control the propagation of SAW, analogous to photonic crystals, enabling components such as waveguides and cavities. Here we present an approach for the realisation of robust, tailorable SAW phononic crystals, based on annular holes patterned in a SAW substrate. Using simulations and experiments, we show that this geometry supports local resonances which create highly attenuating phononic bandgaps at frequencies with negligible coupling of SAWs into other modes, even for relatively shallow features. The enormous bandgap attenuation is up to an order-of-magnitude larger than that achieved with a pillar phononic crystal of the same size, enabling effective phononic crystals to be made up of smaller numbers of elements. This work transforms the ability to exploit phononic crystals for developing novel SAW device concepts, mirroring contemporary progress in photonic crystals.The control and manipulation of propagating sound waves on a surface has applications in on-chip signal processing and sensing. Here, Ash et al. deviate from standard designs and fabricate frequency tailorable phononic crystals with an order-of-magnitude increase in attenuation.

Lymph node yield in right colectomy for cancer: a comparison of open, laparoscopic and robotic approaches.

AIM: Studies have demonstrated a relationship between lymph node (LN) yield and survival after colectomy for cancer. The impact of surgical technique on LN yield has not been well explored. METHOD: This is a retrospective study of right colectomy (RC) for cancer at a single institution from 2012 to 2014. Exclusion criteria were previous colectomy and emergent and palliative operations. All data were collected by chart review. Primary outcomes were LN yield and the LN to length of surgical specimen (LN-LSS) ratio. Multivariable mixed models were created with surgeon and pathologist as random effects. Sensitivity analyses were performed to exclude Stage IV cancers and to analyse groups on an 'as-treated' basis. RESULTS: We identified 181 open (O-RC), 163 laparoscopic (L-RC) and 119 robotic (R-RC) right colectomies. O-RC was more commonly performed in women with metastatic disease. The mean LN yield was 28, 29 and 34 in O-RC, L-RC and R-RC, respectively; the respective mean LN-LSS ratios were 0.83, 0.91 and 1.0. The R-RC approach produced a higher LN yield than the other approaches (P < 0.01), and a higher LN-LSS ratio than O-RC (P < 0.01). These findings were unchanged in sensitivity analyses. CONCLUSION: Robotic right colectomy improves LN yield and the LN-LSS ratio, which may reflect better mesocolic excision. The effect of these findings on survival requires further investigation.

Acoustoelectric Current in Graphene Nanoribbons.

Surface acoustic waves (SAWs) propagating on piezoelectric substrates offer a convenient, contactless approach to probing the electronic properties of low-dimensional charge carrier systems such as graphene nanoribbons (GNRs). SAWs can also be used to transport and manipulate charge for applications such as metrology and quantum information. In this work, we investigate the acoustoelectric effect in GNRs, and show that an acoustoelectric current can be generated in GNRs with physical widths as small as 200 nm at room temperature. The positive current in the direction of the SAWs, which corresponds to the transportation of holes, exhibits a linear dependence on SAW intensity and frequency. This is consistent with the description of the interaction between the charge carriers in the GNRs and the piezoelectric fields associated with the SAWs being described by a relatively simple classical relaxation model. Somewhat counter-intuitively, as the GNR width is decreased, the measured acoustoelectric current increases. This is thought to be caused by an increase of the carrier mobility due to increased doping arising from damage to the GNR edges.

Incisional hernias after laparoscopic and robotic right colectomy.

PURPOSE: Incisional hernia (IH) is a common complication after colectomy, with impacts on both health care utilization and quality of life. The true incidence of IH after minimally invasive colectomy is not well described. The purpose of this study was to examine IH incidence after minimally invasive right colectomies (RC) and to compare the IH rates after laparoscopic (L-RC) and robotic (R-RC) colectomies. METHODS: This is a retrospective review of patients undergoing minimally invasive RC at a single institution from 2009 to 2014. Only patients undergoing RC for colonic neoplasia were included. Patients with previous colectomy or intraperitoneal chemotherapy were excluded. Three L-RC patients were included for each R-RC patient. The primary outcome was IH rate based on clinical examination or computed tomography (CT). Univariate and multivariate time-to-event analyses were used to assess predictors of IH. RESULTS: 276 patients where included, of which 69 had undergone R-RC and 207 L-RC. Patient and tumor characteristics were similar between the groups, except for higher tumor stage in L-RC patients. Both the median time to diagnosis (9.2 months) and the overall IH rate were similar between the groups (17.4 % for R-RC and 22.2 % for L-RC), as were all other postoperative complications. In multivariable analyses, the only significant predictor of IH was former or current tobacco use (hazard raio 3.0, p = 0.03). CONCLUSIONS: This study suggests that the incidence of IH is high after minimally invasive colectomy and that this rate is equivalent after R-RC and L-RC. Reducing the IH rate represents an important opportunity for improving quality of life and reducing health care utilization after minimally invasive colectomy.

Steelhead trout Oncorhynchus mykiss metabolic rate is affected by dietary Aloe vera inclusion but not by mounting an immune response against formalin-killed Aeromonas salmonicida.

The oxygen consumption (MO2) of two groups of 10° C acclimated steelhead trout Oncorhynchus mykiss was measured for 72 h after they were given a 100 µl kg(-1) intraperitoneal injection of formalin-killed Aeromonas salmonicida (ASAL) or phosphate-buffered saline (PBS). In addition, plasma cortisol levels were measured in fish from both groups prior to, and 1 and 3 h after, they were given a 30 s net stress. The first group was fed an unaltered commercial diet for 4 weeks, whereas the second group was fed the same diet but with 0·5% (5 g kg(-1) ) Aloe vera powder added; A. vera has potential as an immunostimulant for use in aquaculture, but its effects on basal and acute phase response (APR)-related metabolic expenditures and stress physiology, are unknown. Injection of ASAL v. PBS had no measurable effect on the MO2 of O. mykiss indicating that the APR in this species is not associated with any net increase in energy expenditure. In contrast, incorporating 0·5% A. vera powder into the feed decreased routine metabolic rate by c. 8% in both injection groups and standard metabolic rate in the ASAL-injected group (by c. 4 mg O2 kg(-1) h(-1) ; 5%). Aloe vera fed fish had resting cortisol levels that were approximately half of those in fish on the commercial diet (c. 2·5 v. 5·0 ng ml(-1) ), but neither this difference nor those post-stress reached statistical significance (P > 0·05).

Consensus guidelines from The American Society of Peritoneal Surface Malignancies on standardizing the delivery of hyperthermic intraperitoneal chemotherapy (HIPEC) in colorectal cancer patients in the United States.

BACKGROUND: The American Society of Peritoneal Surface Malignancies (ASPSM) is a consortium of cancer centers performing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC). This is a position paper from the ASPSM on the standardization of the delivery of HIPEC. METHODS: A survey was conducted of all cancer centers performing HIPEC in the United States. We attempted to obtain consensus by the modified method of Delphi on seven key HIPEC parameters: (1) method, (2) inflow temperature, (3) perfusate volume, (4) drug, (5) dosage, (6) timing of drug delivery, and (7) total perfusion time. Statistical analysis was performed using nonparametric tests. RESULTS: Response rates for ASPSM members (n = 45) and non-ASPSM members (n = 24) were 89 and 33 %, respectively. Of the responders from ASPSM members, 95 % agreed with implementing the proposal. Majority of the surgical oncologists favored the closed method of delivery with a standardized dual dose of mitomycin for a 90-min chemoperfusion for patients undergoing cytoreductive surgery for peritoneal carcinomatosis of colorectal origin. CONCLUSIONS: This recommendation on a standardized delivery of HIPEC in patients with colorectal cancer represents an important first step in enhancing research in this field. Studies directed at maximizing the efficacy of each of the seven key elements will need to follow.

Broadband and efficient plasmonic control in the near-infrared and visible via strong interference of surface plasmon polaritons.

Broadband and tunable control of surface plasmon polaritons in the near-infrared and visible spectrum is demonstrated theoretically and numerically with a pair of phased nanoslits. We establish, with simulations supported by a coupled wave model, that by dividing the incident power equally between two input channels, the maximum plasmon intensity deliverable to either side of the nanoslit pair is twice that for an isolated slit. For a broadband source, a compact device with nanoslit separation of the order of a tenth of the wavelength is shown to steer nearly all the generated plasmons to one side for the same phase delay, thereby achieving a broadband unidirectional plasmon launcher. The reported effect can be applied to the design of ultra-broadband and efficient tunable plasmonic devices.

Prognostic aspects of DCE-MRI in recurrent rectal cancer.

OBJECTIVE: To explore whether pre-reoperative dynamic contrast-enhanced (DCE)-MRI findings correlate with clinical outcome in patients who undergo surgical treatment for recurrent rectal carcinoma. METHODS: A retrospective study of DCE-MRI in patients with recurrent rectal cancer was performed after obtaining an IRB waiver. We queried our PACS from 1998 to 2012 for examinations performed for recurrent disease. Two radiologists in consensus outlined tumour regions of interest on perfusion images. We explored the correlation between K(trans), Kep, Ve, AUC90 and AUC180 with time to re-recurrence of tumour, overall survival and resection margin status. Univariate Cox PH models were used for survival, while univariate logistic regression was used for margin status. RESULTS: Among 58 patients with pre-treatment DCE-MRI who underwent resection, 36 went directly to surgery and 18 had positive margins. K(trans) (0.55, P = 0.012) and Kep (0.93, P = 0.04) were inversely correlated with positive margins. No significant correlations were noted between K(trans), Kep, Ve, AUC90 and AUC180 and overall survival or time to re-recurrence of tumour. CONCLUSION: K(trans) and Kep were significantly associated with clear resection margins; however overall survival and time to re-recurrence were not predicted. Such information might be helpful for treatment individualisation and deserves further investigation.

Goblet cell carcinoid neoplasm of the appendix: clinical and CT features.

PURPOSE: To describe the clinical and CT imaging features of goblet cell carcinoid (GCC) neoplasm of the appendix. METHODS AND MATERIALS: A computer search of pathology and radiology records over a 19-year period at our two institutions was performed using the search string "goblet". In the patients with appendiceal GCC neoplasms who had abdominopelvic CT, imaging findings were categorized, blinded to gross and surgical description, as: "Appendicitis", "Prominent appendix without peri-appendiceal infiltration", "Mass" or "Normal appendix". The CT appearance was correlated with an accepted pathological classification of: low grade GCC, signet ring cell adenocarcinoma ex, and poorly differentiated adenocarcinoma ex GCC group. RESULTS: Twenty-seven patients (age range, 28-80 years; mean age, 52 years; 15 female, 12 male) with pathology-proven appendiceal GCC neoplasm had CT scans that were reviewed. Patients presented with acute appendicitis (n=12), abdominal pain not typical for appendicitis (n=14) and incidental finding (n=1). CT imaging showed 9 Appendicitis, 9 Prominent appendices without peri-appendiceal infiltration, 7 Masses and 2 Normal appendices. Appendicitis (8/9) usually correlated with typical low grade GCC on pathology. In contrast, the majority of Masses and Prominent Appendices without peri-appendiceal infiltration were pathologically confirmed to be signet ring cell adenocarcinoma ex GCC. Poorly differentiated adenocarcinoma ex GCC was seen in only a small minority of patients. Hyperattenuation of the appendiceal neoplasm was seen in a majority of cases. CONCLUSIONS: GCC neoplasm of the appendix should be considered in the differential diagnosis in patients with primary appendiceal malignancy. Our cases demonstrated close correlation between our predefined CT pattern and the pathological classification.

Interactions in the aetiology, presentation and management of synchronous and metachronous adenocarcinoma of the prostate and rectum.

Adenocarcinoma of the prostate and rectum are common male pelvic cancers and may present synchronously or metachronously due to their anatomic proximity. The treatment of rectal or prostate cancer (in particular surgery and/or radiotherapy) may alter the presentation, incidence and management should a metachronous tumour develop. This review focuses on the interaction between prostatic and rectal cancer diagnosis and management. We have restricted the scope of this large topic to general considerations, management of rectal cancer after prostate cancer treatment and vice versa, management of synchronous disease and cancer follow-up issues.

Multivisceral resections for rectal cancer.

BACKGROUND: En bloc resection of adjacent pelvic organ(s) may be needed to achieve clear surgical margins in rectal cancer surgery. An institutional experience is reported with perioperative morbidity and oncological outcomes. METHODS: Patients were identified retrospectively from a prospectively collected institutional database (1992-2010). Outcomes, and clinical and pathological factors were determined from medical records. Estimated overall survival, overall recurrence and local recurrence were compared using the log rank method and Cox regression analysis. RESULTS: Among 1831 patients with rectal cancer, 124 (6·8 per cent) underwent en bloc resection of part or all of an adjacent organ (vagina/uterus/ovary 90, prostate/seminal vesicle 23, bladder/ureter 15, small bowel/appendix 7). Five-year overall survival and local recurrence rates were 53·3 and 18·8 per cent respectively. There was one postoperative death, from multiple organ failure in a patient with liver cirrhosis. Fifty-two patients underwent sphincter-preserving surgery and three (6 per cent) developed an anastomotic leak. On univariable analysis, the only factor associated with local recurrence was completeness of resection (local recurrence rate 15 per cent versus 69 per cent for R0 versus R1 resection; P < 0·001). On multivariable analysis, factors associated with overall survival were sphincter-preserving surgery, absence of metastatic disease and R0 resection. CONCLUSION: Multiple organ resection for locally advanced primary rectal cancer had good oncological outcomes when clear resection margins were achieved.