A Qualitative Study of Decision-making (DM) in Surgery and Cancer Care: an Indian Perspective.

Cancer psychology is a vitally important part of cancer management. Qualitative research is a gateway to exploring this. Weighing the treatment options in terms of quality of life and survival is important. Given the globalization of healthcare seen in the last decade, the exploration of the decision-making process in a developing nation was deemed highly appropriate. The aim is to explore the thoughts of surgical colleagues and care providing clinicians about patient decision-making in cancer care in developing countries, with special reference to India. The secondary objective was to identify factors that may have a role to play in decision-making in India. A prospective qualitative study. The exercise was carried out at Kiran Mazumdhar Shah Cancer Center. The hospital is a tertiary referral center for cancer services in the city of Bangalore, India. A qualitative study by methodology, a focus group discussion was undertaken with the members of the head and neck tumor board. The results showed, in India, decision-making is predominantly led by the clinicians and the patient's family members. A number of factors play an important role in the decision-making process. These include as follows: health outcome measures (quality of life, health-related quality of life), clinician factors (knowledge, skill, expertise, judgment), patient factors (socio-economic, education, cultural), nursing factors, translational research, and resource infrastructure. Important themes and outcomes emerged from the qualitative study. As modern healthcare moves towards a patient-centered care approach, evidence-based patient choice and patient decision-making clearly have a greater role to play, and the cultural and practical issues demonstrated in this article must be considered. Supplementary Information: The online version contains supplementary material available at 10.1007/s13193-022-01521-x.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease.

AIM: There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology. METHODS: Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines. RESULTS: All aspects of surgical care for IBD have been included along with 157 recommendations for management. CONCLUSION: These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

Hughes Abdominal Repair Trial (HART) - Abdominal wall closure techniques to reduce the incidence of incisional hernias: study protocol for a randomised controlled trial.

BACKGROUND: Incisional hernias are common complications of midline closure following abdominal surgery and cause significant morbidity, impaired quality of life and increased health care costs. The 'Hughes Repair' combines a standard mass closure with a series of horizontal and two vertical mattress sutures within a single suture. This theoretically distributes the load along the incision length as well as across it. There is evidence to suggest that this technique is as effective as mesh repair for the operative management of incisional hernias; however, no trials have compared the Hughes Repair with standard mass closure for the prevention of incisional hernia formation following a midline incision. METHODS/DESIGN: This is a 1:1 randomised controlled trial comparing two suture techniques for the closure of the midline abdominal wound following surgery for colorectal cancer. Full ethical approval has been gained (Wales REC 3, MREC 12/WA/0374). Eight hundred patients will be randomised from approximately 20 general surgical units within the United Kingdom. Patients undergoing open or laparoscopic (more than a 5-cm midline incision) surgery for colorectal cancer, elective or emergency, are eligible. Patients under the age of 18 years, those having mesh inserted or undergoing musculofascial flap closure of the perineal defect in abdominoperineal wound closure, and those unable to give informed consent will be excluded. Patients will be randomised intraoperatively to either the Hughes Repair or standard mass closure. The primary outcome measure is the incidence of incisional hernias at 1 year as assessed by standardised clinical examination. The secondary outcomes include quality of life patient-reported outcome measures, cost-utility analysis, incidence of complete abdominal wound dehiscence and C-POSSUM scores. The incidence of incisional hernia at 1 year, assessed by computerised tomography, will form a tertiary outcome. DISCUSSION: A feasibility phase has been completed. The results of the study will be used to inform current and future practice and potentially reduce the risk of incisional hernia formation following midline incisions. TRIAL REGISTRATION NUMBER: ISRCTN 25616490 . Registered on 1 January 2012.

Revisiting an ancient treatment for transphincteric fistula-in-ano 'There is nothing new under the sun' Ecclesiastes 1v9.

OBJECTIVE: The history of treatments for fistula-in-ano can be traced back to ancient times. Current treatment of transphincteric fistulae is controversial, with many options available. We reviewed the history of treatment using cutting setons and present our series of transphincteric fistulae in the light of the series in the literature. DESIGN: Literature review and case series. SETTING: Hospital based coloproctology service PARTICIPANTS: 140 consecutive patients presenting with fistula-in-ano were included. MAIN OUTCOME MEASURES: The literature pertaining to treatment of transphincteric fistula was reviewed, along with the outcome of various treatment methods for this condition. Data were collected for 140 consecutive patients presenting with fistula- in-ano were assessed for fistula healing, recurrence and complications. RESULTS: A total of 140 consecutive patients with fistula-in-ano were identified, of which 111 were cryptoglandular (79.3%). Eighty-one of these 111 were transphincteric (73.0%). At a median follow-up of 35 months (range, 2-83 months), 70 transphincteric fistulae had healed (86.4%), 10 were still undergoing treatment (12.3%) and one patient was lost to follow-up prior to treatment (1.2%). Two patients in this group required a stoma (2.5%), six patients developed recurrence (7.4%); three 'true' recurrences (3.7%). One (1.2%) developed a chronic fissure. There were no reported cases of incontinence. CONCLUSIONS: The management of transphincteric fistula-in-ano is complex and controversial, for which no clear surgical procedure has gained acceptance as the gold standard. This study demonstrates that transphincteric fistulae can be successfully treated using cutting setons. A high healing rate (86.4%), low recurrence rate (7.4%) and a low complication rate (3.7%) are shown, which compares favourably with published rates over a long follow-up.

A case-control study of risk factors for wound infection in a colorectal unit.

INTRODUCTION: Postoperative wound infections have been responsible for increasing morbidity and are associated with an increased use of hospital resources. Previous studies have identified several risk factors. However, most studies are outdated, and few relate to the era of enhanced recovery and laparoscopic surgery. This study investigated the association between patient and operative factors and the development of postoperative wound infections in colorectal surgery. METHODS: Patients with documented wound infections or dehiscences were identified from a database of elective and emergency colorectal surgery. Patients with wound infections were matched by operation type to a control group of colorectal patients. Differences in patient and operative factors between case and control group were analysed using conditional logistic regression. RESULTS: A total of 56 patients with wound infection were identified from 647 operations (8.6%). Fifty-seven per cent were emergency operations and eighty-eight per cent were performed as open surgery or as laparoscopic surgery converted to open. Forty per cent of patients had high ASA (American Society of Anesthesiologists) grades (3 or 4). Multivariate logistical regression showed that obese patients and those having open surgery had the highest risk of infections. The median postoperative hospital stay for patients with wound infections was twice as long as for those patients without wound infections. CONCLUSIONS: Open surgery and obesity are independent risk factor for wound infections. An increase in laparoscopically performed operations and new strategies for managing wounds in obese patients may help to reduce the rate of wound infection.

Highly prevalent colorectal cancer-infiltrating LAP⁺ Foxp3⁻ T cells exhibit more potent immunosuppressive activity than Foxp3⁺ regulatory T cells.

Although elevated CD4⁺Foxp3⁺ regulatory T cell (Treg) frequencies within tumors are well documented, the functional and phenotypic characteristics of CD4⁺Foxp3⁺ and CD4⁺Foxp3⁻ T cell subsets from matched blood, healthy colon, and colorectal cancer require in-depth investigation. Flow cytometry revealed that the majority of intratumoral CD4⁺Foxp3⁺ T cells (Tregs) were Helios⁺ and expressed higher levels of cytotoxic T-lymphocyte antigen 4 (CTLA-4) and CD39 than Tregs from colon and blood. Moreover, ∼30% of intratumoral CD4⁺Foxp3⁻ T cells expressed markers associated with regulatory functions, including latency-associated peptide (LAP), lymphocyte activation gene-3 (LAG-3), and CD25. This unique population of cells produced interleukin-10 (IL-10) and transforming growth factor-ß (TGF-ß), and was ∼50-fold more suppressive than Foxp3⁺ Tregs. Thus, intratumoral Tregs are diverse, posing multiple obstacles to immunotherapeutic intervention in colorectal malignancies.

Death-associated protein-3, DAP-3, correlates with preoperative chemotherapy effectiveness and prognosis of gastric cancer patients following perioperative chemotherapy and radical gastrectomy.

BACKGROUND: DAP3 is a member of the death-associated protein (DAP) family and is characterised by proapoptotic function. It is involved in both exogenous and endogenous apoptotic pathways. In our previous studies, apoptotic level was found to be correlated with the effectiveness of preoperative chemotherapy. The effectiveness of preoperative chemotherapy was also associated with the overall effectiveness of the combined therapy and prognosis. The present study aimed to investigate the role of DAP3 in the evaluation of preoperative chemotherapy effectiveness and its ability to predict prognosis in gastric cancer. METHODS: Quantitative PCR and immunohistochemistry staining were performed in 87 patients who received combined therapy. Knockdown of DAP3 was conducted in gastric cancer cell lines to investigate its impact on cell growth, migration, adhesion and invasion. Tolerance to chemotherapy agents was determined by assessing apoptosis and caspase-3. RESULTS: Higher DAP3 expression in gastric tumours was correlated with better prognosis. Knockdown of DAP3 expression promoted cell migration and enhanced resistance to chemotherapy by inhibiting apoptosis. CONCLUSION: DAP3 is a potential molecular marker for response to preoperative chemotherapy and for predicting prognosis in gastric cancer patients treated with neoadjuvant chemotherapy and gastrectomy.

Large bowel obstruction due to colorectal carcinoma can be safely treated by colonic stent insertion--case series from a UK district general hospital.

AIM: The aim of this study is to audit our outcomes and experience of colonic stent insertion for malignant bowel obstruction. METHOD: Retrospective audit of all stent insertions in a single district general hospital between August 2003 and December 2009. All patients had presented with acute bowel obstruction caused by malignant colorectal disease and details were collected prospectively and contemporaneously onto a database. Stent insertion was a combined endoscopic and fluoroscopic procedure involving a colorectal surgeon and consultant radiologist. RESULTS: Stenting was attempted on 62 occasions in 54 patients. The technical success rate was 86% and the clinical success rate 84%. The indications for stenting were for relief of acute bowel obstruction, palliation and as a bridge to surgery. There were complications in 14 cases (22.5%) including three perforations and one perioperative mortality. There were three cases of stent migration, six cases of re-stenosis and two stents became impacted with stool. There were no incidents of acute or delayed haemorrhage in any patients. CONCLUSION: Our experience shows that stenting for obstructing colorectal cancer is a safe and effective method of alleviating acute and impending bowel obstruction and can be provided safely and effectively in a district general hospital.

Bilateral breast metastases of a renal carcinoma: a case report and review of the literature.

Metastatic tumours account for <1% of all breast malignancies, most originating in the contralateral breast. An 88-year-old woman presented with bilateral breast lumps 4 years after radical nephrectomy for a T2N0M0 renal cancer. Mammography showed a circumscribed 15 mm mass just below and medial to the left nipple without any micro-calcification. Ultrasound scan showed the presence of a solid vascular mass in the left breast; a guided core biopsy confirmed it as a metastatic renal cell carcinoma. Left simple mastectomy and excision of right breast lump was done. Histology of both lesions confirmed them as metastatic deposits. Bilateral breast metastasis from a renal cancer is very rare and this is the second reported case. This case illustrates the potential for rare sites of metastases and for the consideration of metastasis in the presence of previous renal cancer. Recognition as metastatic neoplasm is important to prevent unnecessary radical procedures.

Intra-abdominal hypertension and the abdominal compartment syndrome.

BACKGROUND: Abdominal compartment syndrome (ACS) occurs when intra-abdominal pressure is abnormally high in association with organ dysfunction. It tends to have a poor outcome, even when treated promptly by abdominal decompression. METHODS: A search of the Medline database was performed to identify articles related to intra-abdominal hypertension and ACS. RESULTS: Currently there is no agreed definition or management of ACS. However, it is suggested that intra-abdominal pressure should be measured in patients at risk, with values above 20 mmHg being considered abnormal in most. Abdominal decompression should be considered in patients with rising pressure and organ dysfunction, indicated by increased airway pressure, reduced cardiac output and oliguria. Organ dysfunction often occurs at an intra-abdominal pressure greater than 35 mmHg and may start to develop between 26 and 35 mmHg. The mean survival rate of patients affected by compartment syndrome is 53 per cent. CONCLUSION: The optimal time for intervention is not known, but outcome is often poor, even after decompression. Most of the available information relates to victims of trauma rather than general surgical patients.

APC, beta-Catenin and hTCF-4; an unholy trinity in the genesis of colorectal cancer.

Mutations in APC have been identified in up to 80% of 'classic' sporadic colorectal cancers. Although the APC gene was first sequenced over a decade ago, new functions are still being described and its importance in the genesis of colorectal cancer continues to increase. The current focus of attention is on the APC/beta-Catenin/TCF signal transduction pathway as the main effector mechanism, and recent work has also implicated this pathway in the aetiology of the minority of CRCs that develop through mismatch repair. At the same time, new evidence on the interactions of APC with the cytoskeleton and the demonstration of a nuclear export function in the protein have shown that it has multiple additional roles in colorectal carcinogenesis. Thus this is an area that benefits from further review of the ever expanding literature.

Preclinical studies of gene transfer for the treatment of desmoid disease in familial adenomatous polyposis.

BACKGROUND: Familial adenomatous polyposis (FAP) arises following mutation or loss of the adenomatous polyposis coli (APC) gene. Desmoid tumours are proliferations of fibroblasts and occur as an extracolonic manifestation of FAP. They are a leading cause of death after colectomy. The aim of this study was to assess the potential for APC gene transfer into fibroblasts in vitro and in vivo as a basis for consideration of gene therapy in the prevention or treatment of desmoid tumours. METHODS: The APC gene was transferred by lipofection into fibroblasts in tissue culture and into peritoneum and small bowel mesentery in vivo. Reverse transcriptase-polymerase chain reaction was used to determine whether or not transfection was successful. RESULTS: Transgene expression was recorded in vitro to 7 days after transfection. High levels of transgene expression were also seen in samples of peritoneum (all eight mice), small bowel mesentery (seven of eight), liver (seven of eight) and intestinal tissues (five to six of eight) following intraperitoneal treatment. Interestingly, transgene expression in gonadal tissues was occasionally noted. CONCLUSION: Liposomal transfection of APC gave prolonged high-level expression of the transgene, an important basis for gene therapy. No adverse effects were recorded. Further work is needed in animal models of desmoid disease to assess the clinical effects of gene therapy.

Prophylactic gene therapy for cancer.

Attempts at cancer gene therapy to date have focused on the treatment of existing neoplasms, using genetic techniques either to target toxic compounds at or enhance the host's response to a tumour. These cytotoxic and immunological approaches have to be tailored to a specific tumour, and often fail because new cellular mutations can overcome the treatment, as for traditional lines of therapy. There has been less attention given to the possibility of using gene therapy to prevent malignant transformation in certain specific contexts for high-risk tissues. Such approaches could add functional proto-oncogenes or tumour suppressor genes, or nullify pathogenic mutations in such genes using antisense or gene replacement techniques. These strategies will not apply to all tumours, but are more likely to be effective where tissue-specific stem cells can be targeted, and for tumours where mutations in one of several genes are involved in carcinogenesis, as for cancer of the colon. Safer vectors for gene delivery will also be required if therapy is to be considered for prevention rather than treatment.

Expression of the APC gene after transfection into a colonic cancer cell line.

Mutations in the adenomatous polyposis coli (APC) gene cause the hereditary cancer syndrome familial adenomatous polyposis and are implicated in the early stages of sporadic colorectal carcinogenesis. APC is therefore a promising candidate for use in prophylactic gene therapy of intestinal tissues at high risk of becoming malignant. The aim of the study was to discover if functional full length APC gene can be introduced into somatic gut epithelial cells and to define the optimum conditions for such transfer. Copies of the normal APC gene were introduced into SW480 cells, a colonic epithelial cell line with an APC gene mutation, using plasmid DNA combined with liposomes. Reverse transcriptase polymerase chain reaction and restriction enzyme digestion allowed the endogenous gene to be distinguished from the transgene. It was shown that the normal APC gene is expressed at high levels for 72 hours after transfection and disappears within one week. This study shows that short-term expression of normal APC gene can be achieved after transfection with liposome-DNA complexes at sufficiently high levels to permit assessment of biological effects.