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.

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.

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.

Laparoscopic proctocolectomy with restorative ileal-anal pouch.

OBJECTIVE: The aim of the study was to analyse the outcome of restorative proctocolectomy carried out by laparoscopic surgery. METHODS: A prospectively collected electronic database of all colorectal laparoscopic procedures performed between April 2001 and July 2003 has been used to identify surgical outcomes in 14 consecutive patients who have undergone laparoscopic RPC. RESULTS: Fourteen patients (5 male), median BMI 24 kg/m(2) have undergone restorative laparoscopic proctocolectomy over a two year period: 13 (ulcerative colitis, one with cancer) and 1 (FAP). The median operation time was 260 min; time has not decreased with experience. There were no intra-operative surgical complications or deaths. Patient controlled analgesia continued for a median of 36 h. The median time to diet was 48 h and median hospital stay 7 days; three patients required nasogastric aspiration for delayed gastric emptying. Eighteen regional lymph nodes were retrieved local to the carcinoma. There was one anastomotic leak. All covering stomas were closed by 6 months (12 by eight weeks). All 14 patients are fully continent, able to suppress urgency and have a median pouch frequency of 4/24 h. None admit to having problems with potency, orgasm sensation, ejaculation, micturition. One lady reports dysparunia. All are highly satisfied with functional outcome and cosmesis. CONCLUSION: We are encouraged to continue to offer our patients the option of a laparoscopic resection.

Management of recurrent anastomotic stricture and iatrogenic stenosis by circular stapler.

Anastomotic stricture is an increasingly common clinical finding. It is thought to arise because of ischemia, disruption, or leakage at an anastomosis site. Its management can be difficult and strictures often are resistant to standard dilation therapy. Major corrective surgery is possible; however, it is technically challenging and not without risk. We have used a circular stapler to excise colorectal strictures, introducing the anvil of the stapler via a proximal stoma or colotomy, drawing the anvil through the stricture with a snare via a colonoscope and affixing it to the body of a circular staple gun and excising the stricture. We have with found this to be an effective treatment in appropriately selected patients.

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.

Reliability of sequential naloxone challenge tests.

To determine the reliability of serial naloxone challenges, five heroin addicts stabilized on methadone were given 0.2 mg naloxone intravenously on three consecutive days. Two-factor ANOVA revealed that the between-subjects effect accounted for at least 63% of the variance in each of the dependent measures, and the effect of challenge number for at most 22%. Withdrawal tended to be slightly more severe for the first challenge. Intraclass correlation coefficients were calculated for the area-under-the-curve of the change from baseline: subject-rated (.74) and observer-rated (.71) withdrawal, pulse (.88), systolic blood pressure (.58), diastolic blood pressure (.85), and skin temperature (.63).

Sulfate conjugates of catecholamines in the allantoic fluid of the chicken embryo.

In addition to free dopamine (DA), norepinephrine (NE), and epinephrine (E), the allantoic fluid of the 13-day-old chicken embryo contains sulfate conjugates of these three catecholamines (CAs). The concentration of DA sulfate is relatively low, while NE and E sulfates occur at levels similar to those of the free fractions. The comparatively low concentration of free CAs in the amniotic fluid, seen in a previous study, is confirmed. However, the amniotic barrier for sulfated CAs is much stronger, possibly absolute. Though some technical difficulties remain to be resolved, the chicken embryo may become a useful model for the study of the prenatal functions of CA conjugates.

Stress-related changes in the hematological profile of the American eel (Anguilla rostrata).

The authors investigated the impact of environmentally realistic concentrations of cadmium (Cd) on the hematological responses of the eel to acute stress. After 8 weeks of exposure to 150 micrograms Cd/liter, there was a significant reduction in the total erythrocyte count, hemoglobin (Hb), and hematocrit (Hct). Total leukocyte counts, leukocrit, and large lymphocytes were significantly increased, while the proportion of small lymphocytes fell. After 8 weeks of Cd exposure, acute stress was induced by a 2-min exposure to CO2 bubbles. The untreated control fish responded strongly by erythrocyte swelling, which was evident from a marked increase in the Hct and mean cellular volume, and a decreased mean cellular hemoglobin concentration. Furthermore, there was a marked granulocytosis and a strong drop in the thrombocyte count. After Cd treatment, the erythrocyte changes were attenuated and shorter, granulocytes were increased, and there was no drop in the thrombocyte count. It appears that the Cd exposure decreased the erythrocyte response to adrenergic stress signals. It also decreased the stress-related granulocytosis, and it prevented the drop of the thrombocyte count.

Response of plasma cortisol to environmental cadmium in the eel, Anguilla rostrata LeSueur.

1. Long-term exposure (16 weeks) of the American eel, Anguilla rostrata, to an environmentally realistic concentration of cadmium (150 micrograms/l) causes a chronic elevation of plasma cortisol. During this time span, the eels retain the ability to respond to a weak additional stress (CO2 bubbles for 1 min) with a further increase in plasma cortisol. 2. Plasma glucose levels are significantly lowered after two weeks of exposure to cadmium (75 and 150 micrograms/l). However, subsequently they return close to control levels. 3. It is concluded that (a) a moderate cadmium pollution of the eel's habitat suffices to cause chronic stimulation of the eel's adrenocortical axis, and (b) the resulting continued hypercortisolemia must seriously affect the eel's metabolism, immunosystem, gonadal maturation, and ability to migrate to its spawning grounds.

Trace metal (Cu and Zn) adaptation of organ systems of the American eel, Anguilla rostrata, to external concentrations of cadmium.

1. The impact of external cadmium on the concentrations of cadmium (Cd), copper (Cu) and zinc (Zn) in seven tissues of the American eel, Anguilla rostrata was investigated. Even after a week in freshwater with undetectable levels of Cd, the tissues of eels caught in fresh and/or brackish waters of the United States east coast contained Cd in kidney, liver, gut, and brain. 2. When the eels were exposed up to 16 weeks to low and high sublethal concentrations of Cd (75 and 150 micrograms/l, respectively), the highest tissue concentrations of Cd were found after two weeks of exposure. The accumulation was dose-related in all tissues studied except for the kidney. After 8 weeks of Cd exposure, the tissue levels of Cd were markedly reduced, and they were in a similarly low range after 16 weeks. At this time, the highest Cd concentrations were found in the gills and kidney. 3. After two weeks of Cd exposure, there was a drop of the tissue concentrations of Cu in liver and heart, and of Zn in gut and liver. The low concentrations of the two metals in other organs did not allow an evaluation of the Cd impact. After 16 weeks, the Cu concentrations in all tissues, with the exception of the liver, were similar to, or even higher than control levels. At the same time, Zn concentrations exceeded the control levels in heart and kidney of eels exposed to 75 and 150 micrograms Cd/l, respectively. 4. It is clear that some tissues of the eel are able to maintain or restore normal levels of Cu and Zn, up to 16 weeks, despite concomitant Cd accumulation.

Short- and long-term effects of copper on the rosy barb (Puntius conchonius Ham.).

The rosy barb (Puntius conchonius) was exposed to copper (Cu) for short (48 hr) and long (8 weeks) terms and effects on enzyme activities and biochemical variables in the blood and tissues were examined. In vivo exposure to 571 micrograms CuSO4/liter (96-hr median tolerance limit (TLm)) for 48 hr stimulated to varying degrees acid phosphatase (AcP), alkaline phosphatase (AlP) (except in the liver), and acetylcholinesterase activities in selected tissues. The alanine aminotransferase and lactic dehydrogenase (LDH) (except in the heart) activities were inhibited to varying degrees in vivo. In vitro, the presence of 10(-6) M Cu suppressed enzyme activities in the tissues examined, with a few exceptions such as AcP in ovaries and gut, AlP in liver, gills, gut, and testes, and LDH in liver. Hyperglycemia, hyperlactemia, hyperproteinemia, elevated blood free fatty acid (FFA) levels, and hypocholesterolemia were manifested in the fish exposed to 190 micrograms CuSO4/liter (1/3 96-hr TLm). Effects on the tissues included glycogenolysis (liver and skeletal muscles), glycogenesis (brain and heart), a marked rise in hepatic proteins, accumulation of FFAs in liver and skeletal muscles, and reduction in hepatic and gonadal cholesterol contents. After 8 weeks, a trend toward recovery was noted in the biochemical variables (except blood and hepatic protein levels).

Impact of cadmium on the mummichog Fundulus heteroclitus and the role of calcium in suppressing heavy metal toxicity.

1. Freshwater adapted mummichogs (Fundulus heteroclitus) were exposed to cadmium. In soft water (less than or equal to 5 mg/l CaCO3), the 4-day safe (TL100) and sublethal (TL50) tolerance limits (TLs) for cadmium were 0.14 microgram/l and 12.2 micrograms/l, respectively. 2. Survival declined with increasing cadmium concentration and the length of exposure. The toxicity of cadmium was reduced in water with high calcium concentration (200 mg/l CaCO3). Pre-exposure to calcium also prolonged the survival in cadmium-containing water. 3. The mummichog appears to be extremely well suited for monitoring environmental cadmium poisoning.

The avian allantois: a depot for stress-released catecholamines.

Plasma and amniotic and allantoic fluid of 10- and 14-day-old chicken embryos contain free dopamine (DA), norepinephrine (NE), and epinephrine (E). Compared with postnatal chickens, concentrations of DA and E in the plasma are very high, and they are even higher in the allantoic fluid. In contrast, the allantoic concentration of NE is below the plasma level. In the amniotic fluid, the concentrations of all three catecholamines (CAs) are below the plasma levels. High concentrations of DA and E in the allantoic fluid after opening of the egg shell decline during the following 24 hr, which indicates that they are due to stress. Asphyxia, handling, disturbance of allantoic fluid, and cooling are also perceived as stress and are followed by immediate accumulation of CAs in the allantoic fluid. DA and E respond to stress in like manner, while NE often responds with an opposite trend. It appears that the avian allantois, in addition to its role in respiration and urea disposal, also serves the instant CA removal from the circulation. Both the amniotic and the allantoic membranes of the chicken should be ideal models for the study of CA transport mechanisms.

Morphology of the adrenal homologues in two hillstream teleostean fishes from India.

In Garra gotyla and Pseudecheneis sulcatus, the interrenal and chromaffin tissues represent homologues of the adrenal cortex and medulla, respectively, and are confined to the largely lymphoid head kidneys in a bilaterally symmetrical topographical pattern. Together they form a collar round the postcardinal vein, with a thickness of 300 microns in Garra gotyla and 150 microns in Pseudecheneis sulcatus. Distributionally, the interrenal tissue conforms to Nandi's type III and type I and the chromaffin tissue to type V and type III in Garra gotyla and Pseudecheneis sulcatus, respectively. The interrenal cells in these species are polygonal, cuboidal or columnar, and are filled with coarse basophilic cytoplasm. The chromaffin cells form syncytial patches and have sparsely granular cytoplasm.