Totally minimally invasive two-stage esophagectomy with intrathoracic hand-sewn anastomosis: short-term clinical and oncological outcomes.

Several esophageal resection techniques have been reported in literature. The objective of this study is to assess postoperative and oncological outcomes of two-stage minimally invasive esophagectomy (MIE) in a prone position using thoracoscopic hand-sewn anastomosis. Consecutive patients who underwent two-stage MIE in 2016 performed by the senior author were included. This was compared with the preceding cohort of consecutive patients who underwent two-stage hybrid esophagectomy (HE). The primary outcome was 30-day morbidity and mortality. The secondary outcomes were operation duration, length of stay (LOS), total nodes examined (TNE), number of positive nodes (NPN), and resection margin. Overall, 15 patients underwent MIE and 11 patients underwent HE. Respiratory complications occurred in three (20.0%) patients in the MIE group and in five (45.5%) patients in the HE group (P = 0.218). Cardiac complications occurred in two (18.2%) patients, and two other patients (18.2%) experienced anastomotic leak in the HE group. Mean operative duration was 349 ± 41.6 min in MIE and 309 ± 47.8 min in HE (P = 0.040). Median LOS was 10 days (range: 7-70) in MIE and 13 days (range: 10-116) in HE (P = 0.045). Median TNE was 23 (range: 12-36) in MIE and 20 (range: 14-47) in HE (P = 0.775). Longitudinal margin was involved in one patient (9.1%) in HE and no longitudinal margin was involved in the MIE group. Circumferential resection margin was involved in seven patients (46.7%) in MIE and in four patients (36.4%) in HE (P = 0.391). Two-stage MIE using hand-sewn technique is safe and feasible without compromising surgical and oncological outcomes. A multicenter large trial is recommended to confirm these results.

Male infertility following inguinal hernia repair: a systematic review and pooled analysis.

INTRODUCTION: The aim of this systematic review is to establish the clinical impact of open (mesh and/or without mesh) and laparoscopic hernia repair (transabdominal pre-peritoneal (TAP) and/or totally extra-peritoneal (TEP)) on male fertility. The incidence of male infertility following various types of inguinal hernia repair is currently unknown. The lack of high-quality evidence has led to various speculations, suggestions and reliance on anecdotal experience in the clinical practice. METHODS: An electronic search of the literature in Medline, Scopus, Embase and Cochrane library from 1966 to October 2015 according to PRISMA checklist was conducted. Quality assessment of articles was conducted using the Oxford Critical Appraisal Skills Programme (CASP) and their recommendation for practice was examined through National Institute for Health and Care Excellence (NICE). This resulted in ten studies (n = 10), comprising 35,740 patients. RESULTS: Sperm motility could be affected following any type and/or technique of inguinal hernia repair but this is limited to the immediate postoperative period (≤48 h). Obstructive azoospermia was noted in 0.03% of open and 2.5% of bilateral laparoscopic (TAP) hernia repair with mesh. Male infertility was detected in 0.8% of the open hernia repair (mesh) with no correlation to the type of mesh (lightweight vs. heavyweight). CONCLUSION: Inguinal hernia repair without mesh has no impact on male fertility and obstructive azoospermia. However, the use of mesh in bilateral open and/or laparoscopic repair may require the inclusion of male infertility as the part of informed consent in individuals that have not completed their family or currently under investigations.

Patients' attitudes towards "do not attempt resuscitation" status.

INTRODUCTION: The decision of "do not attempt resuscitation" (DNAR) in the event of cardiopulmonary arrest is usually made when the patients are critically ill and cannot make an informed choice. Although, various professional bodies have published guidelines, little is know about the patients' own views regarding DNAR discussion. AIM: The aim of this study was to determine patients' attitudes regarding discussing DNAR before they are critically ill. METHODS: A prospective study was performed in a general out patients department. A questionnaire was distributed to consecutive outpatients along with an explanatory leaflet in the adult outpatient clinic. RESULTS: 364 patients completed the questionnaire (response rate 77%). 90% of respondents wanted all patients to be asked regarding DNAR decision at some point during a hospital admission. The majority would not find a DNAR discussion distressing. Only 10% would find it upsetting, however, 48% of these still wanted a discussion. 37% of respondents wanted to discuss DNAR decisions on admission; 32% in outpatients; 17% at consent for surgery, 14% when they are critically ill. 87% of respondents would not object to their relatives being involved in making decisions about their resuscitation status. However, only 12% of the subjects in the study had been involved in discussing the resuscitation status of a relative and 21% would not be comfortable to discuss a relative's resuscitation status. Although 33% of patients preferred their resuscitation status to simply be documented within their clinical notes, 77% wanted it to be more easily accessible. CONCLUSIONS: This study suggests that contrary to current practice most patients want to discuss their DNAR status prior to becoming critically ill. This includes half of the small number that find it distressing to discuss. Although most patients are comfortable with relatives being involved in discussing DNAR, a significant proportion do not want their relatives to be asked. Furthermore, once a decision has been made, the majority of patients want it to be more accessible than current practice allows.

The clinical and microbiological correlates of premature rupture of membranes.

Prematurity is the cause of 85% of neonatal morbidity and mortality. Premature rupture of the membranes (PROM) is associated with 30-40% of preterm deliveries. A case-control study conducted between July 2002 and 2003 examined the correlates and risk factors for PROM in Mysore, India. WBCs in vaginal fluid, leucocytes in urine, UTI and infection with E. coli, S. aureus, C. albicans and BV were significantly associated with PROM. BV, E. coli and WBCs in vaginal fluid were independent risk factors. Screening and treatment of BV and E. coli infection in pregnancy may reduce the risk of PROM.

Pre-vertebral surgical emphysema following functional endoscopic sinus surgery.

Functional endoscopic sinus surgery (FESS) is a widely practiced technique in the UK. This procedure has variable complication rates and can have some serious consequences. We present a case of surgical emphysema of the neck, face and the pre-vertebral space following FESS. Emphysema of the face and neck has been previously reported. However, to our knowledge, emphysema of the pre-vertebral space following FESS has not been documented. Pre-vertebral emphysema following FESS is an unusual and potentially serious complication.

The importance of pancreatic embryonic epithelium for mesenchyme-to-epithelial transition during islet development.

Stem or progenitor cells are a promising potential alternative source of pancreatic islets for transplantation in the treatment of juvenile-onset diabetes. However, to derive islets from such cells, it is important to elucidate the mechanisms of normal pancreatic development. Previous work in our laboratory has shown that, contrary to previous thinking, pancreatic mesenchyme when combined with pancreatic epithelium can contribute cells to islets. However, the signals and role of individual tissues involved in this mesenchyme-to-epithelial transition (MET) have yet to be elucidated. The aim of this study was to investigate whether MET can occur in the absence of pancreatic epithelium. Chick and quail eggs were incubated for 4 days and the dorsal pancreatic buds and stomach rudiments were microdissected. Mesenchyme and epithelium of the organ rudiments were separated after collagenase treatment. Separated pancreatic mesenchyme were cultured alone and in combination with stomach (nonpancreatic). After 7 days of culture, the specimens were analysed using immunohistochemistry for quail-specific nucleolar antigen (QCPN), insulin, and islet precursor cell marker (ISL-1). Pancreatic mesenchyme when cultured in the absence of epithelium did not differentiate into islets, but differentiated into fibroblast-like cells. When pancreatic mesenchyme were cultured in combination with stomach epithelium, there was no evidence of mesenchymally derived islets. We have demonstrated that pancreatic mesenchyme require pancreatic epithelium to differentiate into islet cells. These findings further increase our understanding of normal pancreatic islet development and may help to elucidate the molecular mechanisms of MET in islet development.