Major low anterior resection syndrome has equivalent health-related quality of life implications as having a permanent colostomy.

BACKGROUND: The literature is inconclusive when comparing health-related quality of life following restorative anterior resection (AR) compared with abdominoperineal resection (APR). Consideration of functional outcomes may explain this inconsistency. The aim of this study was to compare health-related quality of life in patients post-anterior resection, stratified by low anterior resection syndrome score, and post-abdominoperineal resection patients. METHODS: A cross-sectional study of consecutive patients post APR and AR for rectal or sigmoid adenocarcinoma at a tertiary centre in Sydney, Australia (Jan 2012- Dec 2021) was performed. HRQoL outcomes (SF36v2 physical [PCS] and mental component summary [MCS] scores) were compared between APR and AR patients, with subgroup analyses stratifying AR patients according to LARS score (no/minor/major). Age- and gender-adjusted comparisons were performed by linear regression. RESULTS: Overall, 248 post-AR patients (57.3% male, mean age 70.8 years, SD 11.6) and 64 post-APR patients (62.5% male, mean age 68.1 years, SD 13.1) participated. When stratified by LARS, 'major LARS' had a similar negative effect on age-and sex-adjusted PCS scores as APR. 'No LARS' (p < 0.001) and 'minor LARS' (p < 0.001) patients had higher PCS scores compared to post-APR patients. 'Major LARS' had a similarly negative effect on MCS scores compared with post-APR patients. MCS scores were higher in 'no LARS' (p = 0.006) compared with APR patients. CONCLUSIONS: Postoperative bowel dysfunction significantly impacts health-related quality of life. Patients with 'major LARS' have health-related quality of life as poor as those following APR. This requires consideration when counselling patients on postoperative health-related quality of life, especially where poor postoperative bowel function is anticipated following restorative surgery.

Deep learning of renal scans in children with antenatal hydronephrosis.

INTRODUCTION: Antenatal hydronephrosis (ANH) is one of the most common anomalies identified on prenatal ultrasound, found in up to 4.5% of all pregnancies. Children with ANH are surveilled with repeated renal ultrasound and when there is high suspicion for a ureteropelvic junction obstruction on renal ultrasound, a mercaptuacetyltriglycerine (MAG3) Lasix renal scan is performed to evaluate for obstruction. However, the challenging interpretation of MAG3 renal scans places patients at risk of misdiagnosis. OBJECTIVE: Our objective was to analyze MAG3 renal scans using machine learning to predict renal complications. We hypothesized that our deep learning model would extract features from MAG3 renal scans that can predict renal complications in children with ANH. STUDY DESIGN: We performed a case-control study of MAG3 studies drawn from a population of children with ANH concerning for ureteropelvic junction obstruction evaluated at our institution from January 2009 until June of 2021. The outcome was renal complications that occur ≥6 months after an equivocal MAG-3 renal scan. We created two machine learning models: a deep learning model using the radiotracer concentration versus time data from the kidney of interest and a random forest model created using clinical data. The performance of the models was assessed using measures of diagnostic accuracy. RESULTS: We identified 152 eligible patients with available images of which 62 were cases and 90 were controls. The deep learning model predicted future renal complications with an overall accuracy of 73% (95% confidence inteveral [CI] 68-76%) and an AUC of 0.78 (95% CI 0.7, 0.84). The random forest model had an accuracy of 62% (95% CI 60-66%) and an AUC of 0.67 (95% CI. 0 64, 0.72) DISCUSSION: Our deep learning model predicted patients at high risk of developing renal complications following an equivocal renal scan and discriminate those at low risk with moderately high accuracy (73%). The deep learning model outperformed the clinical model built from clinical features classically used by urologists for surgical decision making. CONCLUSION: Our models have the potential to influence clinical decision making by providing supplemental analytical data from MAG3 scans that would not otherwise be available to urologists. Future multi-institutional retrospective and prospective trials are needed to validate our model.

Combined use of two separate but protective vaccine antigens provides protection against Taenia ovis infection in lambs in the presence of protective maternal antibody.

Three recombinant Taenia ovis antigens (To45, To16, To18) each induce protective immunity in lambs or ewes against infection with T. ovis metacestodes. The degree and duration of immunity were assessed in lambs born from vaccinated ewes. Treatment group sizes varied, typically not fewer than 5 animals per group. Ewes were immunised with one T. ovis recombinant protein prior to lambing and the degree and duration of passive immunity in their lambs was assessed by challenge infection up to 18 weeks. Lambs were fully protected up to 6 weeks of age but immunity waned from 6 to 12 weeks and there was no protection when lambs were challenged at 15 weeks. Immunisation of lambs with the homologous recombinant antigen was not effective when vaccinations were given when maternal antibody was high. Lambs were effectively immunised in the presence of passively protective antibody when vaccinated with an antigen that was different to that given to ewes. Vaccination of lambs with a combination of two proteins, To16 and To18, was more effective than giving these single antigens and gave a significant reduction of cyst numbers when lambs were challenged 12 months after immunisation. These results indicate that the use of combinations of T. ovis recombinant antigens could enable complete protection of lambs against infection, if a delivery system becomes available that will maintain antibody at protective levels for 12 months. Alternatively, a third injection given at 6 months may promote the anamnestic response to give long lasting protection.

Relative effects of direct spread, lymph node metastasis and venous invasion in relation to blood borne distant metastasis present at the time of resection of colorectal cancer.

Conventionally, lymphatic spread is regarded as the principal mechanism by which haematogenous metastasis occurs in colorectal cancer. The aim of this cross sectional study was to determine the relative strengths of direct tumour spread, the presence of lymph node metastasis and histologically demonstrated venous invasion as drivers of haematogenous metastasis diagnosed at the time of resection of colorectal cancer. The data were drawn from a hospital database of consecutive bowel cancer resections between 1995 and 2017 inclusive. The presence of haematogenous metastasis was determined at the time of surgery by imaging or other investigations or operative findings. Where possible, histological confirmation was obtained. Specimen dissection and reporting followed a standardised procedure. Tumour staging was according to the 7th edition of the UICC/AJCC pTNM system. Analysis was by multivariable logistic regression. After exclusions 3133 patients remained, among whom 380 (12.1%) had one or more haematogenous metastases. In bivariate analyses, the frequency of haematogenous metastasis was directly associated with increasing T status (p<0.001), increasing N status (p<0.001) and increasing extent of venous invasion (p<0.001) and with some other patient and tumour features. In a multivariable model, after adjustment for other features, associations with the occurrence of haematogenous metastasis were as follows: T3 odds ratio (OR) 4.41 (95% confidence interval 2.40-8.10), p<0.001; T4a OR 6.29 (3.27-12.10), p<0.001; T4b OR 5.50 (2.71-11.15), p<0.001; N1 OR 3.39 (2.47-4.64), p<0.001; N2 OR 4.59 (3.21-6.54), p<0.001; mural venous invasion OR 2.18 (1.14-4.16), p=0.018; extramural venous invasion OR 2.91 (2.21-3.83), p<0.001. Only three other features had significant, though weak effects in the model. These results led to the conclusion that venous invasion, demonstrated histologically and also inferred independently by the extent of direct tumour spread, made a greater contribution to the occurrence of haematogenous metastasis than did spread through lymphatics. Our approach and findings may have implications for other cancer sites apart from colorectal cancer.

Perfecting detection through education.

INTRODUCTION: Radiologists' image reading skills vary, such variations in image interpretations can influence the effectiveness of the early treatment of disease and may have important clinical and economic implications. In screening mammography, clinical audits are used to assess radiologists' performance annually, however, the nature of these audits prevent robust data analysis due to the low prevalence of breast cancer and the long waiting periods for the audit results. Research-based evidence revealed a need for changes in the methods utilised to optimise the assessment of the efficacy of radiologists' interpretations. METHODS: A cloud-based platform was developed to assess and enhance radiologists' performance help reduce variability in medical image interpretations in a research environment; however, to address a number of limitations, the platform was commercialised to make it available worldwide. RESULTS: DetectED-X's team have been able to make their cloud-based platform available worldwide, tailored to the needs of radiologists and accredited for continuing medical/professional education; thus, changing the continuous professional development practice globally. CONCLUSION: DetectED-X's Rivelato, was developed to address a need for effective, available and affordable educational solutions for clinicians and health care workers wherever they are located. A true fusion of industry, academia, clinics and consumer to adapt to the growing needs of clinicians' around the world, the latest being COVID-19 global pandemic. DetectED-X repurposed its platform to educate physicians around the world on the appearances of COVID-19 on Lung Computed Tomography scans, introducing CovED to clinicians worldwide free of charge as a multi-national consortium of collaboration to help fight COVID-19, showing how research-based evidence can create effective and scalable change globally.

Crowding, Sticking, and Partial Folding of GTT WW Domain in a Small Cytoplasm Model.

Recent experimental data has shown that protein folding in the cytoplasm can differ from in vitro folding with respect to speed, stability, and residual structure. Here we investigate the all-atom molecular dynamics (MD) simulations of 9 copies of the model protein GTT WW domain in a small bacterial cytoplasm model using three force fields. GTT has been well-studied by MD in aqueous solution for comparison. We find that folded copies remain folded for up 25 µs, whereas unfolded copies do not fold for up to 190 µs. Unfolded GTT in our cytoplasm model does populate partly folded intermediates with one of the two hairpins formed. Relative to aqueous solution, GTT gets stuck in metastable states with a small RMSD and radius of gyration and extensive burial of surface area against other macromolecules. In particular, GTT is even able to form transient intermolecular ß-sheets with other proteins, resulting in a "chimeric structure" that could be a precursor to oligomeric ß-aggregates. We conclude that sticking, enhanced by the non-native mutations of GTT, is largely responsible, and we propose, on the basis of our result as well as recent experiments, that coevolution of protein surfaces with their solvation environment (including chaperones) is important for folding and diffusion of proteins in the cytoplasm.

Competing risks analysis of the association between perioperative blood transfusion and long-term outcomes after resection of colorectal cancer.

AIM: Despite numerous reports over three decades, the association between perioperative blood transfusion and long-term outcomes after resection of colorectal cancer remains controversial. This cohort study used competing risks statistical methods to examine the association between transfusion and recurrence and colorectal cancer-specific death after potentially curative and noncurative resection. METHOD: A hospital database provided prospectively recorded clinical, operative and follow-up information. All surviving patients were followed for at least 5 years. Data were analysed by multivariable competing risks regression. RESULTS: From 2575 patients in the period 1995-2010 inclusive, after exclusions, 2334 remained for analysis. Among 1941 who had a potentially curative resection and 393 who had a noncurative resection the transfusion rates were 24.9% and 33.6%, respectively. After potentially curative resection there was no significant bivariate association between transfusion and recurrence (HR 0.93, CI 0.74-1.16, P = 0.499) or between transfusion and colorectal cancer-specific death (HR 1.04, CI 0.82-1.33, P = 0.753). After noncurative resection there was no significant association between transfusion and cancer-specific death (HR 0.93, CI 0.73-1.19, P = 0.560). Multivariable models showed no material effect of potential confounder variables on these results. CONCLUSION: The competing risks findings in this study showed no significant association between perioperative transfusion and recurrence or colorectal cancer-specific death.

Quality of reporting and fragility index for randomized controlled trials in the vesicoureteral reflux literature: where do we stand?

BACKGROUND/INTRODUCTION: Randomized controlled trials (RCTs) are considered the "gold standard" methodology for examining the effects of clinical interventions, yet only 1% of urology literature employs this design. The Consolidated Standards of Reporting Trials (CONSORT) statement contains a standardized checklist of 37 items to be included when reporting RCTs to ensure transparency and completeness of information [2]. Despite the robust design of RCTs, the number of events can greatly change the significance of the results, which can be represented by the fragility index (FI). OBJECTIVE: The objective was to assess the quality of reporting of RCTs in the pediatric vesicoureteral reflux (VUR) literature using the 2010 CONSORT statement and, for studies with significant positive findings, to determine the FI as a measure of robustness of the results. STUDY DESIGN: A comprehensive search was conducted through MEDLINE® and Embase® to identify RCTs in VUR literature from 2000 to 2016. Two reviewers independently selected articles, which were evaluated using the CONSORT checklist. An overall quality of reporting score (OQS) (%) was calculated by dividing the number of checklist items present in each study by the maximum possible score (34) and expressed as a percentage. Studies were classified as low (<40%), moderate (40-70%) and high quality (>70%) based on the modified assessing the methodological quality of systematic reviews (AMSTAR) checklist. Of the 2052 initial matches, 98% were excluded due to methodology or content, a further 28 studies were found not to meet inclusion criteria after full text review. The FI was calculated for the 7 studies that met inclusion criteria with significantly different results by manually adding events to the study groups until p>0.05. RESULTS: Twenty-two studies met inclusion criteria. The mean OQS was 46+17% with 9 (41%) identified as low quality (score <40%), 11 (50%) as moderate (40-70%) and 2 (9%) as high quality (>70%). There was no significant difference in OQS between RCTs with a sample size > 100 (n=15) versus <100 patients (n=7) (45+17% vs. 47+17%, p=0.7). However, we noted a difference when we compared RCTs with biostatistician support (n=4) vs. those without (n=18) (59+20% vs. 43+15%, p<0.05). Seven studies reported significant positive results making calculation of FI possible. The mean FI was 5.8+5.1 indicating that most studies were fragile. There was no correlation between the OQS and FI. DISCUSSION AND CONCLUSION: The mean OQS of VUR RCTs was suboptimal (46%), with most studies having low FI scores indicating the instability of the findings. The only variable that significantly impacted the OQS was biostatistician support. Implementation of the CONSORT checklist with a minimum of 50% inclusion as a prerequisite for submission of manuscripts may improve the quality and transparency of reporting. Calculation of the FI could provide readers with an objective measure of robustness for the published trials, allowing for appropriate interpretation of the results.

Recurrence and cancer-specific death after adjuvant chemotherapy for Stage III colon cancer.

AIM: The recommended standard of care for patients after resection of Stage III colon cancer is adjuvant 5-fluorouracil based chemotherapy - FOLFOX (fluorouracil, leucovorin with oxaliplatin) - or CAPOX (capecitabine, oxaliplatin). This may be modified in older patients or depending on comorbidity. This has been challenged recently as the apparent benefit of adjuvant chemotherapy may arise from improvements in surgery or preoperative imaging or pathology staging. This study compares recurrence and colon-cancer-specific death between patients who received postoperative adjuvant chemotherapy and those who did not. METHOD: Prospectively recorded data from 363 consecutive patients who had a resection for Stage III colonic adenocarcinoma between 1995 and 2010 inclusive were analysed. Surviving patients were followed for at least 5 years. The suitability of patients for chemotherapy was discussed routinely at multidisciplinary team meetings. The incidence of recurrence and colon-cancer-specific death was evaluated by competing risk methods. RESULTS: After adjustment for the competing risk of non-colorectal cancer death, there was no significant difference in recurrence between the 204 patients who received chemotherapy and the 159 who did not [hazard ratio (HR) 0.94, 95% CI 0.66-1.32, P = 0.700) and no significant difference in colon-cancer-specific death (HR 0.73, 95% CI 0.50-1.04, P = 0.084; HR 0.88, 95% CI 0.57-1.36, P = 0.577 after adjustment for relevant covariates). CONCLUSION: These findings question the routine use of chemotherapy after complete mesocolic excision for Stage III colon cancer. Recurrence and cancer-specific death, assessed by competing risk methods, should be the standard outcomes for evaluating the effectiveness of adjuvant chemotherapy after potentially curative resection.

Historical bibliometric analysis of the top cited articles on vesicoureteral reflux 1950-2016, and incorporation of a novel impact index.

INTRODUCTION AND OBJECTIVES: Vesicoureteral reflux (VUR) has been one of the defining conditions unique to pediatric urology since its inception. The clinical implications of this disease process depend on intrinsic patient factors such as age, genetics, epigenetics, voiding habits, anatomic anomalies, and extrinsic factors such as the pathogenicity of infectious agents. Knowledge about its natural history, the implications of conservative and surgical management, and their associated outcomes have evolved dramatically over time. This study aimed to use bibliometric analyses to summarize the evolution of VUR management over time. In order to accomplish this, the most referenced articles for VUR since 1950 were identified, and a comprehensive analysis of their impact on the management and understanding of VUR was performed by creating a novel impact index. METHODS: A reference search was carried out for indexed citations through the portal 'Science Citation Index' in the subsection 'Web of Science Core Collection' using 'vesicoureteral reflux' as a MeSH term. References were analyzed and subcategorized according to various subtopics. A unique impact index was developed to adjust the number of publications for the time since publication, in order to define the impact of the paper amongst the most frequently cited papers. Articles were analyzed and data were tabulated according to the number of citations, country and institute of origin, journal of publication, impact factor, and first authorship. RESULTS: Citation counts ranged from 43 to 510, and the mean number of citations per publication was 101.43. The most discussed topic was 'treatment'. The impact index showed that more recent publications have a higher impact. The author with the highest index impact had 271 citations in a period of 5 years. The top 150 articles were published across 23 countries, the majority being from the USA (Summary fig.). The most frequently cited institution had 12 publications. The journal with the highest publication referencing rate was the Journal of Urology. CONCLUSION: The most cited articles were valuable sources of information to describe the historical evolution of the pathophysiology and management of VUR. After adjusting for time since publication, the most recent publications (i.e. those published after 1990) had a higher impact index. Combining traditional bibliometric analysis with this novel impact index may allow researchers to optimize future literature analyses, while also assisting clinicians in understanding best practices for patient management based on the available literature.

Three steps and a join: a simple guide to right- and left-sided medial to lateral laparoscopic colorectal surgery.

BACKGROUND: To provide a standardised 'medial to lateral' approach to laparoscopic colorectal surgery. METHODS: Both right- and left- sided laparoscopic colorectal procedures were simplified into three well-defined steps and a join. An instructional video and procedural guide provides the important pearls and pitfalls in performing laparoscopic colorectal surgery. RESULTS: During a 10-year period (2006-2016) at a single institution, 20 senior colorectal trainee surgeons and 20 general surgery registrars were trained in the 'three steps and a join' technique. Five hundred and sixty-eight laparoscopic anterior resections using this technique were performed. There were 5 (0.9%) leaks. Five hundred and forty-three laparoscopic right-sided resections were performed. There were 3 (0.6%) anastomotic leaks requiring reoperation and loop ileostomy. CONCLUSIONS: This step-by-step instructional video and procedural guide provides a simple and standardised approach which may be incorporated into a training pathway for laparoscopic right- and left-sided colorectal surgery.

The impact of a bladder training video versus standard urotherapy on quality of life of children with bladder and bowel dysfunction: A randomized controlled trial.

INTRODUCTION: Bladder and bowel dysfunction (BBD) can negatively impact the quality of life (QoL) of children. Urotherapy is an accepted treatment option for BBD; however, literature that examines the impact of management options on QoL in this population is scarce. OBJECTIVE: To determine whether a bladder training video (BTV) is non-inferior to standard urotherapy (SU) in improving QoL in children with BBD. METHODS: Children aged 5-10 years and who scored ≥11 on the Vancouver Non-Neurogenic Lower Urinary Tract Dysfunction/Dysfunctional Elimination Syndrome Questionnaire (NLUTD/DES) were recruited from a pediatric tertiary care center. Children were excluded with known vesicoureteral reflux; spinal dysraphism; learning disabilities; recent urotherapy; and primary nocturnal enuresis. Quality of life was evaluated using the Pediatric Incontinence Quality-of-Life questionnaire (PinQ). Questionnaires were administered at the baseline and 3-month follow-up clinic visits. Following centralized electronic blocked randomization schemes to guarantee allocation concealment, patients were assigned to receive SU or BTV during their regular clinic visits. An intention-to-treat protocol was followed. Between-group baseline and follow-up QoL scores were compared using paired and unpaired t-tests, and linear regression analysis. RESULTS: Of the 539 BBD patients who were screened, 173 (32%) were eligible, and 150 (87%) were randomized. Of these, 143 (96%) completed the study, five (3%) were lost to follow-up, and two (1%) withdrew. In total, 140/143 (97%) completed the QoL questionnaire at baseline and follow-up. Mean follow-up time was 3.5 ± 1.1 months for BTV patients and 3.7 ± 1.6 months for SU. At baseline, BTV and SU patients had a mean QoL score of 26.6 ± 13 and 23.8 ± 12, respectively (P = 0.17). Between-group mean change in PinQ scores from baseline was not statistically significant (BTV: 6.25 ± 12.5 vs SU: 3.75 ± 12.2; P = 0.23; Summary Fig.). Significant predictors of positive change in QoL were: higher symptomatology score, with a correlation coefficient of 0.5 (95% CI: 0.2-0.9; P = 0.003), and worse baseline QoL score, with a correlation coefficient of 0.5 (95% CI: 0.4-0.7; P < 0.001). Overall, most patients had improved symptomatology and QoL scores. CONCLUSION: Significant and similar QoL changes from baseline to follow-up were observed in both the BTV and SU groups, suggesting that BTV was non-inferior to SU in improving QoL in children with BBD. Quality of life assessment should be considered when evaluating interventions for BBD, as it appears to be an important clinical outcome with which to determine urotherapy success.

The risk of internal hernia or volvulus after laparoscopic colorectal surgery: a systematic review.

AIM: To determine the incidence of internal hernias after laparoscopic colorectal surgery and evaluate the risk factors and strategies in the management of this serious complication. METHOD: Two databases (MEDLINE from 1946 and Embase from 1949) were searched to mid-September 2015. The search terms included volvulus or internal hernia and laparoscopic colorectal surgery or colorectal surgery or anterior resection or laparoscopic colectomy. We found 49 and 124 articles on MEDLINE and Embase, respectively, an additional 15 articles were found on reviewing the references. After removal of duplicates, 176 abstracts were reviewed, with 33 full texts reviewed and 15 eligible for qualitative synthesis. RESULTS: The incidence of internal hernia after laparoscopic colorectal surgery is low (0.65%). Thirty-one patients were identified. Five cases were from two prospective studies (5/648, 0.8%), 20 cases were from seven retrospective studies (20/3165, 0.6%) and six patients were from case reports. Of the 31 identified cases, 21 were associated with left-sided resection, four with right sided resection, two with transverse colectomy, one with a subtotal colectomy and in three cases the operation was not specified. The majority of cases (64.3%) were associated with a restorative left sided resection. Nearly all cases occurred within 4 months of surgery. All patients required re-operation and reduction of the internal hernia and 35.7% of cases required a bowel resection. In 52.2% of cases, the mesenteric defect was closed at the second operation and 52.6% of cases were successfully managed laparoscopically. There were three deaths (0.08%). CONCLUSION: Mesenteric hernias are a rare but important complication of laparoscopic colorectal surgery. The evidence does not support routine closure for all cases, but selective closure of the mesenteric defect during left-sided restorative procedures in high-risk patients at the initial surgery may be considered.

Percent improvement in renal pelvis antero-posterior diameter (PI-APD): Prospective validation and further exploration of cut-off values that predict success after pediatric pyeloplasty supporting safe monitoring with ultrasound alone.

INTRODUCTION: Renograms are frequently obtained post-pyeloplasty in patients with residual hydronephrosis to confirm adequate drainage. Recent evidence suggests that percent improvement in antero-posterior diameter (PI-APD) ≥38 is predictive of success. We sought to further explore PI-APD ranges that would allow identification of patients who would benefit from ultrasound (US) monitoring alone vs. post-operative renal scan, and those more likely to develop recurrent ureteropelvic junction obstruction (rUPJO). METHODS: A single-center prospectively-collected pyeloplasty database (2008-2015) was queried (n = 151). Only patients with both pre- and post-operative APD measurements were included (n = 138). PI-APD was divided into 3 categories: <20%; 20-39%; ≥40%. The following variables were collected post-operatively: patients monitored with US alone, renogram and US, rUPJO and minimal or resolved hydronephrosis (SFU ≤2; UTD ≤1; APD ≤15 mm). RESULTS: Mean age at first and last follow-up were 4.8 (median 4.0; range 0-60) months and 26.6 (median 20.5; range 1-77) months, respectively. Of 138 patients, 84 (61%) had US alone, 54 (39%) had a renogram and US post-operatively, and 6 (4%) developed rUPJO. Of 84 patients who had US alone, 71 (84%; p < 0.01) demonstrated ≥40% PI-APD. Of 54 patients with renogram and US 46 (85%; p < 0.01) had ≥40 PI-APD. Of the 6 patients who developed rUPJO, all were in the <20 PI-APD group (100%; p < 0.01). Resolution of hydronephrosis according to SFU, UTD and APD occurred in 96/138 (70%), 89/138 (64%) and 113/138 (82%) patients respectively. Of these, 87 (91%), 81 (91%), and 108 (95%) occurred in >40% PI-APD group. CONCLUSION: ≥40% PI-APD at the first post-operative visit strongly predicts pyeloplasty success, as up to 82% of these patients showed resolved hydronephrosis and 61% underwent non-invasive monitoring by US alone. Our data suggests that up to 85% of renograms may have been unnecessary. Finally, <20% PI-APD permitted identification of all rUPJO cases. Stratification of patients based in PI-APD is a promising strategy for further minimizing radiation exposure while safely detecting children at risk for rUPJO.

Long-term results following an anatomically based surgical technique for resection of colon cancer: a comparison with results from complete mesocolic excision.

AIM: Complete mesocolic excision (CME) has been advocated as likely to improve the long-term oncological outcome of colon cancer resection, although there is a paucity of long-term results in the literature. The aim of this study was to supplement our previously published results on colon cancer resection based on a standardized technique of precise dissection along anatomical planes with high vascular ligation and to compare our long-term results with those of recent European studies of CME. METHOD: Data were drawn from a prospective hospital registry of consecutive resections for colon cancer between 1996 and 2007, including follow-up to the end of 2012. The principal outcomes from potentially curative resections were 5-year Kaplan-Meier rates of local recurrence, systemic recurrence, overall survival and cancer-specific survival. Secondary outcomes for all resections were postoperative complications, number of lymph nodes retrieved and R0 status. RESULTS: For 779 potentially curative resections the local recurrence rate was 2.1% (95% CI 1.3-3.4), the systemic recurrence rate was 10.2% (95% CI 8.1-12.7), the 5-year overall survival rate was 76.2% (95% CI 73.0-79.0) and the cancer-specific survival rate was 89.8% (95% CI 87.3-91.9). For all 905 resections, rates of 14 surgical complications were low and not dissimilar to those in a comparable study. The median lymph node count was 15 (range 0-113). R0 status was confirmed in 883/905 patients (97.6%; 95% CI 96.4-98.5). CONCLUSION: For colon cancer, meticulous dissection along anatomical planes together with high vascular ligation results in few complications, a high R0 rate, low recurrence and high survival.

Supervised surgical training and its effect on the short-term outcome in laparoscopic colorectal surgery.

AIM: Laparoscopic colorectal surgery requires supervised training. In this paper we examine the short-term outcome following a component-based training in laparoscopic colorectal surgery. METHOD: Surgical outcome following laparoscopic colorectal resection was recorded on a prospective database. Patients were divided into three groups, including those performed by the fellows, those completed by the consultant and those completed by a combination of both. Analysis of data was carried out for all colorectal resections and the subgroup with colorectal cancer. RESULTS: 511 operations were examined between June 2006 and January 2011. There was no statistically significant difference in operating time between fellows and consultants but it was significantly longer for procedures where consultants and fellows performed components. Conversion rate, postoperative morbidity, recovery and length of stay were similar for all three groups for the whole patient cohort and also the subgroup of cancer patients. In the cancer subgroup, there was no difference in the pathological stage in the three groups. CONCLUSION: Closely supervised training in laparoscopic colorectal surgery is not associated with any adverse effect on the short-term outcome.

Digital tomosynthesis: a new future for breast imaging?

The aim of this article is to review the major limitations in current mammography and to describe how these may be addressed by digital breast tomosynthesis (DBT). DBT is a novel imaging technology in which an x-ray fan beam sweeps in an arc across the breast, producing tomographic images and enabling the production of volumetric, three-dimensional (3D) data. It can reduce tissue overlap encountered in conventional two-dimensional (2D) mammography, and thus has the potential to improve detection of breast cancer, reduce the suspicious presentations of normal tissues, and facilitate accurate differentiation of lesion types. This paper reviews the latest studies of this new technology. Issues including diagnostic efficacy, reading time, radiation dose, and level of compression; cost and new innovations are considered.

A comparison of published rates of resection margin involvement and intra-operative perforation between standard and 'cylindrical' abdominoperineal excision for low rectal cancer.

AIM: The study aimed to compare recent reports on standard and alternative methods of abdominoperineal excision for low rectal cancer regarding the rates of circumferential resection margin involvement and intra-operative bowel perforation. METHOD: Data on rates of margin involvement and perforation were obtained from eight recently published reports and also from a prospective registry of resections at Concord Hospital. Rates of these outcomes and their 95% confidence intervals were evaluated. RESULTS: There was no evidence that extralevator abdominoperineal excision yielded significantly lower rates of resection margin involvement or intra-operative bowel perforation compared with standard abdominoperineal excision in six independent hospital- and population-based patient series. Abdominosacral resection of the rectum, on the other hand, did show significantly lower rates of these endpoints, albeit in selected patients. CONCLUSION: The role of extralevator abdominoperineal excision and abdominosacral resection of the rectum should be investigated further in randomized controlled trials.