Comparative evaluation of different pre-treatment alternatives for granular media filters treating greywater and their ranking using analytical hierarchy process.

In this study, the performance of four different pre-treatment alternatives for granular media filtration, namely, settling, aeration, coarse media filtration and chemical coagulation were compared experimentally. Further, analytical hierarchy process (AHP) was used to compare their performance based on economic, environmental, technical and performance criteria. Performance of settling and aeration were evaluated up to 24 h duration. The coarse media filter was intermittently operated with 10 L of greywater in downflow mode while alum was used for chemical coagulation. Experimental results showed that settling up to 6 h did not show significant removal of different pollutants whereas 24 h settling resulted in moderate removal of turbidity and organic content but was not efficient in the removal of nutrients and faecal coliforms. Chemical coagulation reduced 93, 66, 48 and 97% of turbidity, COD, NH4-N and faecal coliforms, respectively from greywater but resulted in excessive sludge generation and is difficult to adopt on-site and requires skilled supervision. Coarse filtration of greywater resulted in 61, 41, 36 and 35% removal of turbidity, COD, PO4-P and faecal coliforms, respectively. Considering different criteria AHP gave coarse filtration as the best pre-treatment option to the granular media filters treating greywater.

Perceptions of theatre team members to robotic assisted surgery and the aid of technology in colorectal surgery.

The implementation of robotic assisted surgery (RAS) has brought in a change to the perception and roles of theatre staff, as well as the dynamics of the operative environment and team. This study aims to identify and describe current perceptions of theatre staff in the context of RAS. 12 semi-structured interviews were conducted in a tertiary level university hospital, where RAS is utilised in selected elective settings. Interviews were conducted by an experienced research nurse to staff of the colorectal department operating theatre (nursing, surgical and anaesthetics) with some experience in operating within open, laparoscopic and RAS surgical settings. Thematic analysis on all interviews was performed, with formation of preliminary themes. Respondents all discussed advantages of all modes of operating. All respondents appreciated the benefits of minimally invasive surgery, in the reduced physiological insult to patients. However, interviewees remarked on the current perceived limitations of RAS in terms of logistics. Some voiced apprehension and anxieties about the safety if an operation needs to be converted to open. An overarching theme with participants of all levels and backgrounds was the 'Teamwork' and the concept of the [robotic] team. The physical differences of RAS changes the traditional methods of communication, with the loss of face-to-face contact and the physical 'separation' of the surgeon from the rest of the operating team impacting theatre dynamics. It is vital to understand the staff cultures, concerns and perception to the use of this relatively new technology in colorectal surgery.

Robotic ambulatory colorectal resections: a systematic review.

Colorectal surgery has progressed greatly via minimally invasive techniques, laparoscopic and robotic. With the advent of ERAS protocols, patient recovery times have greatly shortened, allowing for same day discharges (SDD). Although SDD have been explored through laparoscopic colectomy reviews, no reviews surrounding robotic ambulatory colorectal resections (RACrR) exist to date. A systematic search was carried out across three databases and internet searches. Data were selected and extracted by two independent reviewers. Inclusion criteria included robotic colorectal resections with a length of hospital stay of less than one day or 24 h. 4 studies comprising 136 patients were retrieved. 56% of patients were female and were aged between 21 and 89 years. Main surgery indications were colorectal cancer and recurrent sigmoid diverticulitis (43% each). Most patients had low anterior resections (48%). Overall, there was a 4% complication rate postoperatively, with only 1 patient requiring readmission due to postoperative urinary retention (< 1%). Patient selection criteria involved ASA score cut-offs, nutritional status, and specific health conditions. Protocols employed shared similarities including ERAS education, transabdominal plane blocks, early removal of urinary catheters, an opioid-sparing regime, and encouraged early oral intake and ambulation prior to discharge. All 4 studies had various follow-up methods involving telemedicine, face-to-face consultations, and virtual ward teams. RACrRs is safe and feasible in a highly specific patient population; however, further high-quality studies with larger sample sizes are needed to draw more significant conclusions. Several limitations included small sample size and the potential of recall bias due to retrospective nature of 2 studies.

Circumferential resection margin positivity due to direct or indirect tumour involvement in rectal cancer - a call for better stratification.

BACKGROUND: A positive circumferential resection margin (CRM) after rectal cancer surgery, which can be the result of direct or indirect tumour involvement, has consistently been associated with increased local recurrence and poorer survival. However, little is known of the differential impact of the mode of tumour involvement on outcomes. METHODS: 1460 consecutive patients undergoing rectal cancer resection between 2003 and 2018 were retrospectively assessed. Histopathology reports for patients with a positive CRM were reviewed to determine cases of direct (R1-tumour) or indirect tumour involvement (R1-other). Disease-free survival (DFS) and overall survival (OS) were assessed by Kaplan-Meier analysis. The role of the mode of CRM positivity was examined by univariate and multivariate Cox proportional hazards models. RESULTS: Eighty-five patients had an R1 resection due to CRM involvement (5.8%). Of those, 69 were due to direct tumour involvement, while 16 were from indirect causes. Kaplan-Meier analysis revealed that R1-other was associated with increased OS (hazard ratio 0.40, log-rank P = 0.006) and DFS (P = 0.043). Multivariate regression confirmed that the mode of CRM positivity was an independent predictor of OS. More interestingly, the patterns of recurrence were different between the two groups, with R1-tumour leading to significantly more local recurrence (P = 0.04). CONCLUSIONS: Our data strongly suggests that direct tumour involvement of the CRM confers worse prognosis after rectal cancer surgery. Importantly, differences in the site and frequency of recurrences make a case for better stratification of patients with a positive CRM to guide treatment decisions.

Use of zero-valent iron-modified sand filters for greywater treatment: performance evaluation and modelling using response surface methodology.

The conventional sand filter when used alone for on-site treatment of greywater fails to meet different reuse standards, and hence there is a need to improve the potential of sand filters to remove different contaminants from greywater. Performance of zero-valent iron-modified (ZVI) sand filters is investigated in the present study for the treatment of real greywater. The experiments were conducted using three filters: an unmodified filter (SF) and two iron-modified filters, MSF-2 (with 2 kg of ZVI) and MSF-4 (with 4 kg of ZVI). The study evaluated the performance of these filters under different conditions: daily feed volumes of 10 L (72 L/m2/day), 20 L (144 L/m2/day), and 30 L (217 L/m2/day), as well as pause periods of 12, 24, and 36 h. The results showed that the ZVI-modified filters outperformed the unmodified filter significantly. Specifically, MSF-4 showed higher pollutant removal compared to MSF-2. The filter MSF-4 achieved 58% COD removal, 59% BOD removal, 56% NH4-N removal, 82% PO4-P removal, and a significant 1.96 log reduction in fecal coliforms. To optimize the filter operation, three key parameters, amount of ZVI, feed volume, and pause period were considered. The Box-Behnken design (BBD) with response surface methodology was employed to achieve optimization. The results of the optimization study indicated that the optimal conditions for the filters were 2.67 kg of ZVI quantity, a feed volume of 30 L (217 L/m2/day), and a pause period of 32.1 h.

Comparison of robotic vs laparoscopic left-sided colorectal cancer resections.

Robotic assisted surgery (RAS) has become increasingly adopted in colorectal cancer surgery. This study aims to compare robotic and laparoscopic approaches to left sided colorectal resections in terms of surgical outcomeswith no formal enhanced recovery programme. All patients undergoing robotic or laparoscopic left sided or rectal (high and low anterior resection) cancer surgery at a single tertiary referral centre over 3 years were included.A total of 184 consecutive patients from July 2017 to December 2020 were included in this study, with 40.2% (n=74/184) undergoing RAS. The median age at time of surgery was 68 years (IQR 60-73 years). RAS had a significantly shorter length of median stay of 3 days, compared to 5 days in the conventional laparoscopic surgery (CLS) group (p<0.001). RAS had a significantly lower rate of conversion to open surgery (0% vs 16.4%, p<0.001). The median operative time was also shorter in RAS (308 minutes), compared to CLS (326 minutes, p=0.019). The overall rate of any complication was 16.8%, with the RAS experiencing a lower complication rate (12.2% vs 20.0%, p=0.041). There was no significant difference in anastomotic leak rates between the two groups (4.0% vs 5.5%, p=0.673), or in terms of complete resection (R0) (robotic 98.6%, laparoscopic 100%, p=0.095). Robotic left sided colorectal surgery delivers equivalent oncological resection compared to laparoscopic approaches, with the added benefits of reduced length of stay and lower rates of conversion to open surgery. This has both clinical and healthcare economic benefits.

Computed tomographic colonography for symptomatic patients: the diminutive polyp dilemma.

BACKGROUND: Computed tomographic colonography (CTC) is sensitive to polyp detection but is considered inaccurate for measuring diminutive polyps (<6 mm), with divergence between CTC and either colonoscopic or histopathological polyp measurements. Reporting diminutive polyps remains debatable. This study aims to compare outcomes of symptomatic patients with diminutive versus borderline polyps on CTC and to thereby examine the potential implication of reporting diminutive polyps. METHODS: A single-centre retrospective study of symptomatic patients who underwent CTC from October 2016 through September 2018 was performed. After excluding CTC demonstrating cancer, no polyps, or polyps >6 mm, cases were categorized as either 'diminutive' (largest polyp <6 mm), or 'borderline' (largest polyp = 6 mm). The outcome measures were progression to endoscopy, surgery, procedure-related morbidity, dysplasia and malignancy. RESULTS: A total of 308 cases (211 diminutive and 97 borderline) were analysed. The groups were similar (P > 0.05) in mean age (73 vs. 74 years), female proportion (57% vs. 49%), endoscopy-related morbidity (6% vs. 7%) and CTC-related morbidity (0 vs. 1%). Most patients (64%) underwent endoscopy, which was more common in the borderline vs. the diminutive group (76% vs. 59%; P = 0.003). Dysplasia was more common in the borderline vs. the diminutive group (69% vs. 48%; P = 0.003). No malignancies were diagnosed, and no patients proceeded to surgery. CONCLUSION: Reporting diminutive polyps on CTC for symptomatic patients frequently leads to endoscopy, which often reveals dysplasia but rarely malignancy. This raises the question of how referring clinicians can best counsel and manage symptomatic patients with diminutive polyps on CTC, by considering the balance between utilitarianism and deontology.

Granular media filtration for on-site treatment of greywater: A review.

Rapid urbanization and industrialization have put pressure on water resources and centralized wastewater treatment facilities and the need for greywater treatment at decentralized levels is increasing. This paper reviews the studies that used granular filtration for the treatment of greywater. Filter media characteristics that helps in the selection of suitable sustainable and environmental friendly materials without compromising the quality of treated greywater is first reported. The effect of type of filter media, media size and media depth along with the effect of operating conditions are discussed in detail. The choice, role and effect of different pre-treatment alternatives to granular media filtration are also presented. The efficiency of the filters to remove different physicochemical and microbial parameters was compared with different reuse guidelines and standards. Reported studies indicate that not only filter media characteristics and operating conditions but also the quality of raw greywater significantly influence the filter performance. Based on the source of greywater and desired reuse option, different granular media filtration alternatives are suggested. Operation of filters with properly selected media at optimum conditions based on the source of greywater helps filter in achieve the different reuse standards.

An acute gastroenteritis outbreak associated with a contaminated water supply system, Turkey, 2018.

Disruption of routine monitorization and chlorination of the water supply system during a week-long holiday led to a multi-organism gastroenteritis outbreak in a district with limited laboratory support. More than a 10-fold increase in patients with gastroenteritis was reported. Enteropathogenic Escherichia coli, Enteroaggregative E. coli, and norovirus were detected in human specimen samples. The main water tank and pipes were rusted; 13 out of the 19 water samples tested positive for total Coliform (1-920 colony-forming units (CFU)/100 ml) and E. coli (1-720 CFU/100 ml). Chlorine levels were below 0.2 ppm in seven of the nine samples. Information of 1,815 cases was obtained from the hospital records with a crude attack rate of 2.9%. Cases widespread in the district increased throughout the holiday, epidemic curve revealed a point-source outbreak. The case-control study revealed that consumption of drinking tap water and using it to clean vegetables/fruits were significantly associated with the illness. While drinking only bottled water had a protective effect against the illness. The culture technique showed that the water supply samples were positive for pathogenic bacteria. Upon decision in a multi-stakeholder meeting, the water tank was cleaned, and the Municipality initiated the renovation of the water supply system.

Quantity and quality characteristics of greywater from an Indian household.

A year-long study was conducted to assess the quantity and quality characteristics of greywater generated from different sources of an Indian household. The effect of source separation on greywater quantity and pollutant load contribution was also assessed. Composite samples were collected separately over a period of 24 h from each of the greywater source, namely hand basin, bathroom, kitchen, and laundry, and were analysed for different physico-chemical and microbiological parameters. The mean greywater generation averaged 62 L per person per day. Quantitatively, kitchen and bathroom greywater contributed 37 and 31% of the total greywater volume, respectively, while hand basin and laundry greywater accounted for 11 and 21% of the total greywater generation. Kitchen greywater contributed about 60% of the organic load in terms of biochemical oxygen demand (BOD) and chemical oxygen demand (COD), while laundry greywater was the major contributor of heavy metals and PO4-P loads. Hand basin and bathroom greywaters were the major sources of total coliforms. The analysis shows that separation of kitchen and laundry greywater is beneficial as it reduces pollutant load considerably.

The management of asymptomatic radiological anastomotic leakage following anterior resection.

BACKGROUND: The evidence to guide the management of asymptomatic radiologically-detected anastomotic leakages (ARAL) following anterior resection (AR) with diverting ileostomy is deficient. This study describes the outcomes of managing ARAL one of the UK teaching hospitals. METHOD: The study included all patients diagnosed with ARAL following AR during 8 years period (2012-2020). The following data were retrospectively collected: patient demographics, surgical indication, anastomotic technique, tumour staging, neoadjuvant therapy, how ARAL was managed, the outcomes and duration to heal and ileostomy reversal. RESULTS: A total of 35 patients (M = 24) who developed ARAL during the study period were included. In 32 patients, AR was performed for rectal cancer. All patients with ARAL were treated conservatively and in 31 (89%) patients, there was complete resolution of the leakage within a median duration of 6 months. Covering loop ileostomies were reversed in 26 (74%) patients with a median interval to reversal of 10 months. CONCLUSION: Most asymptomatic radiologically-detected anastomotic leakages after anterior resection heal with conservative treatment in the presence of a covering loop ileostomy with an expected average delay of 6 months for the leakage to heal before covering ileostomies can be reversed.

Economizing on a 12 mm port incision site: modification of robotic bowel stapling technique in Da Vinci X/Xi left colonic resections-the modified Norfolk and Norwich robotic stapling technique.

The modified Norfolk and Norwich technique allows to replace a 12 mm port incision site by an 8 mm one, therefore reducing potential postoperative complications linked to 12 mm incisions by robotically stapling through the routinely placed suprapubic Alexis port.

Knowledge, attitude and practices regarding implants among women of childbearing age.

A cross-sectional survey was conducted from February 2016 to September 2016 to assess the knowledge, attitude and practices regarding contraceptive implants among women of childbearing age visiting the Reproductive Health Services Centre, Civil Hospital, Karachi. A total of 396 adult, non-pregnant, married women of childbearing age, between 18 and 49 years, were interviewed using a structured questionnaire. Only 153 (38.6%) of the respondents had any knowledge about implants, out of whom 122 (79.7%) had acquired the information from family planning clinics. Almost two thirds of the respondents, 267(67.4%) were in favour of using implants as a contraceptive method. Moreover, 244 (61.6%) respondents were of the opinion that if given a choice, they will use implanon, though out of the 316 (79.8%) respondents who had ever used contraceptives, only 3 (0.9%) used implants. Despite a favourable attitude, limited knowledge and poor practices of the respondents were the highlights of the study findings.

The combined use of pedicled profunda artery perforator and bilateral gracilis flaps for pelvic reconstruction: A cohort study.

The result of an extra-levator abdominoperineal excision of the rectum (ELAPE) is a composite three-dimensional defect. This is performed for locally advanced anorectal cancer, and may involve partial excision of the vagina. The aim of reconstruction is to achieve wound healing, restore the pelvic floor and to allow micturition and sexual function. We aim to evaluate the concurrent use of profunda artery perforator (PAP) and bilateral gracilis flaps for vaginal and pelvic floor reconstruction. We performed a retrospective case note review of patients undergoing pelvo-perineal reconstruction with combined gracilis and PAP flaps between July 2018 and December 2019. Eighteen pedicled flaps were performed on six patients with anal or vulval malignancies. All underwent pre-operative radiotherapy. Four patients had extended abdominoperineal tumour resections, while two patients underwent total pelvic exenteration. The median age was 57 (range 47-74) years, inpatient stay was 22 (11-47) days and the follow-up was 10 (5-21) months. Four patients developed partial perineal wound dehiscence, of which one was re-sutured. One patient had a post-operative bleed requiring radiological embolisation of an internal iliac branch and had subsequent 1cm PAP flap loss. All other flaps survived completely. Median time to heal was 4 (1-6) months. This is the first series reporting combined bilateral gracilis and PAP flaps for pelvic reconstruction. The wound dehiscence rate and healing times were expected in the context of irradiation and radical pelvic tumour resection. This is a reliable technique for perineal and vaginal reconstruction with minimal donor site morbidity.

Complete mesocolic excision versus conventional surgery for colon cancer: A systematic review and meta-analysis.

AIM: Complete mesocolic excision (CME) lacks consistent data advocating operative superiority compared to conventional surgery for colon cancer. We performed a systematic review and meta-analysis, analysing population characteristics and perioperative, pathological and oncological outcomes. METHODS: D3 extended lymphadenectomy dissection was considered comparable to CME, and D2 and D1 dissection to be comparable to conventional surgery. Outcomes reviewed included lymph node yield, R1 resection, overall complications, overall survival and disease-free survival. RESULTS: In all, 3039 citations were identified; 148 studies underwent full-text reviews and 31 matched inclusion criteria: total cohort 26 640 patients (13 830 CME/D3 vs. 12 810 conventional). Overall 3- and 5-year survival was higher in the CME/D3 group compared with conventional surgery: relative risk (RR) 0.69 (95% CI 0.51-0.93, P = 0.016) and RR 0.78 (95% CI 0.64-0.95, P = 0.011) respectively. Five-year disease-free survival also demonstrated CME/D3 superiority (RR 0.67, 95% CI 0.52-0.86, P < 0.001), with similar findings at 1 and 3 years. There were no statistically significant differences between the CME/D3 and conventional group in overall complications (RR 1.06, 95% CI 0.97-1.14, P = 0.483) or anastomotic leak (RR 1.02, 95% CI 0.81-1.29, P = 0.647). CONCLUSIONS: Meta-analysis suggests CME/D3 may have a better overall and disease-free survival compared to conventional surgery, with no difference in perioperative complications. Quality of evidence regarding survival is low, and randomized control trials are required to strengthen the evidence base.