Laparoscopic resection of locally advanced gastrointestinal stromal tumour (GIST) of the stomach following neoadjuvant imatinib chemoreduction

AbstractIntroductionLaparoscopic resection of locally advanced gastrointestinal stromal tumours (GISTs) is rarely offered to patients as a first line of treatment.Presentation of casesWe present two cases of locally advanced gastric GISTs successfully treated with neoadjuvant imatinib and followed up by complete laparoscopic excision of the residual tumour mass. There was no evidence of local recurrence or distant metastases after a mean follow up of more than 40 months.DiscussionOver the last decade, the development of imatinib has totally revolutionized management of metastatic GISTs and it is now possible to achieve primary tumour downstaging of more than 80%. Unfortunately, current literature on laparoscopic excision of locally advanced gastric GISTs following neoadjuvant treatment of imatinib remains scarce. The present cases strongly suggest that this new therapeutic approach might become the preferred medical option in such clinical situation.ConclusionPatients with locally advanced non-metastatic gastric GISTs should be offered first-line neoadjuvant. Imatinib-based cytoreductive chemotherapy as an alternative to radical debulking surgery, as a substantial proportion of them will experience significant tumour shrinkage and therefore benefit from a much less invasive laparoscopic approach

Starting a movement: An epidemiological audit into the distribution and determinants of Clostridium Difficele infection at an Australian tertiary hospital site

BackgroundThe emergence of hypervirulent strains of Clostridioides (Clostridium) difficile over the past few decades has cemented C. difficile infection (CDI) as the most common cause of nosocomial infectious diarrhoea within Australia. This report was initiated to better understand the burden of disease at the Bankstown-Lidcombe Hospital through analysis of CDI incidence, risk factors, and treatment.AimsThe specific objectives of this study were two-fold; 1) to determine the prevalence of hospitalised patients affected with CDI and 2) to identify risk factors for CDI in hospitalised patients.Methods A retrospective review of all consecutive CDI cases at the Bankstown-Lidcombe Hospital between 1 July 2014 and 31 December 2018 was performed. CDI incidence was calculated based on the number of CDI cases observed per 10,000 patient days. Annual incidence and predisposing antibiotics to CDI were compared via univariate analysis and Student t-tests. Treatment for CDI was compared using contingency analysis via Pearson’s chi-squared analysis. Results The CDI diagnoses ranged from 3.2–4.6 (as a proportion of 10,000 occupied bed days) throughout 2014 and 2018. There was a significant decrease in CDI associated with Macrolides between 2017 and 2018 (p=0.03). There was a significant rise in CDI associated with Beta lactamase inhibitors and Penicillins (e.g., Tazobactam/Piperacillin). The majority of CDI patients were treated with single therapy metronidazole during their hospital stays.ConclusionCDI risk minimisation presents a significant challenge to all hospital departments. This audit highlights the importance of antibiotic usage influencing in-patient CDI cases and the vital role of multidisciplinary teams (microbiologists, pathologists, physicians, surgeons and pharmacists) in managing and monitoring these patients

The Protist Ribosomal Reference database (PR2): a catalog of unicellular eukaryote Small Sub-Unit rRNA sequences with curated taxonomy

The interrogation of genetic markers in environmental meta-barcoding studies is currently seriously hindered by the lack of taxonomically curated reference data sets for the targeted genes. The Protist Ribosomal Reference database (PR2, http://ssu-rrna.org/) provides a unique access to eukaryotic small sub-unit (SSU) ribosomal RNA and DNA sequences, with curated taxonomy. The database mainly consists of nuclear-encoded protistan sequences. However, metazoans, land plants, macrosporic fungi and eukaryotic organelles (mitochondrion, plastid and others) are also included because they are useful for the analysis of high-troughput sequencing data sets. Introns and putative chimeric sequences have been also carefully checked. Taxonomic assignation of sequences consists of eight unique taxonomic fields. In total, 136 866 sequences are nuclear encoded, 45 708 (36 501 mitochondrial and 9657 chloroplastic) are from organelles, the remaining being putative chimeric sequences. The website allows the users to download sequences from the entire and partial databases (including representative sequences after clustering at a given level of similarity). Different web tools also allow searches by sequence similarity. The presence of both rRNA and rDNA sequences, taking into account introns (crucial for eukaryotic sequences), a normalized eight terms ranked-taxonomy and updates of new GenBank releases were made possible by a long-term collaboration between experts in taxonomy and computer scientist

The Protist Ribosomal Reference database (PR2): a catalog of unicellular eukaryote Small Sub-Unit rRNA sequences with curated taxonomy

International audienceThe interrogation of genetic markers in environmental meta-barcoding studies is currently seriously hindered by the lack of taxonomically curated reference data sets for the targeted genes. The Protist Ribosomal Reference database (PR2, http://ssu-rrna.org/) provides a unique access to eukaryotic small sub-unit (SSU) ribosomal RNA and DNA sequences, with curated taxonomy. The database mainly consists of nuclear-encoded protistan sequences. However, metazoans, land plants, macrosporic fungi and eukaryotic organelles (mitochondrion, plastid and others) are also included because they are useful for the analysis of high-troughput sequencing data sets. Introns and putative chimeric sequences have been also carefully checked. Taxonomic assignation of sequences consists of eight unique taxonomic fields. In total, 136 866 sequences are nuclear encoded, 45 708 (36 501 mitochondrial and 9657 chloroplastic) are from organelles, the remaining being putative chimeric sequences. The website allows the users to download sequences from the entire and partial databases (including representative sequences after clustering at a given level of similarity). Different web tools also allow searches by sequence similarity. The presence of both rRNA and rDNA sequences, taking into account introns (crucial for eukaryotic sequences), a normalized eight terms ranked-taxonomy and updates of new GenBank releases were made possible by a long-term collaboration between experts in taxonomy and computer scientists

Mutational signatures of ionizing radiation in second malignancies

Ionizing radiation is a potent carcinogen, inducing cancer through DNA damage. The signatures of mutations arising in human tissues following in vivo exposure to ionizing radiation have not been documented. Here, we searched for signatures of ionizing radiation in 12 radiation-associated second malignancies of different tumour types. Two signatures of somatic mutation characterize ionizing radiation exposure irrespective of tumour type. Compared with 319 radiation-naive tumours, radiation-associated tumours carry a median extra 201 deletions genome-wide, sized 1-100 base pairs often with microhomology at the junction. Unlike deletions of radiation-naive tumours, these show no variation in density across the genome or correlation with sequence context, replication timing or chromatin structure. Furthermore, we observe a significant increase in balanced inversions in radiation-associated tumours. Both small deletions and inversions generate driver mutations. Thus, ionizing radiation generates distinctive mutational signatures that explain its carcinogenic potential.This work was supported by funding from the Wellcome Trust (grant reference 077012/Z/05/Z), Skeletal Cancer Action Trust, Rosetrees Trust UK, Bone Cancer Research Trust, the RNOH NHS Trust, the National Institute for Health Research Health Protection Research Unit in Chemical and Radiation Hazards and Threats at Newcastle University in partnership with Public Health England. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, the Department of Health or Public Health England. Tissue was obtained from the RNOH Musculoskeletal Research Programme and Biobank, co-ordinated by Mrs Deidre Brooking and Mrs Ru Grinnell, Biobank staff, RNOH. Support was provided to AMF by the National Institute for Health Research, UCLH Biomedical Research Centre, and the CRUK UCL Experimental Cancer Centre. S.N.Z. and S.B. are personally funded through Wellcome Trust Intermediate Clinical Research Fellowships, P.J.C. through a Wellcome Trust Senior Clinical Research Fellowship

Functional outcomes in symptomatic versus asymptomatic patients undergoing incisional hernia repair: Replacing one problem with another? A prospective cohort study in 1312 patients

Background: Incisional hernias can be associated with pain or discomfort. Surgical repair especially mesh reinforcement, may likewise induce pain. The primary objective was to assess the incidence of pain after hernia repair in patients with and without pre-operative pain or discomfort. The secondary objectives were to determine the preferred mesh type, mesh location and surgical technique in minimizing postoperative pain or discomfort. Materials and methods: A registry-based prospective cohort study was performed, including patients undergoing incisional hernia repair between September 2011 and May 2019. Patients with a minimum follow-up of 3–6 months were included. The incidence of hernia related pain and discomfort was recorded perioperatively. Results: A total of 1312 patients were included. Pre-operatively, 1091 (83%) patients reported pain or discomfort. After hernia repair, 961 (73%) patients did not report pain or discomfort (mean follow-up = 11.1 months). Of the pre-operative asymptomatic patients (n = 221), 44 (20%, moderate or severe pain: n = 14, 32%) reported pain or discomfort after mean follow-up of 10.5 months. Of those patients initially reporting pain or discomfort (n = 1091), 307 (28%, moderate or severe pain: n = 80, 26%) still reported pain or discomfort after a mean follow-up of 11.3 months postoperatively. Conclusion: In symptomatic incisional hernia patients, hernia related complaints may be resolved in the majority of cases undergoing surgical repair. In asymptomatic incisional hernia patients, pain or discomfort may be induced in a considerable number of patients due to surgical repair and one should be aware if this postoperative complication

Safety of Laparoscopic Colorectal Surgery in a Low-Volume Setting: Review of Early and Late Outcome

Background. There is increasing evidence suggesting that the laparoscopic technique is the treatment of choice for large bowel resection, including for malignancy. The purpose of the study was to assess whether general surgeons, with particular skills in advanced laparoscopy, can adequately provide safe laparoscopic colorectal resections in a low-volume setting. Methods. A retrospective review of prospectively collected case series of all laparoscopic colorectal resections performed under the care of a single general surgeon is presented. The primary endpoint was postoperative clinical outcome in terms of morbidity and mortality. Secondary endpoints were adequacy of surgical margins and number of lymph nodes harvested for colorectal cancer cases. Results. Seventy-three patients underwent 75 laparoscopic resections between March, 2003, and May, 2011. There was no elective mortality and the overall 30-day postoperative morbidity was 9.3%. Conversion and anastomotic leakage rates were both 1.3%, respectively. None of the malignant cases had positive margins and the median number of lymph nodes retrieved was 17. Conclusions. Our results support the view that general surgeons with advanced skills in minimally invasive surgery may safely perform laparoscopic colorectal resection in a low-volume setting in carefully selected patient cases

A diagnostic workup and laparoscopic approach for median arcuate ligament syndrome

Background Median arcuate ligament syndrome (MALS) is a rare disorder characterized by the compression of the coeliac trunk and plexus by fibrous arches of the median ligament. It commonly occurs in young women with postprandial epigastric pain, weight loss and nausea. We present a single surgeon experience on the diagnostic approach and management of MALS with a focus on laparoscopic surgery. Methods A retrospective review of adult patients diagnosed with MALS during a 10-year period (2011–2021) was conducted at Bankstown-Lidcombe hospital in New South Wales, Australia. Results MALS was diagnosed in six patients (mean 46 years, range: 27–74 years old), all confirmed on mesenteric duplex ultrasound and computed tomography angiography. The most common presentations were women with post-prandial pain, exercise induced pain and an average weight loss of 14.5 kg. The median interval from onset of symptoms to surgical referral was 10.5 months. The average BMI was 24.1 kg/m2 and most had a grade III American Society of Anaesthesiologist physical status. All patients underwent laparoscopic release of median arcuate ligament with one patient requiring endovascular stenting. The mean operative time was 119 minutes with two minor post-operative complications, but no mortalities. The median hospital length of stay was 3.5 days with a median follow up of 3.5 years. Conclusion Laparoscopic median arcuate ligament release with endovascular support for selected cases provides sound clinical resolution of symptoms and long-term results

Impact of preoperative smoking on patients undergoing right hemicolectomies for colon cancer

Purpose: The tobacco epidemic is one of the biggest global public health issues impacting quality of life and surgical outcomes. Although 30% of colon cancers warrant a right hemicolectomy (RH), there is no specific data on the influence of smoking on postoperative complications following RH for cancer. The aim of this study was to determine its effect on post-surgical outcomes. Methods: Patients who underwent elective RH for colon cancer between 2016 and 2019 were identified from the ACS-NSQIP database. Propensity score matching (PSM) was used with a maximum absolute difference of 0.05 between propensity scores. Primary outcome was to assess the 30-day complication risk profile between smokers and non-smokers. Secondary outcomes included smoking impact on wound and major medico-surgical complication rates, as well as risk of anastomotic leak (AL) using multivariable logistic regression models. Results: Following PSM, 5652 patients underwent RH for colon cancer with 1,884 (33.3%) identified as smokers. Smokers demonstrated a higher rate of organ space infection (4.1% vs 3.1%, p = 0.034), unplanned return to theatre (4.8% vs 3.7%, p = 0.045) and risk of AL (3.5% vs 2.1%, p = 0.005). Smoking was found to be an independent risk factor for wound complications (OR 1.32, 95% CI 1.03–1.71, p = 0.032), primary pulmonary complications (OR 1.50, 95% CI 1.06–2.13, p = 0.024) and AL (OR 1.66, 95% CI 1.19–2.31, p = 0.003). Conclusion: Smokers have increased risk of developing major post-operative complications compared to non-smokers. Clinicians and surgeons must inform smokers of these surgical risks and potential benefit of smoking cessation prior to undergoing major colonic resection