Port-site tumour recurrence of oral squamous carcinoma following percutaneous endoscopic gastrostomy: a lesson to be aware of

BACKGROUND: Patients with aero-digestive malignancy will often require a feeding gastrostomy during their treatment to maintain their nutritional status. These are usually placed percutaneously using an endoscopic technique. CASE PRESENTATION: A fifty-six year old male underwent placement of a percutaneous gastrostomy (PEG) prior to commencement of his treatment for an oral squamous cell carcinoma. The treatment for this was locally curative. However, he developed a metastasis at the site of his PEG tube. This was excised en-bloc with the anterior gastric and abdominal walls. CONCLUSION: Tumour implantation into wounds has been previously reported. In this case the direct trauma of passing the PEG tube through the oropharynx led to implantation of cells in the anterior abdominal wall. In these cases laparoscopic placement may be more beneficial to avoid this problem

Bioabsorbable mesh use in midline abdominal wall prophylaxis and repair achieving fascial closure: a cross-sectional review of stage of innovation

Background: Achieving stable closure of complex or contaminated abdominal wall incisions remains challenging. This study aimed to characterise the stage of innovation for bioabsorbable mesh devices used during both midline closure prophylaxis and complex abdominal wall reconstruction and to evaluate the quality of current evidence. Methods: A systematic review of published and ongoing studies was performed until 31st December 2019. Inclusion criteria were studies where bioabsorbable mesh was used to support fascial closure either prophylactically after midline laparotomy or for repair of incisional hernia with midline incision. Exclusion criteria were: (1) study design was a systematic review, meta-analysis, letter, review, comment, or conference abstract; (2) included less than p patients; (3) only evaluated biological, synthetic or composite meshes. The primary outcome measure was the IDEAL framework stage of innovation. The key secondary outcome measure was the risk of bias in non-randomised studies of interventions (ROBINS-I) criteria for study quality. Results: Twelve studies including 1287 patients were included. Three studies considered mesh prophylaxis and nine studies considered hernia repair. There were only two published studies of IDEAL 2B. The remainder was IDEAL 2A studies. The quality of the evidence was categorised as having a risk of bias of a moderate, serious or critical level in nine of the twelve included studies using the ROBINS-I tool. Conclusion: The evidence base for bioabsorbable mesh is limited. Better reporting and quality control of surgical techniques are needed. Although new trial results over the next decade will improve the evidence base, more trials in emergency and contaminated settings are required to establish the limits of indication.This article is freely available via Open Access. Click on the Publisher URL to access it via the publisher's site.published version, accepted version (12 month embargo

Peritoneal carcinomatosis from a small bowel carcinoid tumour

BACKGROUND: Peritoneal carcinomatosis from a gastrointestinal carcinoid tumour is rare and the long-term management and prognosis have not been clearly defined. The natural history is different from gastrointestinal adenocarcinoma, although its capacity to invade regional lymph nodes and generate distal metastasis can make the management more complex. Whilst the development of carcinomatosis is uncommonly reported, it may be higher than expected. CASE PRESENTATION: A 63 years-old woman underwent emergency surgery in 1993 for right iliac fossa pain and a mass that was found to be an ileal carcinoid tumour. Over the next ten years, further surgery was required for disseminated disease with peritoneal carcinomatosis and liver metastasis. Systemic chemotherapy had little effect, although Somatostatin was used effectively to relieve symptoms caused by the disseminated disease (flushing and diarrhoea). CONCLUSION: Peritoneal carcinomatosis from carcinoid tumours is not well documented in the literature. Aggressive surgery must be performed in order to control the disease since chemotherapy has not been reported to be effective. With repeated surgery long-term survival can be achieved in these patients

Female urogenital dysfunction following total mesorectal excision for rectal cancer

BACKGROUND: The effect of Total Mesorectal Excision (TME) on sexual function in the male is well documented. However, there is little literature in female patients. The aim of this study was to review the pelvic autonomic nervous anatomy in the female and to perform a retrospective audit of urinary and sexual function in women following surgery for rectal cancer where TME had been performed. Urogenital dysfunction was assessed through interview and questionnaire. METHOD: Twenty-three questionnaires, eighteen returned, were sent to women with a mean age 65.5 yrs (range 34–86). All had undergone total mesorectal excision for rectal cancer between 1998–2001. Mean follow-up was 18.8 months (range 3–35). RESULTS: Preoperatively 5/18 (28%) were sexually active, 3/18 (17%) of patients described urinary frequency and nocturia and 7/18 (39%) described symptoms of stress incontinence prior to surgery. Postoperatively all sexually active patients remained active although all described some discomfort with penetration. Two of the patients sexually active described reduced libido secondary to the stoma. Postoperative urinary symptoms developed with 59% reporting the development of nocturia, 18% developed stress incontinence and one patient required a permanent catheter. Of those with symptoms, 80% persisted longer than three months from surgery. Symptoms were predominant in those patients with low rectal cancers, particularly those undergoing abdomino-perineal excision and in those who had previously undergone abdominal hysterectomy. CONCLUSION: The treatment of rectal cancer involves surgery to the pelvic floor. Despite nerve preservation this is associated with the development of worsening nocturia and stress incontinence. This is most marked in those patients who had previously undergone a hysterectomy. Further studies are warranted to assess the interaction with previous gynaecological surgery

Adhesion of Silicone Elastomer Seals for NASA's Crew Exploration Vehicle

Silicone rubber seals are being considered for a number of interfaces on NASA's Crew Exploration Vehicle (CEV). Some of these joints include the docking system, hatches, and heat shield-to-back shell interface. A large diameter molded silicone seal is being developed for the Low Impact Docking System (LIDS) that forms an effective seal between the CEV and International Space Station (ISS) and other future Constellation Program spacecraft. Seals between the heat shield and back shell prevent high temperature reentry gases from leaking into the interface. Silicone rubber seals being considered for these locations have inherent adhesive tendencies that would result in excessive forces required to separate the joints if left unchecked. This paper summarizes adhesion assessments for both as-received and adhesion-mitigated seals for the docking system and the heat shield interface location. Three silicone elastomers were examined: Parker Hannifin S0899-50 and S0383-70 compounds, and Esterline ELA-SA-401 compound. For the docking system application various levels of exposure to atomic oxygen (AO) were evaluated. Moderate AO treatments did not lower the adhesive properties of S0899-50 sufficiently. However, AO pretreatments of approximately 10(exp 20) atoms/sq cm did lower the adhesion of S0383-70 and ELA-SA-401 to acceptable levels. For the heat shield-to-back shell interface application, a fabric covering was also considered. Molding Nomex fabric into the heat shield pressure seal appreciably reduced seal adhesion for the heat shield-to-back shell interface application

Quality of life in restorative versus non-restorative resections for rectal cancer:systematic review

BACKGROUND: Low rectal cancers could be treated using restorative (anterior resection, AR) or non-restorative procedures with an end/permanent stoma (Hartmann’s, HE; or abdominoperineal excision, APE). Although the surgical choice is determined by tumour and patient factors, quality of life (QoL) will also influence the patient's future beyond cancer. This systematic review of the literature compared postoperative QoL between the restorative and non-restorative techniques using validated measurement tools. METHODS: The review was registered on PROSPERO (CRD42020131492). Embase and MEDLINE, along with grey literature and trials websites, were searched comprehensively for papers published since 2012. Inclusion criteria were original research in an adult population with rectal cancer that reported QoL using a validated tool, including the European Organization for Research and Treatment of Cancer QLQ-CR30, QLQ-CR29, and QLQ-CR38. Studies were included if they compared AR with APE (or HE), independent of study design. Risk of bias was assessed using the Risk Of Bias In Non-Randomized Studies of Interventions (ROBINS-I) tool. Outcomes of interest were: QoL, pain, gastrointestinal (GI) symptoms (stool frequency, flatulence, diarrhoea and constipation), and body image. RESULTS: Nineteen studies met the inclusion criteria with a total of 6453 patients; all papers were observational and just four included preoperative evaluations. There was no identifiable difference in global QoL and pain between the two surgical techniques. Reported results regarding GI symptoms and body image documented similar findings. The ROBINS-I tool highlighted a significant risk of bias across the studies. CONCLUSION: Currently, it is not possible to draw a firm conclusion on postoperative QoL, pain, GI symptoms, and body image following restorative or non-restorative surgery. The included studies were generally of poor quality, lacked preoperative evaluations, and showed considerable bias in the data

Major surgery induces acute changes in measured DNA methylation associated with immune response pathways

Surgery is an invasive procedure evoking acute inflammatory and immune responses that can influence risk for postoperative complications including cognitive dysfunction and delirium. Although the specific mechanisms driving these responses have not been well-characterized, they are hypothesized to involve the epigenetic regulation of gene expression. We quantified genome-wide levels of DNA methylation in peripheral blood mononuclear cells (PBMCs) longitudinally collected from a cohort of elderly patients undergoing major surgery, comparing samples collected at baseline to those collected immediately post-operatively and at discharge from hospital. We identified acute changes in measured DNA methylation at sites annotated to immune system genes, paralleling changes in serum-levels of markers including C-reactive protein (CRP) and Interleukin 6 (IL-6) measured in the same individuals. Many of the observed changes in measured DNA methylation were consistent across different types of major surgery, although there was notable heterogeneity between surgery types at certain loci. The acute changes in measured DNA methylation induced by surgery are relatively stable in the post-operative period, generally persisting until discharge from hospital. Our results highlight the dramatic alterations in gene regulation induced by invasive surgery, primarily reflecting upregulation of the immune system in response to trauma, wound healing and anaesthesia.This article is freely available via Open Access. Click on the Publisher URL to access it via the publisher's site.This work was supported by the Medical Research Council (Grant MR/M008924/1), the Sasakawa Foundation (Butterfield Awards B108) and the UK National Institute for Health Research (NIHR) Exeter Clinical Research Facility (Exeter CRF).Published version, Accepted version, Submitted versio

Incidence of and risk factors for stoma-site incisional herniation after reversal

This letter is available via Open Access. Click on the Publisher URL to access via the publisher's site.Published

Growth of CuCl thin films by magnetron sputtering for ultraviolet optoelectronic applications

Copper (I) chloride (CuCl) is a potential candidate for ultraviolet (UV) optoelectronics due to its close lattice match with Si (mismatch less than 0.4%) and a high UV excitonic emission at room temperature. CuCl thin films were deposited using radio frequency magnetron sputtering technique. The influence of target to substrate distance (dts) and sputtering pressure on the composition, microstructure, and UV emission properties of the films were analyzed. The films deposited with shorter target to substrate spacing (dts=3 cm) were found to be nonstoichiometric, and the film stoichiometry improves when the substrate is moved away from the target (dts=4.5 and 6 cm). A further increase in the spacing results in poor crystalline quality. The grain interface area increases when the sputtering pressure is increased from 1.1×10–³ to 1×10–² mbar at dts=6 cm. Room temperature cathodoluminescence spectrum shows an intense and sharp UV exciton (Z₃) emission at ~385 nm with a full width at half maximum of 16 nm for the films deposited at the optimum dts of 6 cm and a pressure of 1.1×10–³ mbar. A broad deep level emission in the green region (~515 nm) is also observed. The relative intensity of the UV to green emission peaks decreased when the sputtering pressure was increased, consistent with an increase in grain boundary area. The variation in the stoichiometry and the crystallinity are attributed to the change in the intensity and energy of the flux of materials from the target due to the interaction with the background gas molecules

Root-cause analyses of missed opportunities for the diagnosis of colorectal cancer in patients with inflammatory bowel disease

Background: Colonoscopic surveillance in patients with inflammatory bowel disease (IBD) leads to earlier detection of colorectal cancer (CRC) and reduces CRC-associated mortality. However, it is limited by poor adherence in practice. Aim: To identify missed opportunities to detect IBD-associated CRC at our hospital METHODS: We undertook root-cause analyses to identify patients with missed opportunities to diagnose IBD-associated CRC. We matched patients with IBD-associated CRC to patients with CRC in the general population to identify differences in staging at diagnosis and clinical outcomes. Results: Compared with the general population, patients with IBD were at increased risk of developing CRC (odds ratio 2.7 [95% CI 1.6-3.9], P < 0.001). The mean incidence of IBD-associated CRC between 1998 and 2019 was 165.4 (IQR 130.4-199.4) per 100 000 patients and has not changed over the last 20 years. Seventy-eight patients had IBD-associated CRC. Forty-two (54%) patients were eligible for CRC surveillance: 12% (5/42) and 10% (4/42) patients were diagnosed with CRC at an appropriately timed or overdue surveillance colonoscopy, respectively. Interval cancers occurred in 14% (6/42) of patients; 64% (27/42) of patients had a missed opportunity for colonoscopic surveillance where root-cause analyses demonstrated that 10/27 (37%) patients known to secondary care had not been offered surveillance. Four (15%) patients had a delayed diagnosis of CRC due to failure to account for previous colonoscopic findings. Seventeen (63%) patients were managed by primary care including seven patients discharged from secondary care without a surveillance plan. Matched case-control analysis did not show significant differences in cancer staging or 10-year survival outcomes. Conclusion: The incidence of IBD-associated CRC has remained static. Two-thirds of patients eligible for colonoscopic surveillance had missed opportunities to diagnose CRC. Surveillance programmes without comprehensive and fully integrated recall systems across primary and secondary care are set to fail.This article is freely available via Open Access. Click on the Publisher URL to access it via the publisher's site.published version, accepted version (12 month embargo), submitted versio