Abstract Aim Intestinal lymphomas can rarely present as abdominal catastrophes with perforation or small bowel obstruction. There is little data regarding their optimal surgical management and associated outcomes. We aimed to systematically review relevant published literature to assess optimal surgical approach and post-operative outcomes. Methods A systematic on-line literature search of Embase and Medline identified 1485 articles of which 34 relevant studies were selected, including 7 retrospective studies, 1 case series and 26 case reports. Selected articles were assessed by two reviewers to extract relevant data. Results 95 patients with abdominal catastrophes secondary to lymphoma (predominately Burkitt (28%) and Diffuse Large B-cell lymphoma (29%)) were identified with a median age of 52 years, 40% female. The most common presentation was perforation in 69% of patients compared to obstruction (28%) and ischaemia (2%). The most common site of perforation was the ileum (32%), followed by the jejunum (27%). Small bowel resection and primary anastomosis (76%) was the most common procedure performed followed by ileocolic resection (11%), primary repair (4%) and defunctioning stoma (3%). Of those receiving small bowel resection 25% (n=18) suffered post-operative complications with a 30-day mortality of 13.8% (n=10). This compared favourably to those receiving ileocolonic resections (27% complications 18% mortality) or primary repair (25% complications and 25% mortality). Median follow-up was 8 days (range 1-96). Conclusion Abdominal catastrophes secondary to intestinal lymphomas are most commonly present with perforation. If suitable intra-operatively, small bowel resection offers the most favourable short-term outcomes with the lowest levels of morbidity and 30-day mortality.
Abstract Introduction Oesophageal defects are associated with poor morbidity and mortality and often require prolonged hospitalisation and artificial nutrition. Existing endoscopic treatment modalities exhibit limitations. Covered stents are associated with a migration rate of up to 50% and closure with endoscopic clips is limited to simple defects. Vacuum therapy is a well understood and established surgical therapy to promote wound healing. Endoscopic Vacuum Therapy (EVT) utilises these principles in the management of transmural oesophageal defects. The VACstent GITM (MicroTech) is a novel device which synergistically incorporates the advantages of a fully covered oesophageal stent while concurrently employing EVT. This approach seals the defect while mitigating against stent migration through the vacuum effect. Luminal patency is also maintained which helps to preserve nutritional independence. Accelerated healing and enhanced nutrition are thought to help reduce morbidity and enhance patient quality of life. Methods This single-centre prospective case series describes outcomes for patients with transmural oesophageal defects treated with the VACstent GITM device. All procedures were performed with propofol sedation and fluoroscopic guidance. The VACstent GITM was exchanged every 5-7 days until endoscopic closure. A contrast study was used to confirm closure after which oral nutrition was restarted. The primary outcome was clinical success, defined as the endoscopic and radiological evidence of defect closure. Secondary outcomes included number of stent exchanges, technical success, and the adverse event (AE) rate. Results The VACstent GITM device was used for seven patients between October 2023 and February 2024. Four patients had anastomotic leaks with three having iatrogenic perforations. The mean patient age was 60 (± 19.3) years with 57% of the patient cohort being male. The clinical success rate was 86% with a technical success rate of 100% and a median defect closure time of 13 (± 6.6) days. A median number of 1 stent exchanges was required. The median defect size was 8mm (± 6.2). There were no reported AEs. All patients were able to successfully come of artificial nutrition. Conclusion This case series illustrates the safety and efficacy of the VACstent for the treatment of a heterogenous group of oesophageal defects. To our knowledge this represents the largest series in a cohort of patients from the United Kingdom. Larger scale comparative studies incorporating a more diverse patient cohort will further clarify the potential of the VACstent device in reducing the necessity for major surgical interventions in this complex and challenging patient population. It will also help to refine future treatment algorithms for oesophageal defect management.
Oesophageal cancer is the 7th commonest cause of cancer death worldwide. Radiological staging of local oesophageal cancer is inaccurate. CT currently relies on attenuation of x-rays to generate contrast. Soft tissues have very similar attenuation properties so minimal contrast is generated. X-ray phase contrast imaging (XPCI) uses refraction of x-rays as they pass through tissue instead of attenuation and provides much higher soft tissue contrast. This technology can be tuned to a resolution of approximately 10 µm. This may allow for easy assessment of extent of disease infiltration. We aimed to use XPCI to image oesophagectomy specimens to assess pathological tumour and nodal stage for oesophageal cancer
Methods
Following ethical approval, 10 oesophagectomy specimens were obtained from patients having surgery for oesophageal cancers. These included both squamous and adenocarcinomas. Specimens were fixed in formalin for 12 hours. Sutures were placed through tissue to enable co-registration between CT slices and histology sections. For some scans, tissue was then dehydrated with graded ethanol for between 4.5 hours and 72 hours before being imaged. A Rigaku (MicroMax 007) xray source was used at 40 kV and 20 mA; a detector with 50µm pixel size; and sample and detector masks made of graphite substrate with gold overlay. Phase contrast was generated using edge illumination technique. We reconstructed the images using MATLAB® software. Specimens were returned for clinical histopathological assessment allowing correlation between H&E slides and CT images.
Results
We have performed 25 scans on 10 oesophagectomy samples and correlated them with histology Scans of samples in formalin failed to show adequate contrast between oesophageal layers to enable tumour visualisation and staging. Infiltrating the tissue with ethanol led to much better image contrast. We could easily identify mucosa, submucosa and both layers of muscle in reconstructed CT images. We also identified tumour infiltration through tissue layers and destruction of normal oesophageal morphology (figure 1). This was confirmed histologically and could be recognised by radiologists blinded to pathological staging This is the first time that XPCI has been used to image human oesophageal tissue. We have demonstrated the feasibility of the technique and the possibility of obtaining high resolution images which mimic histology with the extra benefit of demonstrating three dimensional structure.
Background: Laparoscopic surgery is based on 2D imaging, with limited depth perception.The aim of this study was to analyse the impact of 3D training on the performance of surgical trainees in 2D laparoscopic simulation.Methods: Thirty medical students were randomised into group A, completing five training attempts of three modified Fundamentals of Laparoscopic Surgery tasks (peg transfer, pattern cutting, and intra-corporeal suturing) using a 3D simulator, or group B, who were only exposed to the 2D platform.Time to completion, error rate, and efficiency improvement were measured.Results: The overall performance time was lower for group A than for group B, and this was statistically significant in task 2 (P = 0.02) and task 3 (P 5 0.01).The mean error rate was lower for group A versus group B, which was statistically significant for all three tasks (task 1, 0 vs 0.2; task 2, 0.4 vs 1.8; task 3, 0.24 vs 1.1).When efficiency improvement was evaluated, group B displayed a faster rate of improvement during task 1 (132.1% vs 248.8%;P 5 0.01) and task 2 (123.9%vs 139%; P = 0.15).For task 3, group A demonstrated a superior rate of improvement (190% vs 173.1%;P = 0.2).Conclusions: Introducing 3D training is beneficial for novices to execute 2D laparoscopic skills, particularly for complex tasks where depth perception is critical.3D-based laparoscopic training, in conjunction with standard 2D platforms, should be introduced into surgical training to facilitate quicker and better preparation before translation of these skills into clinical practice.
Trefoil factor family (TFF) peptides promote wound healing in the gut. Recent evidence has suggested that TFF3 may be a pancreatic mitogen, an unusual role for TFF peptides. We sought to clarify human pancreatic TFF and mucin expression and performed in vitro experiments to see how pancreatic cell lines respond to TFF3 in particular.Samples of normal and diseased pancreas (chronic pancreatitis, pancreatic intraepithelial neoplasia, neuroendocrine tumors, and pancreatic ductal adenocarcinoma [PDAC]) were studied by immunohistochemistry and in situ hybridization. Pancreatic cell lines were challenged with TFF2 and TFF3 in wound and migration assays.In normal islets, colocalization of insulin or glucagon with TFF3 was common. All TFF messenger RNAs were seen in ductal epithelium. Adenocarcinomas expressed all TFF messenger RNAs. Normal ducts were mucin free; MUC5AC was strongest in pancreatic intraepithelial neoplasia and chronic pancreatitis but was reduced in PDAC. TFF2 induced Panc-1 migration and accelerated wound closure in Capan-2 and COLO-357. Double immunohistochemistry for insulin or TFF3 and Ki67 colabeled only very rare islet cells. TFF3-positive PDAC ducts showed some Ki67 colocalization.No correlation between TFF3 or insulin and Ki67 was seen without ductal hyperplasia. TFF2 may assist pancreatic tumor cell movement, but TFF3 may not be a pancreatic mitogen.
Biliary cholesterol saturation indices (SI's) were measured in fasting duodenal bile from (i) obese and non-obese individuals with and without cholesterol gallstones, (ii) obese individuals undergoing weight reduction and (iii) obese gallstone patients receiving chenodeoxycholic acid (CDCA) therapy. Biliary lipid secretion rates were also measured in three obese subjects before and during 11 days starvation. The mean SI in fifteen non-obese controls (0.89 +/- SEM 0.06) was significantly lower than that in the twenty-four obese without (1.14 +/- 0.07; P less than 0.01), and in the twenty-nine non-obese with gallstones (1.30 +/- 0.05; P less than 0.001) while in sixteen obese gallstone patients, the mean SI of 1.55 +/- 0.06 was significantly higher than that seen in the other three groups (P less than 0.01-0.001). Although fifteen obese subjects lost 15% of their initial body weight during dieting, this did not change their SI's consistently. However in three obese individuals, total starvation did reduce the SI's and significantly lowered the biliary cholesterol secretion rate. Ten obese gallstone patients responded to 15.8 +/- 0.3 mg CDCA kg-1 day-1 by developing unsaturated fasting duodenal bile (SI 0.89 +/- 0.04). A further increase in CDCA dose to 19.0 +/- 0.7 mg kg-1 day-1, as a result of reducing body weight, was more effective in lowering SI's (0.75 +/- 0.06, range 0.51-1.0) than that achieved by increasing the dose to 18.9 +/- 0.46 mg kg-1 day-1 through more capsules per day (SI 0.89 +/- 0.03, range 0.67-1.25). These studies show that (i) biliary cholesterol SI's are greater when obesity and gallstones occur together than in either obesity or gallstones alone, and (ii) although weight loss in obese individuals does not consistently alter biliary cholesterol SI's, it may be beneficial in obese patients receiving CDCA therapy for gallstone dissolution.
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