Search

Cancer has presented to be the most challenging disease, contributing to one in six mortalities worldwide. The current treatment regimen involves multiple rounds of chemotherapy administration, alone or in combination. The treatment has adverse effects including cardiomyopathy, hepatotoxicity, and nephrotoxicity. In addition, the development of resistance to chemo has been attributed to cancer relapse and low patient overall survivability. Multiple drug resistance development may be through numerous factors such as up-regulation of drug transporters, drug inactivation, alteration of drug targets and drug degradation. Doxorubicin is a widely used first line chemotherapeutic drug for a myriad of cancers. It has multiple intracellular targets, DNA intercalation, adduct formation, topoisomerase inhibition, iron chelation, reactive oxygen species generation and promotes immune mediated clearance of the tumor. Agents that can sensitize the resistant cancer cells to the chemotherapeutic drug are currently the focus to improve the clinical efficiency of cancer therapy. This review summarizes the recent 10-year research on the use of natural phytochemicals, inhibitors of apoptosis and autophagy, miRNAs, siRNAs and nanoformulations being investigated for doxorubicin chemosensitization., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

To evaluate the role of circulating dd-cfDNA in allograft surveillance in immunologically high-risk patients, a retrospective cross-sectional study of 261 kidney transplant recipients who underwent outpatient allograft biopsy at our center between September 2020 and August 2021 was performed. Of the 236 dd-cfDNA results included, 37 samples were obtained at the time of a surveillance biopsy in sensitized recipients and 199 at the time of a clinically indicated biopsy. The median serum creatinine at the time of the biopsy was 1.3 mg/dl and 2.1 mg/dl for surveillance biopsies and clinically indicated biopsies, respectively (P < .001). Rejection was diagnosed in 27% of surveillance biopsies and 29% of clinically indicated biopsies. Among surveillance biopsies, sensitivity and specificity to detect rejection were 0% and 89%, respectively, and among clinically indicated biopsies they were 28% and 96%, respectively. The sensitivity and specificity to detect antibody-mediated rejection were 0% and 91% among surveillance biopsies and 50% and 94% among clinically indicated biopsies. Nine biopsies without rejection findings had corresponding dd-cfDNA of ≥1%. Our data does not support dd-cfDNA as a biomarker for kidney allograft rejection, even in immunologically high-risk patients in the absence of graft dysfunction., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

A 36-year-old female with chronic watery diarrhea and persistent hypokalemia for more than eight months duration eventually being diagnosed as vasoactive intestinal peptide tumor (VIPoma) clinically and histologically is presented here. The patient achieved complete recovery after starting octreotide, a somatostatin analog. She underwent a distal pancreatectomy along with the removal of the tumor at Teaching Hospital Jaffna for the permanent cure., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Thivacaren et al.)

A 32-year-old man with a background of Behçet's disease developed severe chest pain. The onset coincided with an episode of sacroiliitis. The patient was diagnosed with pericarditis and was successfully treated with a combination of anti-inflammatory agents. Pericarditis is a rare manifestation of Behçet's disease., Competing Interests: The authors declare that there is no conflict of interest regarding the publication of this article., (Copyright © 2022 Steen Reed et al.)

Objectives:  To study the frequency of risk factors affecting the development of parastomal hernias in patients undergoing stoma formation., Study Design: A retrospective descriptive cross-sectional study. Duration of Study: This study was conducted at the Department of General Surgery between January 2017 to December 2020., Methodology:  A total of 163 patients aged between 20 and 100 years and who required a stoma formation were included in the study. The patients with incomplete data and those lacking post-operative imaging were excluded. According to this selection criteria, 80 patients were excluded. The data was collected for all patients from the hospital database. This included patient's demographic information, co-morbidities, pre-surgery patient characteristics, an indication of stoma formation, the location of stoma exit, type of surgery, associated comorbidities, subcutaneous fat thickness, and type of stoma formed. Data were analyzed using IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp., Results:  The mean age was 68.46 ± 16.50 years, with males in the majority: 48 (57.8%). Most of the patients, 53 (63.8%), had malignant disease. Post-stoma formation, a total of 38 (45.9%) patients developed parastomal hernias, mostly involving the sigmoid colon (n=62, 74.7%). However, there was a statistically significant relationship between paroxysmal sympathetic hyperactivity (PSH) incidence with non-trans-rectus stomas (trans-oblique n=07, junctional n=28) (OR 3.04, CI 1.23-7.5, p=0.014). Furthermore, malignancy was also not an independent predictor of PSH (OR 0.408, CI 0.15-1.2, p=0.056). All other risk factors included in this study were nonsignificant., Conclusion:  Our study shows that the incidence of parastomal hernias is rising with a high rate demonstrated in our patients. There was no statistically significant association between patient-related preoperative and operative factors with increased risk of parastomal hernias in our population except for a non-trans-rectus stoma, which was identified as an independent risk factor for parastomal hernias. Based on our findings, we would recommend a trans-rectus stoma over all other stoma sites. However, a much larger study is needed to validate this finding further., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Soomro et al.)

Telehealth plays a critical role in the response of healthcare organizations during the COVID-19 pandemic. While telemedicine offers a real-time patient-provider encounter, the inability to obtain vital signs during virtual visits is a potential limitation. Remote patient monitoring (RPM) uses portable devices in the patient's home to collect and electronically transmit physiological data to clinicians. Two kidney transplant recipients were enrolled in RPM in their immediate post-transplant period. Real-time monitoring of their physiological data at home through the RPM in combination with the ability to titrate medications resulted in normalization of the blood pressure and blood glucose measurements by six weeks. Our initial experience demonstrates that RPM is feasible and effective in the post-transplant period and can expand care opportunities on the remote care model. This is more relevant than ever as remote monitoring can facilitate the care of COVID-19-positive transplant patients who require close monitoring while isolated at home.

Doxorubicin or Adriamycin, is one of the most widely used chemotherapeutic drug for treating a myriad of cancers. It induces cell death through multiple intracellular targets: reactive oxygen species generation, DNA-adduct formation, topoisomerase II inhibition, histone eviction, Ca 2+ and iron hemostasis regulation, and ceramide overproduction. Moreover, doxorubicin-treated dying cells undergo cellular modifications that enable neighboring dendritic cell activation and enhanced presentation of tumor antigen. In addition, doxorubicin also aids in the immune-mediated clearance of tumor cells. However, the development of chemoresistance and cardiotoxicity side effect has undermined its widespread applicability. Several formulations of doxorubicin and co-treatments with inhibitors, miRNAs, natural compounds and other chemotherapeutic drugs have been essential in reducing its dosage-dependent toxicity and combating the development of resistance. Further, more advanced research into the molecular mechanism of chemoresistance development would be vital in improving the overall survivability of clinical patients and in preventing cancer relapse., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Minimally invasive surgery for resectable esophageal and gastroesophageal junctional (GEJ) cancer significantly reduces morbidity when compared with open surgery, as is evident from published landmark trials. Comparison of outcomes between hybrid esophagectomy (HE) and completely minimally invasive esophagectomy (CMIE) remains unclear., Objective: We aimed to ascertain whether CMIE is associated with less postoperative complications compared with HE without oncological compromise., Methods: All consecutive two-stage HEs and CMIEs performed between 2016 and 2018 were included. All procedures were performed with an intrathoracic anastomosis. Primary clinical outcomes were pulmonary infective and overall complications within 30 days of surgery, while primary oncological outcomes included overall survival (OS) and disease-free survival (DFS) at both 6 months and to date. Secondary outcomes included intraoperative variables and postoperative clinical parameters., Results: Overall, 98 patients had CMIEs and 49 patients had HEs. There were no baseline differences between the two groups. Thirty-day postoperative pulmonary infection rates were lower in the CMIE group compared with the HE group (12.2% vs. 28.6%; p = 0.014), and 30-day overall postoperative complication rates were also lower following CMIE (35.7% vs. 59.2%; p = 0.007). OS and DFS were similar between the two groups at 6 months (p = 0.201 and p = 0.109, respectively)., Conclusions: CMIE is associated with less pulmonary infective and overall postoperative complications compared with HE for resectable esophageal and GEJ cancer. No intergroup difference was observed regarding short-term survival and cancer recurrence in patients undergoing CMIE and HE. A randomized controlled trial comparing the two operative approaches is required to validate these findings.

Curcumin has anti-oxidant, anti-cancer and anti-carcinogen property. Our laboratory had previously reported that, curcumin treatment induces reactive oxygen species (ROS) generation in HT-29 cell line, an effect contradictory to its anti-oxidant property. This study evaluates the role of p53 in curcumin mediated ROS generation and cell death. Curcumin induced ROS was determined by 2',7'-dichlorofluorescein and apoptosis by Hoechst33342/PI staining in HT-29 and HCT-116 cell lines. ROS generation occurs within 1 hour of 40 µM curcumin treatment and a reduction was observed by third hour in HCT-116 insinuating p53 involvement. N-acetyl cysteine (NAC) pre-treatment effectively quenched ROS and inhibited membrane potential loss in HT-29, but less effective in HCT-116. Mitochondrial membrane potential loss is evident with 10 and 40 µM curcumin in HCT-116 and at 40 µM curcumin in HT-29. Total p53 protein level increase was observed by 24 hours in HCT-116 upon NAC pre-treatment. Our results indicate that curcumin induces ROS mediated cell death in colon adenocarcinoma cell lines and may be mediated via p53., (© 2020 Wiley Periodicals LLC.)

Background: Pathophysiology of rumination syndrome (RS) is not well understood. Treatment with diaphragmatic breathing improves rumination syndrome. The aim of the study was to characterize vagal tone in patients with rumination syndrome during and after meals and during diaphragmatic breathing., Methods: We prospectively recruited 10 healthy volunteers (HV) and 10 patients with RS. Subjects underwent measurement of vagal tone using heart rate variability. Vagal tone was measured during baseline, test meal and intervention (diaphragmatic (DiaB), slow deep (SlowDB), and normal breathing). Vagal tone was assessed using mean values of root mean square of successive differences (RMSSD), and area under curves (AUC) were calculated for each period. We compared baseline RMSSD, the AUC and meal-induced discomfort scores between HV and RS. Furthermore, we assessed the effect of respiratory exercises on symptom scores, and number of rumination episodes., Key Results: There was no significant difference in baseline vagal tone between HV and RS. During the postprandial period, there was a trend to higher vagal tone in RS, but not significantly (P > .2 for all). RS had the higher total symptom scores than HV (P < .011). In RS, only DiaB decreased the number of rumination episodes during the intervention period (P = .028), while both DiaB and SlowDB increased vagal tone (P < .05 for both). The symptom scores with the 3 breathing exercises showed very similar trends., Conclusions and Inferences: Patients with RS do not have decreased vagal tone related to meals. DiaB reduced number of rumination events by a mechanism not related to changes in vagal tone., (© 2020 John Wiley & Sons Ltd.)

Cancer cells require higher levels of ATP for their sustained growth, proliferation, and chemoresistance. Mitochondrial matrix protein, C1qbp is upregulated in colon cancer cell lines. It protects the mitochondria from oxidative stress, by inhibiting the Membrane Permeability Transition (MPT) pore and providing uninterrupted synthesis of ATP. This intracellular interaction of C1qbp could be involved in chemoresistance development. Natural chemosensitizing agent, curcumin has been used in the treatment of multiple cancers. In this current study, we elucidate the role of C1qbp during curcumin induced chemosensitization to doxorubicin resistant colon cancer cells. The possible interaction between C1qbp and curcumin was determined using bioinformatics tools-AutoDock, SYBYL, and PyMol. Intracellular doxorubicin accumulation by fluorimetry and dead cell count was carried out to determine development of chemoresistance. Effect of curcumin treatment and cytotoxicity was measured by MTT and lactate dehydrogenase release. Morphological analysis by phase contrast microscopy and colony forming ability by colonogenic assay were also performed. In addition, Cox-2 could mediate P-glycoprotein upregulation via phosphorylation of c-Jun. Thus, the gene level expression of P-glycoprotein and Cox-2 was also investigated using PCR. Through molecular docking we identified possible interaction between curcumin and C1qbp. We observed development of chemoresistance upon 6th day treatment. Concentration dependent alleviation of chemoresistance development by curcumin was confirmed and was found to reduce gene level expression of P-glycoprotein and Cox-2. Hence, curcumin could interact directly with C1qbp protein and this interaction could contribute to the chemosensiting effect to doxorubicin in colon cancer cells.

Background and Objectives: Outcomes of kidney transplant recipients diagnosed with coronavirus disease 2019 as outpatients have not been described., Design, Setting, Participants, & Measurements: We obtained clinical data for 41 consecutive outpatient kidney transplant recipients with known or suspected coronavirus disease 2019. Chi-squared and Wilcoxon rank sum tests were used to compare characteristics of patients who required hospitalization versus those who did not., Results: Of 41 patients, 22 (54%) had confirmed coronavirus disease 2019, and 19 (46%) were suspected cases. Patients most commonly reported fever (80%), cough (56%), and dyspnea (39%). At the end of follow-up, 13 patients (32%) required hospitalization a median of 8 days (range, 1-16) after symptom onset, and 23 (56%) had outpatient symptom resolution a median of 12 days (4-23) after onset. Patients who required hospitalization were more likely to have reported dyspnea (77% versus 21%, P =0.003) and had higher baseline creatinine (median, 2.0 versus 1.3 mg/dl, P =0.02), but there were no other differences between groups., Conclusions: In an early cohort of outpatient kidney transplant recipients with known or suspected coronavirus disease 2019, many had symptomatic resolution without requiring hospitalization., (Copyright © 2020 by the American Society of Nephrology.)

Objective: In this study, we evaluated the potential role of IL-6 and/or IL-17A in regulating the OPG/RANKL (osteoprotegerin/receptor activator of nuclear factor kappa b ligand) system of murine osteoblast cell line (MC3T3-E1) cultured on hydroxyapatite (HA)., Methods: MC3T3-E1 cells were seeded on HA and treated with recombinant IL-6 or rIL-17A or combination of the two cytokines. Cell proliferation and differentiation activity were measured by MTS and alkaline phosphatase assays respectively. Observation of cell adhesion and proliferation was examined by scanning electron microscopy. Gene and protein expressions were performed on RANKL and OPG using qPCR, Western blot and ELISA., Results: We demonstrated that treatment with recombinant IL-17A (rIL-17A) and the combination rIL-6/rIL-17A promoted better adhesion and higher proliferation of cells on HA. Cells treated with rIL-17A and the combination cytokines showed a significant increase in differentiation activity on day 7, 10 and 14 as indicated by ALP activity (p < 0.001). Gene and protein expressions showed significant up-regulation of OPG and ALP (p < 0.001) and down-regulation of RANKL (p < 0.001) expression by all the treated groups. Interestingly, the combination of the two cytokines resulted in a significant increase of OPG/RANKL ratio (p < 0.001)., Conclusion: These findings indicated that treatment with the combination of the two cytokines (IL-6/IL-17A) has synergistic effects to promote osteoblastic differentiation but suppress osteoclastogenesis by altering the OPG/RANKL ratio., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: Two-stage minimally invasive esophagectomy (MIE) has gained popularity in the surgical treatment of esophageal cancer. MIE's limitation is embedded in the construction of intrathoracic anastomosis. Various anastomotic techniques have been reported; however, the mechanical one remains the most commonly adopted. This pilot study aims to describe an efficient, safe, and reproducible way of performing a hand-sewn intrathoracic esophagogastric anastomosis in conjunction with short-term results using 2D and 3D thoracoscopic approaches., Methods: A total of n = 13 patients (mean age 67.4) underwent MIE for distal esophageal or gastroesophageal junction adenocarcinoma between January and September 2016. Resection was performed in prone position, and the esophagogastric anastomosis was constructed in an end-to-side manner in two layers with barbed knotless suture. A 2D thoracoscopic approach was used in n = 10 patients (77%) and a 3D approach in n = 3 (23%)., Results: n = 8 patients (61.5%) had neo-adjuvant chemotherapy and n = 5 (38.5%) had primary surgery. The mean operating time was 420 min, and the average length of stay was 10 days with no associated mortality. n = 1 (7.7%) developed a radiological leak that did not require an intervention. Thoracoscopic approach with the glasses-based 3D optical system using the angulating-tip 100° camera provided a far superior view for precise lymphadenectomy in combination to an efficient and safe construction of the anastomosis., Conclusion: The barbed knotless suturing technique in MIE is an efficient and safe method of constructing the esophagogastric anastomosis with promising short-term outcomes. A 3D thoracoscopic approach appears to be superior in performing the anastomosis to that of a 2D technique.

Gastric banding is a popular method for the treatment of morbid obesity. Amongst complications, gastric erosion remains uncommon but could prove fatal. Multiple techniques, from open surgery to endoscopic and standard laparoscopic technique for their removal, have been previously detailed in the literature. However, only a few reports have mentioned their total laparoscopic transgastric removal in the literature. Herein, we report a successful removal of an eroding gastric band with its technical suggestion in a 43-year-old female patient 22 months following its application., (Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. ©.)

We report two rare cases of female patients presenting with oesophageal leiomyoma associated with oesophageal diverticulum, both of whom were surgically managed. Oesophageal leiomyoma and oesophageal diverticulum are uncommon as separate entities and rare as combined disease presentation. Clinicians need to be aware of the rare combination of the two entities and need to be able to exclude the presence of a tumour (benign or malignant) within a diverticulum and so plan the optimum treatment. Herein, we present two cases of oesophageal leiomyoma within oesophageal diverticulum and we try to elucidate the association between the two. To date, there is no consensus whether a diverticulum is secondary to a leiomyoma or, on the contrary, a leiomyoma arises within a diverticulum., Competing Interests: The authors declare that there is no conflict of interests regarding the publication of this paper.

This in vitro study aimed to evaluate setting time and compressive strength of gypsum-based chitosan biomaterials and its effect on proliferation of stem cells from human exfoliated deciduous teeth (SHED) and alkaline phosphatase (ALP) activity. Pure-GYP was mixed with water (2.5 g: 1.9 mL); Gyp-CHT was prepared with gypsum, chitosan, and water (2.5 g: 0.285 g: 1.9 mL). Cell viability and ALP activity were assessed at different periods. Data were analyzed using SPSS (p<0.05). The setting times were 2.7 min and 2.8 min for pure-GYP and Gyp-CHT, respectively. Significantly higher compressive strength was observed with Gyp-CHT. SHED treatments with both materials were not cytotoxic. ALP was consistently higher in the treated groups compared with the control. Cellular attachments were evident with SEM. Excellent cellular viability with pure-GYP and Gyp-CHT, as well as increased ALP activities, suggested the possibility of tertiary dentin formation. Further studies are necessary to evaluate the biomaterials for its pulp protective potentialities.

Objective: Barrett's oesophagus shows appearances described as 'intestinal metaplasia', in structures called 'crypts' but do not typically display crypt architecture. Here, we investigate their relationship to gastric glands., Methods: Cell proliferation and migration within Barrett's glands was assessed by Ki67 and iododeoxyuridine (IdU) labelling. Expression of mucin core proteins (MUC), trefoil family factor (TFF) peptides and LGR5 mRNA was determined by immunohistochemistry or by in situ hybridisation, and clonality was elucidated using mitochondrial DNA (mtDNA) mutations combined with mucin histochemistry., Results: Proliferation predominantly occurs in the middle of Barrett's glands, diminishing towards the surface and the base: IdU dynamics demonstrate bidirectional migration, similar to gastric glands. Distribution of MUC5AC, TFF1, MUC6 and TFF2 in Barrett's mirrors pyloric glands and is preserved in Barrett's dysplasia. MUC2-positive goblet cells are localised above the neck in Barrett's glands, and TFF3 is concentrated in the same region. LGR5 mRNA is detected in the middle of Barrett's glands suggesting a stem cell niche in this locale, similar to that in the gastric pylorus, and distinct from gastric intestinal metaplasia. Gastric and intestinal cell lineages within Barrett's glands are clonal, indicating derivation from a single stem cell., Conclusions: Barrett's shows the proliferative and stem cell architecture, and pattern of gene expression of pyloric gastric glands, maintained by stem cells showing gastric and intestinal differentiation: neutral drift may suggest that intestinal differentiation advances with time, a concept critical for the understanding of the origin and development of Barrett's oesophagus., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Evidence from anatomical and functional imaging studies have highlighted major modifications of cortical circuits during adolescence. These include reductions of gray matter (GM), increases in the myelination of cortico-cortical connections and changes in the architecture of large-scale cortical networks. It is currently unclear, however, how the ongoing developmental processes impact upon the folding of the cerebral cortex and how changes in gyrification relate to maturation of GM/WM-volume, thickness and surface area. In the current study, we acquired high-resolution (3 Tesla) magnetic resonance imaging (MRI) data from 79 healthy subjects (34 males and 45 females) between the ages of 12 and 23 years and performed whole brain analysis of cortical folding patterns with the gyrification index (GI). In addition to GI-values, we obtained estimates of cortical thickness, surface area, GM and white matter (WM) volume which permitted correlations with changes in gyrification. Our data show pronounced and widespread reductions in GI-values during adolescence in several cortical regions which include precentral, temporal and frontal areas. Decreases in gyrification overlap only partially with changes in the thickness, volume and surface of GM and were characterized overall by a linear developmental trajectory. Our data suggest that the observed reductions in GI-values represent an additional, important modification of the cerebral cortex during late brain maturation which may be related to cognitive development.

A 57-year-old male was referred by his general practitioner (GP) to hospital with right upper quadrant pain and a palpable mass (10 × 9 cm). He had been assessed by his GP several weeks earlier and represented as initial treatment failed. On his second presentation a mass was evident and thought to represent cholecystitis by the referring GP. However, the correct and prompt use of appropriate radiological imaging enabled swift diagnosis and management of atypical acute appendicitis through microbial specific therapy. Atypical appendicitis delays diagnosis and treatment which represents greater levels of appendiceal ischaemia and heightened perforation risk. This case study highlights the non-surgical management of acute atypical appendicitis and also reinforces the use of appropriate imaging modalities., (Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2014.)

Aim: To examine the feasibility of prospective, real-time outcome monitoring in a United Kingdom oesophago-gastric cancer surgery unit., Methods: The first 100 hybrid (laparoscopic abdominal phase, open thoracic phase) Ivor-Lewis oesophagectomies performed by a United Kingdom oesophago-gastric cancer surgery unit were assessed retrospectively using cumulative sum (CUSUM) techniques. The monitored outcome was 30-d post-operative mortality, with the accepted mortality risk defined as 5%. A variable life adjusted display (VLAD) was constructed by plotting a graph of cumulative mortality minus cumulative mortality risk on the y axis vs sequential case number on the x axis. This was modified to a zeroed VLAD by preventing the plot from crossing the y = 0 axis - essentially creating two plots, one examining trends where cumulative mortality was higher than mortality risk (i.e., worse than expected outcomes) where y > 0, and vice versa. Alert lines were set at y = ± 2. At any point where a plot breaches an alert line, it is felt that the 30-d post-operative mortality rate has deviated significantly from that expected and an internal review should be performed., Results: One hundred cases were assessed, with a mean age of 66.4 years, mean T stage of 2.1, and mean N stage of 0.48. Three cases were commenced using a laparoscopic technique and converted to open surgery due to technical factors. Median length of inpatient stay was 15 d. The crude 30 d mortality was 5% and the incidence of clinically significant anastomotic leak was 6%. The VLAD demonstrated a plot of cumulative mortality minus cumulative mortality risk (i.e., 5% per case) which remained in the range -1.4 to +0.5 excess mortalities. With the alert set at two greater or fewer than predicted mortalities, this method does not approach the point of triggering internal review. It is however arguable that a run of performance that is better than expected, causing the plot to be well below y = 0, would mask a subsequent run of poor performance by requiring a rise of greater than two excess mortalities to trigger the alert line. The zeroed VLAD removes this problem by preventing the plot that is examining above expected mortality from passing below y = 0, and vice versa. In this study period, no audit triggers were reached. It is therefore possible to independently assess runs of good, or poor performance and so target internal audit to the appropriate series of cases. It is important to note this technique allows targeted internal review, in response to both above and below average outcomes. This study has demonstrated the feasibility of prospective outcome monitoring using the above techniques, actual real-time implementation has the potential to pick up and reinforce good practices when performance is better than predicted, and provide an early warning system for when performance falls below that predicted. Further development is possible, including more patient specific risk adjustment using the oesophago-gastric surgery physiological and operative severity score for the enumeration of mortality and morbidity score., Conclusion: CUSUM techniques provide a potential method of prospective, real-time outcome monitoring in oesophageal cancer surgery.

Endoscopic mucosal resection (EMR) is increasingly being utilized in the management of early gastric cancer. Metastatic cancer of the stomach is uncommon. We report a case of solitary gastric metastasis from renal cell carcinoma (RCC) that was successfully excised with EMR. A 71-year-old man presented with iron deficiency anemia, he had undergone a radical nephrectomy for RCC 3 years previously. Upper gastrointestinal endoscopy revealed a malignant-appearing 10 × 12 mm polyp in the stomach. Histopathology of the biopsy revealed that it was a metastasis from RCC, confirmed by immunohistochemistry with Vimentin and CAM 5.2 positivity. Computed tomography and bone scanning revealed no other metastases. Simultaneous laparoscopy and upper gastrointestinal endoscopy revealed that the lesion was localized to the gastric mucosa. EMR of the tumor en bloc was performed successfully. Histology confirmed a complete excision. He had an uneventful postoperative course and is well 15 months after surgery, without any tumor recurrence.

We report a case of Fournier's gangrene, where we used the greater omentum as a free flap for scrotal reconstruction and outline the advantages over previously described methods. The greater omentum was harvested using a standard open technique. The deep inferior epigastric vessels were passed through the inguinal canal into the scrotal area as recipient vessels. The detached greater omental flap was prefabricated into a three-dimensional sac prior to inset and microvascular anastomoses. The flap was then covered by skin graft. The reconstruction had shown good early results with complete survival of the flap, as well as good functional and esthetic outcome at six months. The greater omentum can therefore be used as a free flap for scrotal reconstruction. It allows easy prefabrication and flap inset. The deep inferior epigastric vessels are also suitable recipient vessels., ((c) 2010 Wiley-Liss, Inc.)

We report a case of renal autotransplantation performed successfully for an iatrogenic ureteric injury with loss of 9 cm of ureteric length. The surgical options available for management of ureteric injuries are discussed, varying from a simple re-anastomosis to the more complex renal autotransplantation.

Renal angiomyolipomas are innocuous benign tumours which rarely behave aggressively. This is a case of a 48 year old Malay lady presenting with right sided abdominal pain associated with a large right sided abdominal mass. She was diagnosed with renal angiomyolipoma of the right kidney complicated by inferior vena caval tumour thrombosis. She successfully underwent a radical nephrectomy and inferior vena caval thrombectomy using cardiopulmonary bypass and deep hypothermic circulatory arrest.

Distant haematogenous metastasis in penile cancer is rare. A patient who had total penectomy and bilateral inguinal lymphadenectomy for penile cancer but later presented with hypercalcemia of malignancy and pathological fracture of the humerus is reported.