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Human papillomavirus (HPV)-induced anal intraepithelial neoplasia (AIN, graded 1-3) is highly prevalent in HIV-positive (HIV+) men who have sex with men (MSM), but only a minority of lesions progresses to cancer. Our study aimed to characterise comprehensively anal tissue samples from a cross-sectional series (n = 104) of HIV+ MSM and longitudinal series (n = 40) of AIN2/3 progressing to cancer using different biomarkers. The cross-sectional series consisted of 8 normal, 26 AIN1, 45 AIN2, 15 AIN3 and 10 anal squamous cell carcinoma. Tissue sections were immunohistochemically (IHC) stained for p16 (viral transformation marker), Ki-67 (cellular proliferation marker) and HPV-E4 (viral production marker). We evaluated the expression of IHC markers and compared it with DNA methylation, a marker for malignant transformation. E4 positivity decreased, whereas p16 and Ki-67 scores and methylation marker positivity increased (P values .001) with increasing severity of anal lesions. Within AIN2, a heterogeneous biomarker pattern was observed concerning E4, p16 and methylation status, reflecting the biological heterogeneity of these lesions. In the longitudinal series, all AIN2/3 and carcinomas showed high p16 and Ki-67 expression, strong methylation positivity and occasional E4 positivity. We earlier showed that high methylation levels are associated with progression to cancer. The observed E4 expression in some AIN2/3 during the course of progression to cancer and absence of E4 in a considerable number of AIN1 lesions make the potential clinical significance of E4 expression difficult to interpret. Our data show that IHC biomarkers can help to characterise AIN; however, their prognostic value for cancer risk stratification, next to objective methylation analysis, appears to be limited.

Women in Surgery chair Tamzin Cuming interviews the founders of the Surviving in Scrubs website and the stories from surgeons about their experiences in the workplace.

BACKGROUND: Local recurrence is a significant risk after anal squamous cell carcinoma. OBJECTIVES: This study aimed to examine the occurrence of high-grade squamous intraepithelial lesions and local recurrence after anal cancer at surveillance with high-resolution anoscopy. DESIGN: This is a retrospective observational study. SETTING: This study was conducted at an anogenital neoplasia referral center. PATIENTS: There were 76 anal/perianal cancers from 1998 to 2018. Sixty-three patients were eligible and 3 were excluded, for a total of 60 patients; 35 of 60 (58%) patients were male. INTERVENTION: High-resolution anoscopy after chemoradiation or excision only for anal squamous cell carcinoma was performed. MAIN OUTCOME MEASURES: The primary outcomes measured were local recurrence and high-grade squamous intraepithelial lesion detection rates. RESULTS: Sixty patients, 27% HIV positive, underwent surveillance over a median 42 (range 7–240) months of follow-up. Seven had had a prior local recurrence at study entry so were analyzed separately. Thirty of 53 underwent chemoradiation (57%) and 23 of 53 underwent excision alone (43%); 33 had perianal cancer and 20 had anal cancer. Ten of 30 of the chemoradiation group had had stage 1 (33%) disease in comparison with 22 of 23 of the excision only group (96%, p < 0.001). OUTCOMES: High-grade squamous intraepithelial lesions were detected in 4 of 30 (13%) patients after chemoradiation and in 17 of 23 (74%) patients after excision only (p < 0.001). Twenty of 21 (95%) high-grade lesions were treated with ablation. Six of 7 (86%) patients with prior local recurrence had high-grade squamous intraepithelial lesions over a median of 21 months follow-up. One local recurrence (T1N0M0) occurred during surveillance after primary chemoradiation (0.56/1000 person-months), none occurred after excision only, and 2 of 7 with prior local recurrence developed further local recurrence (6.86/1000 person-months). All 3 local recurrences occurred after treatment of high-grade squamous intraepithelial lesions. There were no metastases, abdominoperineal excisions, or deaths from anal squamous cell carcinoma. LIMITATIONS: Retrospective data were used for this study. CONCLUSIONS: High-grade squamous intraepithelial lesions after anal squamous cell carcinoma are more common after excision only than after chemoradiation. Local recurrence is low in this high-resolution anoscopy surveillance group in which high-grade squamous intraepithelial disease was ablated. Excision of small perianal cancers appears safe; however, a subset of patients is at excess risk. See Video Abstract at http://links.lww.com/DCR/B285. VIGILANCIA POR ANOSCOPÍA DE ALTA RESOLUCIÓN EN CASOS DE CARCINOMA ANAL A CÉLULAS ESCAMOSAS: LA DETECCIÓN Y TRATAMIENTO DE UNA LESIÓN INTRAEPITELIAL ESCAMOSA DE ALTO GRADO (HSIL) PUEDE INFLUIR EN LA RECURRENCIA LOCAL ANTECEDENTES: La recurrencia local tiene un riesgo significativo después del carcinoma anal a células escamosas. OBJETIVO: Evaluar la aparición de lesiones intraepiteliales escamosas de alto grado (HSIL) y su recurrencia local durante la vigilancia con anoscopía de alta resolución en casos de cancer anal. DISEÑO: Estudio observacional retrospectivo. AJUSTE: Centro de referencia de neoplasia anogenital. PACIENTES: Se diagnosticaron 76 cánceres anales / perianales entre 1998 y 2018. Un total de 63 pacientes fueron elegidos, 3 excluidos (n = 60), 35/60 (58%) fueron varones. INTERVENCIÓN: Anoscopía de alta resolución después de la quimio-radioterapia, o solo excisión en casos de carcinoma anal a células escamosas. PRINCIPALES MEDIDAS DE RESULTADO: Recurrencia local primaria y tasas de detección de lesión intraepitelial escamosa de alto grado. RESULTADOS: Sesenta pacientes, 27% VIH positivos, fueron sometidos a vigilancia durante una mediana de 42 (rango 7–240) meses de seguimiento. Siete habían tenido una recurrencia local antes de ser incluidos en el estudio, por lo que se analizaron por separado. Treinta de 53 se sometieron a quimio-radioterapia (57%) y 23/53 solo a excisión (43%). 33 eran lesiones perianales, 20 de canal anal. 10/30 del grupo de quimio-radioterpia se encontraban en Fase 1 (33%) comparados con 22/23 del grupo de excisión (96%, p

Background There is currently a lack of information on full anogenital evaluation of women with a previous history of anogenital neoplasia. Methods Retrospective analysis of the Homerton Anogenital Neoplasia Service records from January 2012 to March 2017, to identify all new referrals of women with previous anogenital neoplasia, who had had at least one complete examination of all anogenital sites. Multizonal anogenital disease (MZD) was defined as the presence of high-grade squamous intraepithelial lesions (HSIL)/carcinoma concurrently at two or more of the following sites/zones: perianus, anal canal, vulva, vagina or cervix. Results 253 women were included, mean age was 47 (SD=15) years and median duration of follow-up was 12 (IQR=21) months. Fifty-six women (22%) were diagnosed with MZD at first assessment and/or during follow-up. Current smokers (RR=1.84, 95% CI 1.21–2.79, p=0.004) and women on immunodulators/immunosuppressive drugs (RR=2.57, 95% CI 1.72-3.86, pp=0.006). Conclusions Multizonal assessment was important to diagnose occult areas of disease and should be especially considered in current smokers, pharmacologically immunocompromised and those with a previous history of anogenital HSIL/cancer.

Background Information is lacking regarding anal/perianal precancerous lesions in referral cohorts of pharmacologically immunocompromised patients. Objective The aim of this study is to evaluate the prevalence of anal/perianal high-grade squamous intraepithelial lesions in a referral cohort of patients on immunomodulator/immunosuppressive medications, who were assessed and followed with high-resolution anoscopy. Design This is a retrospective study. Setting This study was conducted in a single anal neoplasia service from January 2012 to June 2017. Patients Patients on chronic immunomodulator/immunosuppressive medications were included. Cases of concomitant immunosuppression due to HIV infection were excluded, and immunosuppression due to chemotherapy was not considered for this analysis. Intervention High-resolution anoscopy was performed. Main outcome The primary outcome measured was the prevalence of anal/perianal high-grade squamous intraepithelial lesions in a referral cohort of pharmacologically immunocompromised patients. Results Fifty-four patients were included, of whom 40 were women (74%), with a mean age of 48 ± 17 years. A total of 232 high-resolution anoscopy examinations were performed in this cohort. At the first evaluation, 28 patients (52%) were diagnosed with anal and/or perianal high-grade squamous intraepithelial lesions (including 2 cases of perianal squamous cell carcinoma); 11 cases (20%) were new diagnoses. Ten of 46 patients (22%) with follow-up developed a new lesion (high-grade/cancer) during a median follow-up period of 17 (interquartile range, 6-28) months. Overall, 37 patients (69%) in our cohort had anal/perianal high-grade squamous intraepithelial lesions ever diagnosed (including previous history, first visit, and follow-up); 5 patients had perianal squamous cell carcinoma. At our center, 6% of the new referrals were known to be pharmacologically immunocompromised patients. Limitations The retrospective nature of this study, the heterogeneity of the cohort, and the absence of human papillomavirus testing were limitations of this study. Conclusions The presence of anal and/or perianal high-grade squamous intraepithelial lesions or cancer detected by high-resolution anoscopy in this referral population was high, and the detection of new lesions suggests that long-term follow-up is needed. Patients on immunomodulator/immunosuppressive drugs represented only a small percentage of the new referrals to our center. See Video Abstract at http://links.lww.com/DCR/A748.

Background Information on the performance of anal cytology in women who are high risk for human papillomavirus-related lesions and the factors that might influence cytology are largely lacking. Methods Retrospective study including all new referrals of women with a previous history of anogenital neoplasia from January 2012 to July 2017, with concomitant anal cytology and high-resolution anoscopy with or without biopsies. Results Six hundred and thirty six anal cytology samples and 323 biopsies obtained from 278 women were included. Overall sensitivity and specificity of "any abnormality" on anal cytology to predict any abnormality in histology was 47% (95% confidence interval [CI], 41%-54%) and 84% (95% CI, 73%-91%), respectively. For detecting high-grade squamous intraepithelial lesions (HSIL)/cancer, sensitivity was 71% (95% CI, 61%-79%) and specificity was 73% (95% CI, 66%-79%). There was a poor concordance between cytological and histological grades (κ = 0.147). Cytology had a higher sensitivity to predict HSIL/cancer in immunosuppressed vs nonimmunosuppressed patients (92% vs 60%, P = .002). The sensitivity for HSIL detection was higher when 2 or more quadrants were affected compared with 1 (86% vs 57%, P = .006). A previous history of vulvar HSIL/cancer (odds ratio [OR], 1.71, 1.08-2.73; P = .023), immunosuppression (OR, 1.88, 1.17-3.03; P = .009), and concomitant genital HSIL/cancer (OR, 2.51, 1.47-4.29; P = .001) were risk factors for abnormal cytology. Conclusions Women characteristics can influence the performance of anal cytology. The sensitivity for detecting anal HSIL/cancer was higher in those immunosuppressed and with more extensive disease.

Anal squamous cell cancer has a precancerous stage of high-grade squamous intraepithelial lesion (HSIL). Some centers still use the terminology of anal intraepithelial neoplasia (AIN) where HSIL covers AIN2 and AIN3. Techniques that may be used for screening to prevent anal cancer aim to detect HSIL with high sensitivity and specificity and relatively low cost. Cytology and human papillomavirus detection are currently available; however, both have insufficient sensitivity and specificity to be reliable screening techniques, especially in the highest-risk groups for anal cancer. Biomarker tests are under consideration. High resolution anoscopy (HRA) is the gold standard for detecting anal precancer lesions; however, it is expensive and labor-intensive. For these reasons, there is a lack of national screening strategies for anal cancer. Guidelines quickly become out of date in this rapidly changing field: the German-Austrian 2015 guidelines are the most current.

Mistrangelo et al raise a number of issues in connection with the International Anal Neoplasia Society guidelines for the practice of High Resolution Anoscopy (HRA) in the era of COVID‐19.The authors suggest that the guidelines advocate “mandatory” HRA for “screening”. On the contrary, the guidelines clearly define risk prioritisation, in terms of both potential COVID‐19 exposure and the dangers associated with delayed diagnosis of anal cancers.Centres without access to high quality HRA services may have to rely on digital anal rectal examination to eventually diagnose large anal cancers. HRA has the ability to accurately identify early anal cancers and worrisome pre‐cancerous lesions, and thus to facilitate early intervention. It therefore has the capacity to substantially improve survival and quality of life of patients. This remains true in the era of COVID‐19, and will be of increasing importance as the epidemic continues and services remain disrupted.

The complications of fibroids include menorrhagia, pain, urinary symptoms and subfertility. Rarer complications such as fistula formation have been reported to have occurred in the context of previ...

Background High-grade anal intraepithelial neoplasia (HGAIN; AIN2–3) is highly prevalent in HIV+ men, but only a minority of these lesions progress towards cancer. Currently, cancer progression risk cannot be established; therefore, no consensus exists on whether HGAIN should be treated. This study aimed to validate previously identified host cell DNA methylation markers for detection and cancer risk stratification of HGAIN. Methods A large independent cross-sectional series of 345 anal cancer, AIN3, AIN2, AIN1, and normal control biopsies of HIV+ men was tested for DNA methylation of 6 genes using quantitative methylation-specific PCR. We determined accuracy for detection of AIN3 and cancer (AIN3+) by univariable and multivariable logistic regression analysis, followed by leave-one-out cross-validation. Methylation levels were assessed in a series of 10 anal cancer cases with preceding HGAIN at similar anatomic locations, and compared with the cross-sectional series. Results Methylation levels of all genes increased with increasing severity of disease (P, Independent validation of host cell DNA methylation markers associated with anal carcinogenesis demonstrates their significant prognostic value for treatment decision making of high-grade anal intraepithelial neoplasia. This is further emphasised by a longitudinal analysis-based association with progression to anal cancer.

Contains fulltext : 215651.pdf (Publisher’s version ) (Open Access) OBJECTIVE: The aim of the study was to develop recommended techniques and quality assurance metrics for the practice of Digital Anal Rectal Examination (DARE). MATERIALS AND METHODS: The International Anal Neoplasia Society undertook a literature review and, using the AGREE II technique, developed guidelines for performing DARE. RESULTS: A consensus was formed regarding the optimum conditions and characteristics of DARE. Several Quality Assurance metrics were developed. CONCLUSIONS: Digital Anal Rectal Examination is a cheap and potentially universally available technique, which has the potential to facilitate the early diagnosis of anal cancers, when they are most amenable to treatment. These guidelines provide a basis for teaching the technique and may be used as for evaluation research.

The challenge of developing an identity as a surgeon educator stems from the widely differing standpoints of surgery, with its biomedical view of the world, and education in its context as a social science. We argue that a social science lens is necessary for exploring the complex educational problems that surgeons face. Various forms of faculty development exist to unite the disparate traditions of education and surgery, yet the transformation from surgeon to surgeon educator is likely to be fostered best from within a community of surgeons who also identify as educators. A surgeon educator is presented as one who is able to integrate the two world views of surgery and education, which will prove of benefit not only to those they educate but also to surgery as a whole.

Summary Background Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. Methods We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. Findings Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96–1·28). Interpretation No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. Funding National Institute for Health Research Health Services and Delivery Research Programme.

Background High resolution anoscopy (HRA) examination is regarded as the best method for the management of anal high grade squamous intraepithelial lesions to prevent anal squamous carcinoma. However, little is known about the acceptability of this procedure. This analysis looks at patient experience of HRA examination and ablative treatment under local anaesthetic. Methods Patients took part in anonymised feedback of their experience immediately after their HRA examinations and/or treatments. A standard questionnaire was used that included assessment of pain and overall satisfaction scores as well as willingness to undergo future HRA examinations. Results Four hundred four (89.4%) responses were received and all responses were analysed. The group consisted of 119 females (29.4%) and 261 males (64.6%) with median age of 45 years (IQR = 19) and 45 years (IQR = 21) respectively, and included 58 new cases, 53 treatment cases and 202 surveillance cases. 158 patients (39.1%) had at least one biopsy during their visits. The median pain score was 2 [Inter Quartile Range (IQR) 3] on a visual analogue scale of 0 to 10, where 0 indicated no pain / discomfort and 10 indicated severe pain. The median pain score was 2 (IQR 2) in men and 4 (IQR = 3) in women [Dunn’s Test = 4.3, p

ObjectivesTo define minimum standards for provision of services and clinical practice in the investigation of anal cancer precursors.MethodsAfter initial face to face meetings of experts at the International Papillomavirus meeting in Lisbon, September 17 to 21, 2015, a first version was drafted and sent to key stakeholders. A complete draft was reviewed by the Board of the International Anal Neoplasia Society (IANS) and uploaded to the IANS Web site for all members to provide comments. The final draft was ratified by the IANS Board on June 22, 2016.ResultsThe essential components of a satisfactory high-resolution anoscopy (HRA) were defined. Minimum standards of service provision, basic competencies for clinicians, and standardized descriptors were established. Quality assurance metrics proposed for practitioners included a minimum of 50 HRAs per year and identifying 20 cases or more of anal high-grade squamous intraepithelial lesions (HSILs). Technically unsatisfactory anal cytological samples at first attempt in high-risk populations should occur in less than 5% of cases. Where cytological HSIL has been found, histological HSIL should be identified in ≥ 90% of cases. Duration of HRA should be less than 15 minutes in greater than 90% of cases. Problematic pain or bleeding should be systematically collected and reported by 10% or lesser of patients.ConclusionsThese guidelines propose initial minimum competencies for the clinical practice of HRA, against which professionals can judge themselves and providers can evaluate the effectiveness of training. Once standards have been agreed upon and validated, it may be possible to develop certification methods for individual practitioners and accreditation of sites.

Laparoscopic cholecystectomy is commonly performed, and several factors increase the risk of open conversion, prolonging operating time and hospital stay. Preoperative stratification would improve consent, scheduling and identify appropriate training cases. The aim of this study was to develop a validated risk score for conversion for use in clinical practice.Preoperative patient and disease-related variables were identified from a prospective cholecystectomy database (CholeS) of 8820 patients, divided into main and validation sets. Preoperative predictors of conversion were identified by multivariable binary logistic regression. A risk score was developed and validated using a forward stepwise approach.Some 297 procedures (3.4%) were converted. The risk score was derived from six significant predictors: age (p = 0.005), sex (p 0.001), indication for surgery (p 0.001), ASA (p 0.001), thick-walled gallbladder (p = 0.040) and CBD diameter (p = 0.004). Testing the score on the validation set yielded an AUROC = 0.766 (p 0.001), and a score6 identified patients at high risk of conversion (7.1% vs. 1.2%).This validated risk score allows preoperative identification of patients at six-fold increased risk of conversion to open cholecystectomy.

Background The first experiences with endoscopic closure of esophageal perforations in animal survival studies encouraged us to extend these procedures to full-thickness resections of pieces of the esophageal wall (FTEW). Objective To learn the feasibility, safety, and long-term effects of FTEW removal and defect closure. Design Feasibility animal study. Setting Approved animal facility. Interventions Twelve pigs were used for 3-month survival studies, autopsy, and histologic examination. Resection of a 2-cm piece of wall was performed with needle-knife and forceps/snare. Closure was performed by using prototype endoscopic suturing. Main Outcome Measurements Feasibility and complication assessment of this new endoscopic method. Results There were no complications relating to incision, resection, or closure. All pigs recovered quickly. In 2 animals a larger piece of wall causing a larger defect was removed, resulting in much air penetrating into the mediastinum, causing difficult ventilation. This was resolved with thoracic drain. In 3 of 12 animals a toxic substance slipped into the mediastinum, resulting in an abscess in 1 pig and misfire of an anchor as a result of obscured vision. This caused temporary illness of the animal but not death. Autopsy and histologic study confirmed no mediastinitis and well-healed scars in all but one. Limitation Animal study. Conclusion FTEW has proven to be feasible. Long-term survival demonstrated no mediastinitis and only 1 abscess after contamination of the mediastinum. These first experiences encourage further animal studies because the prospect of endoscopic full-thickness removal of esophageal lesions in patients might be very advantageous.

BACKGROUND AND STUDY AIMS: Natural-orifice transluminal endoscopic surgery (NOTES) is in the developmental stage for various indications, but several obstacles remain to be overcome before NOTES procedures can come into routine clinical use. Of these obstacles, (1) transluminal injury due to exclusive use of endoluminal endoscopy to create the incision and (2) lack of orientation might be prevented by employing endoscopic ultrasound guidance. In this comparative study we assessed the role of endoscopic ultrasound guidance in various NOTES procedures. METHODS: Three transesophageal (mediastinoscopy/thoracoscopy) or transgastric procedures (gastrojejunostomy, adrenal gland removal) were performed in pigs using NOTES alone or with endoscopic ultrasound guidance (EUS). In NOTES alone the study end point was three major complications, at which point EUS guidance was added for the same procedures up to the same number of cases. The primary outcome was the rate of major complications; secondary outcome parameters were all complications and technical success. RESULTS: Forty-six pigs were included. Three major complications occurred in the first 24 NOTES-alone procedures: these were bleeding and organ injury, all during mediastinoscopy/thoracoscopy procedures. Adrenal gland removal failed in all procedures in which it was attempted, while gastrojejunostomy (n = 6) was performed successfully and without complications. In the next 22 animals EUS guidance enabled safe mediastinal access (n = 10) and adrenal gland removal (n = 6). For gastrojejunostomy, EUS guidance offered no additional benefit. CONCLUSIONS: EUS guidance appears to be helpful in gaining access or identifying structures in anatomically difficult areas in NOTES procedures.

Interventional endoscopies entail a risk of infection secondary to perforation of the luminal wall. Thereby, bacteria may be introduced into the sterile environment of the peritoneal cavity (PC). Limited data are available regarding the efficacy of prophylactic anti-infective treatments. The aim of the study was to examine the efficacy/safety of anti-infective means in the prevention of infection by interventional endoscopies in a randomized controlled animal trial. Forty pigs were randomized to: 1: control; 2: oral lavage; 3: gastric lavage; 4: oral/gastric lavage; 5: i.m. antibiotics. Lavage was performed with Octenisept prior to the operation. After gastric wall perforation, peritoneoscopy was performed. Before the procedure, after closure and prior to autopsy, intraabdominal lavage for bacterial culture was taken using mini-laparoscopy. At autopsy, macroscopic appearance of the PC was scored. Lavage fluids were grown to identify/quantify bacterial load. Concentration of intraperitoneal bacteria at autopsy was defined as main outcome parameter. No major complications occurred in any of the procedures. Bacterial load of the PC at autopsy was significantly reduced with antibiotics compared to all other groups, whereas it did not differ between the lavage groups and control. Macroscopic scoring of the PC showed significant lower rate of intraabdominal abscesses in the antibiotic group compared to the lavage groups and control (p

Patients with conditions affecting the perianal skin present to various clinics, from proctology to sexual health to general practice. The boundaries of such specialties as dermatology, infectious disease and gastrointestinal surgery are crossed by the range of diagnoses that underlie complaints in the perianal region. The problem may be local to the area, be an indication of intestinal disease or represent a manifestation of a generalized dermatological disorder. In the latter case, it is notable that the moist and warm environment of the perianal region often produces differing appearances to those characteristic of the disease elsewhere.

Background and study aims: In cases where biopsies remain inconclusive, removal of mediastinal lymph nodes for further analysis requires surgical means. Natural orifice transluminal endoscopic surgery (NOTES) procedures allow incision/closure of the gut wall, which might enable endoscopic excision of pre-marked nodes. The aims of the current study were to investigate the feasibility, safety, and reproducibility of lymph node generation in an animal model to enable endoscopic ultrasound-guided (EUS) lymph node removal (ELR) using transesophageal NOTES access/closure and to compare this procedure with thoracoscopic lymph node removal (TLR) in a randomized long term survival animal study. Patients and methods: Lymph node creation using graphite injection was performed in 12 pigs. After randomization into ELR and TLR groups, lymph nodes were marked with newly developed anchors under EUS guidance and removed using either ELR or TLR. ELR included incision of the esophageal wall and closure after lymph node removal. The main outcome measures were success in lymph node generation, technical success of lymph node removal, complications, and comparability of ELR and TLR. Results: Generation of lymph nodes proved successful in all animals in 46 /48 sites injected (96 %). Anchors were placed through the selected nodes in a mean of 9.4 minutes. TLR and ELR were successful in all cases. One bleeding occurred during esophageal incision in ELR, which was stopped endoscopically. After lymph node removal, endoscopic suturing of the incision took a mean of 18 minutes. Procedure time was longer for ELR than TLR (mean 48 vs. 42 minutes). All animals survived the procedures. Autopsy after 4 weeks showed two thoracic wall abscesses in the TLR group and none in the ELR group. Microscopic analysis revealed well healed esophageal scars. Conclusion: ELR proved to be feasible in this limited sample size and complications were not observed more frequently in this group than in the TLR group.

BACKGROUND AND STUDY AIMS Natural orifice transluminal endoscopic surgery (NOTES) has not yet been widely adopted because of lack of suitable equipment and fear of possible serious complications, especially in the mediastinum. We compared endoscopic with thoracoscopic esophageal wall repair after full-thickness esophageal wall incision (FTEI) and NOTES mediastinoscopy in healthy versus compromised animals. METHODS After FTEI for mediastinoscopy, 24 pigs (12 healthy, 12 compromised) were randomly allocated to endoscopic or thoracoscopic repair (each arm of each group, n = 6). They were kept alive for 3 months after endoscopic closure with prototype T-anchor suturing or thoracoscopic repair. RESULTS FTEI and mediastinoscopy were uneventful in all as was the initial repair of the incision (mean repair times: thoracoscopic 65 +/- 3.2 minutes, endoscopic 52 +/- 5.1 minutes; P < 0.0005). Post procedure, all 12 healthy pigs thrived with no complications or deaths. Two compromised animals died during the preparation period, and had to be replaced. In the compromised group, during endoscopic repair, 2 / 6 pigs suffered from gastric reflux into esophagus and mediastinum; the repair was completed and the pigs kept alive; one subsequently died of mediastinitis, and in the other, autopsy showed a gastric abscess in the lower mediastinum. Regarding the compromised thoracoscopic subgroup, one animal died from mediastinitis and all had abscesses at or near the incision sites. CONCLUSION Transesophageal mediastinoscopy could be performed equally well as the transthoracic procedure, both in healthy and compromised animals. However, on follow-up, the compromised animals had worse outcomes, with more complications and two deaths (17 %), one in each arm.

Charing Cross Hospital, London. High up on the 12th level, the city’s anatomy is spread out in the November sun. We merely glance at the view as we wait, full of anticipation, for the students to arrive. We are leading an experimental workshop for some 25 undergraduate medical students. They are unaware of just how experimental it is, hence our nerves. Imperial College’s medical school dictates that students must undertake a bachelor of science degree in their fourth year. The students we are meeting today will have worked hard to earn a place on the coveted surgery pathway. Ten minutes later, the same room is a alive with eager activity as the students funnel in to don gloves, gowns and masks in readiness for carrying out a dissection. They have listened restlessly through the laboratory technician’s briefing on safe use of sharps and are now keen to get going. It is early in their surgical pathway, and they have not had much practice with the knife. The students pair up around the tables, which are adorned with draped, stainless steel trays. Here is a hint that all is not as expected, because the smell is not that of formalin, but of something more reminiscent of a market stall. A student tentatively lifts the drape on her tray. She giggles nervously. Beneath is a glistening, fragrant fig. The other students follow suit to reveal an incongruous variety of exotic fruits: guavas, dragon fruit, blood oranges, papayas, grapefruit, kiwi fruit, quinces, pomegranates… We scan their faces surreptitiously. Are they disappointed at not encountering human remains? Already they are unlike the rest of the population in that fruit is more disconcerting for them here than an eyeball or dead dogfish. We quell the sudden chatter by introducing ourselves. Tamzin is a colorectal surgeon at the senior resident level with an interest in education. Giskin is course leader of the Medical Humanities elective. We explain that we are here for a taster session (at which the students titter) for a course in medical humanities that they may wish to take. The students look blank. What is medical humanities? ‘It's a discipline that explores the social and cultural context of medicine’, Giskin explains. ‘This means looking at how medicine is represented in art, literature and the media, and how these in turn affect medicine—how they affect you’. Today, we ask the students to dissect their fruit in an ‘aesthetically pleasing’ way. One objective is to practise their dissection skills (health and safety guidelines specify that a non-touch technique be used, resulting in the fruit being taped to the trays). However, our main aim is to give them the opportunity to think about the art of observation and description. We have asked them to describe in detail what they encounter, avoiding naming the fruit. The reaction in the room varies. Most are keen to start, but others are sceptical, cynical or merely baffled. They suspect an elaborate practical joke. But the dissection gets underway and the students begin to enjoy wielding their scalpels and debating the form their dissection will take. We circulate, giving encouragement. Tamzin dispenses technical advice, while we enjoy a bit of banter as everyone starts to relax. We eavesdrop on how students are describing their observations. Most are focusing purely on what the fruit looks like. We suggest using all their senses. What does it sound like as the scalpel penetrates the fruit? What does it smell like? What is the texture of the pulp? We provide extra fruit for students to taste, as the dissecting trays have been washed but not sterilised, and no one wants to risk inadvertent cannibalism by ingesting so much as a particle of a cadaver. As pairs of students finish disassembling and sometimes reassembling their fruit into miniature sculptures or fleshy mosiacs, a second, more taxing, worksheet is handed out. This time, they are asked to undertake an exercise in vicarious synesthesia. As a medical phenomenon, synethesia is a neurological condition in which individuals experience cross-sensory perceptions, such as hearing sounds as colors or perceiving colors as taste sensations.1 We ask the students to use color words to describe the smell of their fruit, to use touch words to describe what their fruit looks like and taste words to describe its texture. This is challenging. Students with exotic fruits tend to find it easier to reach for new metaphors than those with familiar fruits, their characterisation shaped by pre-existing information. One student looks at the sheet and declaims, ‘Hey, this is really thinking outside the box!’ The works of art are gathered and displayed. Some are fruity versions of ecorche: the skin of a persimmon exquisitely pared into a spiral and artistically draped over the naked flesh. A disembowelled carambola has its parts arranged to make a portrait. A custard apple has been playfully transformed into a cartoon character. Tamzin reads aloud from the worksheets, and there is much mirth as students attempt to match the description to the dissection. The usual boundaries have been breached. Some use violent language or sexual images, like this description of dissecting chicory: ‘The swan cooed with pleasure as the scalpel slid down its soft, silky belly. But as we ripped it open and tore out its heart, it cried in agony’. Many are humorous, like this description of the dissection of a butternut squash: ‘An individual unhappy with his appearance had his facial features cosmetically enhanced. We achieved this using cutting-edge surgical techniques and skin grafting methods. He now looks like a happy, healthy pumpkin’. There is a short break in which students mill around the ‘exhibits’, consuming the remaining edible fruit. The session now takes a cultural turn. We introduce them to doctor-writer William Carlos William’s poem ‘This is Just to Say’.2 After a brief discussion of the poem (what makes it a poem? how do the sounds contribute to the meaning? what themes emerge from it?), Tamzin explains how poetry was a coping strategy for her during her intern year at a time of long hours and high stress. She and a literary-minded fellow student would leave snippets of poetry for each other on ward-doctor desks a floor apart in an increasingly competitive round of quotations, from Shakespeare (‘Th’expense of spirit in a waste of shame/Is lust in action’)3 to Bob Dylan and Louis MacNeice. It evolved from a need to deal, Tamzin tells them, in the compressed time that we have, with seeing so much so quickly in those first few months. Maybe it prevented burnout and depression. Maybe it just provided support. Tamzin literally ‘found’ poems that her friend left for her. But ‘found poetry’ is also text lifted from its usual context and re-presented as a poem, much like William Carlos Williams’s poem could be ‘found’ taped to the fridge. Medicine is a particularly fertile source of found poetry. Tom Hansen, poet, describes medical jargon as being ‘striking to the ear and the aural imagination’. He attributes its ‘accidental richness’ to its heavily Latinate diction that ‘strikes us as being both strange (a foreign language) and strangely familiar (the family resemblance of an ancient forebear)’.4 The students are introduced to the poem ‘Relic’ by Paul Farley in which his dental records are made lyrical,5 and Vernon Rowe’s ‘MRI of a poet’s brain’, which revels in the anatomical terminology of the brain, only to subvert this with the observation that the intricate image shows ‘but not even/a single syllable/of one/tiny/poem’.6 We round off the session by inviting students to write their own poems by ‘finding’ poetry in a medical text. They are gratifyingly willing to try this, and many read them out. Most are insightful and thoughtful. One is an hilarious rap lyric. Had we signalled in advance they would be expected to sculpt fruit and write a poem, it is doubtful whether more than a handful of students would have turned up. But now they leak out of the lecture theatre in chattering groups, having surprised themselves by their own creativity. Hopefully, we will have awakened in them an awareness that using all one’s senses is important in medicine. Most of these students have had no choice but to abandon humanities subjects at high school in order accumulate the necessary science qualifications to allow them entry into medical school. And, although medical jargon can seem intimidating and impenetrable, it has a lyrical quality. They will understand this now, as they seek to master its use. We hope that we have showed that the humanities provide us with creative opportunities that complement the logic of science and encourage innovative thinking. Above all, medicine is a creative profession.