Radical cholecystectomy without liver resection for peritoneal side early incidental gallbladder cancer

Gallbladder cancer(GBC)is a rare disease with a poor prognosis.Simple cholecystectomy may be an adequate treatment only for very early disease(Tis,T1a),whereas reoperation is recommended for more advanced disease(T1b and T2).Radical cholecystectomy should have two fundamental objectives:To radically resect the liver parenchyma and to achieve adequate clearance of the lymph nodes.However,recent studies have shown that compared with lymph node dissection alone,liver resection does not improve survival outcomes.The oncological roles of lymphadenectomy and liver resection is distinct.Therefore,for patients with incidental GBC without liver invasion,hepatic resection is not always mandatory.

Local excision of early rectal cancer: A multi-centre experience of transanal endoscopic microsurgery from the United Kingdom

BACKGROUND Total mesorectal excision remains the gold standard for the management of rectal cancer however local excision of early rectal cancer is gaining popularity due to lower morbidity and higher acceptance by the elderly and frail patients.AIM To investigate the results of local excision of rectal cancer by transanal endoscopic microsurgery(TEMS)approach carried out at three large cancer centers in the United Kingdom.METHODS TEMS database was retrospectively reviewed to assess demographics,operative findings and post operative clinical and oncological outcomes.This is a retro-spective review of the prospective databases,which included all patients operated with TEMS approach,for early rectal cancer(Node-negative T1-T2),selected T3 in unfit/frail patients.RESULTS Two hundred and twenty-two patients underwent TEMS surgery.This included 144 males(64.9%)and 78 females(35.1%),Median age was 71 years.The median distance of the tumours from the anal verge 4.5 cm.Median tumour size was 2.6 cm.The most frequent operative position of the patient was lithotomy(32.3%),Full-thickness rectal wall excision was done in 204 patients.Median operating time was 90 minutes.Average blood loss was minimal.There were two 90-day mortalities.Complete excision of the tumour with free microscopic margins by>1mm were accomplished in 171 patients(76.7%).Salvage total mesorectal excision was performed in 42 patients(19.8%).Median disease-free survival was 65 months(range:3-146 months)(82.8%),and median overall survival was 59 months(0-146 months).CONCLUSION TEMS provides a promising option for early rectal cancers(Large adenomas-cT1/cT2N0),and selected therapy-responding cancers.Full-thickness complete excision of the tumour is mandatory to avoid jeopardising the oncological outcomes.

Robotic complete mesocolic excision for right colon cancer:Learning curve,training,techniques,approach,platforms,and future perspectives

Colon cancer has the fifth highest incidence worldwide and has the sixth highest mortality.Compared with rectal cancer,colon cancer currently has the worst 5-year overall survival for patients with stage Ⅱ and Ⅲ disease.Complete mesocolic excision has been developed as a standardized and optimized surgical technique for the excision of colon cancers.This technique has traditionally been performed through an open approach since laparoscopy is generally considered technically challenging.The robotic approach has been slowly implemented for colon cancer,but the newest robotic platforms allow for a safer and optimized approach for right colon cancer.Several robotic approaches have been developed and explored.The expansion of the current robotic platform ecosystem is gradually providing new outputs in the application of the robotic approach to complete mesocolic excision.This review gains an oversight of existing literature on robotic complete mesocolic excision for right colon cancer(learning curve,training,techniques,approach,platforms,and future perspectives).

Is there sufficient evidence to support the use of antibiotic holiday just before the second stage of an infected total hip or knee arthroplasty revision surgery?

The practice of implementing an antibiotic holiday before the second stage of hip or knee arthroplasty is currently controversial due to limited evidence for this approach,as per the International Consensus Meeting 2018 on Musculoskeletal Infection.A greater understanding of this issue could augment the quality of Alrayes and Sukeik’s mini-review(2023)on diagnosing,managing,and treating periprosthetic knee infections.However,a significant lack of literature exists concerning the optimal duration for the antibiotic holiday,calling for more research before establishing any clinical guidelines.

Urachal Cancer: Experience of a High-Volume Bladder Cancer Center

Introduction: Primary urachal cancer (UrCa) is rare, with an estimated incidence of 0.2% - 0.5% of all bladder tumors. Although the preferred treatment is surgical, there is no consensus on the best approach. We present our experience managing 14 cases of primary UrCa. Methods: A retrospective analysis was conducted on the clinical records of a high-volume bladder cancer center in the UK to identify patients diagnosed with UrCa between May 2013 and June 2022. Results: 9 males and 6 females, aged between 30 and 85 years, were included. The diagnosis was most commonly made via flexible cystoscopy and CT for haematuria. 3 patients had metastasis at presentation, and while radiologically no patients showed positive lymph nodes, 2 patients were found to have positive lymph nodes on histopathology. 13 patients underwent partial cystectomy, with 1 undergoing radical cystoprostatectomy. 8 patients underwent concurrent umbilectomy and/or lymphadenectomy. The most common histological subtype was mucinous adenocarcinoma. 2 patients experienced local recurrence and underwent transurethral resection, while 6 patients experienced metastasis. Metastasis-free survival rate was 74.1% and 55.6% at 12 and 24 months, respectively. Umbilectomy and lymphadenectomy did not decrease rates of positive surgical margin, local recurrence, metastasis, or mortality. Conclusions: UrCa is a rare and aggressive malignancy that can occur at any age and may be advanced upon presentation. Bladder-sparing surgery is becoming more prevalent, with chemotherapy being reserved for recurrence or metastasis. In our series, routine umbilectomy and lymphadenectomy did not improve oncologic outcomes. However, lymphadenectomy may have a role in cancer staging.

Is cardiac resynchronisation therapy feasible, safe and beneficial in the very elderly？

Objective To evaluate whether cardiac resynchronisation therapy （CRT） implantation was feasible and safe in octogenarians and the asso- ciation with symptoms. Methods Consecutive patients undergoing CRT implantation were recruited from two UK centers. Patients grouped according to age： 〈 80 ＆ ≥ 80 years. Baseline demographics, complications and outcomes were compared between those groups. Results A total of 439 patients were included in this study, of whom 26% were aged ≥ 80 years. Octogenarians more often received cardiac resynchronization therapy pacemaker in comparison to cardiac resynchronisation therapy-defibrillator. Upgrade from pacemaker was common in both groups （16% 〈 80 years vs. 22% ≥ 80 years, P = NS）. Co-morbidities were similarly common in both groups （overall diabetes： 25%, atrial fibrillation： 23%, hypertension： 45%）. More patient age ≥ 80 years had significant chronic kidney disease （CKD, estimated glomerular filtration rate 〈 45 mL/min per 1.73 m^2, 44% vs. 22%, P 〈 0.01 ）. Overall complication rates （any） were similar in both groups （16% vs. 17%, P = NS）. Both groups demonstrated symptomatic benefit. One-year mortality rates were almost four fold greater in octogenarians as compared with the younger cohort （13.9% vs. 3.7%, P 〈 0.01）. Conclusions CRT appears to be safe in the very elderly despite extensive co-morbidity, and in particular frequent severe CKD. Symptomatic improvement appears to be meaningful. Strategies to increase the appropriate identification of elderly patients with CHF who are potential candidates for CRT are required.

Drug therapy for heart failure in older patients —what do they want？

Chronic heart failure （CHF） is predominantly seen in older patients, and therefore real life medicine often requires the extrapolation of findings from trials conducted in much younger populations. Prescribing patterns and potential benefits in the elderly are heavily influenced by polypharmacy and co-morbid pathologies. Increasing longevity may become less relevant in the frail elderly, whereas improving quality of life （QoL） often becomes priority; the onus being on improving wellbeing, maintaining independence for longer, and delaying institution- alisation. Specific studies evaluating elderly patients with CHF are lacking and little is known regarding the tolerability and side-effect profile of evidence based drug therapies in this population. There has been recent interest on the impact of heart rate in patients with symptomatic CHF. Ivabradine, with selective heart rate lowering capabilities, is of benefit in patients with CHF and left ventricular systolic dysfunction in sinus rhythm, resulting in reduction of heart failure hospitalisation and cardiovascular death. This manuscript will focus on CHF and the older patient and will discuss the impact of heart rate, drug therapies and tolerability. It will also highlight the tmmet need for specific studies that focus on patient-centred study end points rather than mortality targets that characterise most therapeutic trials. An on-going study evalu- ating the impact of ivabradine on QoL that presents a unique opportunity to evaluate the tolerability and impact of an established therapy on a wide range of real life, older patients with CHF will be discussed.

Ivabradine tolerability in heart failure

The Systolic Heart failure treatment with the I( inhibitor ivabradine Trial (SHIFT, n = 6505) evaluated patients with symptomatic chronic heart failure (CHF), in sinus rhythm with resting heart rate ≥70 beats/min and left ventricular ejection fraction (LVEF)≤ 35%, average age 60 ± 11 years[1].

New treatments for diabetic macular edema

This work comprehensively reviews the latest treatment options for diabetic macular edema(DME) used in its management and presents further work on the topic.Diabetic retinopathy is an important and increasingly prevalent cause of preventable blindness worldwide. To meet this increasing burden there has recently been a proliferation of pharmacological therapies being used in clinical practice. A variety of medical treatment options now exist for DME. These include non-steroidal antiinflammatory drugs such as nepafenac, as well as intravitreal steroids like triamcinolone(kenalog). Longterm results up to 7 years after commencing treatment are presented for triamcinolone. Studies are reviewed on the use of dexamethasone(ozurdex) and fluocinolone(Retisert and Iluvien implants) including the FAME studies. A variety of anti-vascular endothelial growth factor(anti-VEGF) agents used in DME are considered in detail including ranibizumab(lucentis) and the RESTORE, RIDE, RISE and Diabetic Retinopathy Clinical Research Network(DRCR.net) studies. Bevacizumab(avastin) and pegaptinib(macugen) are also considered. The use of aflibercept(eylea) is reviewed including the significance of the DA VINCI, VISTA-DME, VIVIDDME and the DRCR.net studies which have recently suggested potentially greater efficacy when treating DME for aflibercept in patients with more severely reduced visual acuity at baseline. Evidence for the antiVEGF agent bevasiranib is also considered. Studies of anti-tumour necrosis factor agents like infliximab are reviewed. So are studies of other agents targeting inflammation including minocycline, rapamycin(sirolimus) and protein kinase C inhibitors such as midostaurin and ruboxistaurin. The protein kinase C β inhibitor Diabetic Macular Edema Study is considered. Other agents which have been suggested for DME are discussed including cyclo-oxygenase-2 inhibitors like celecoxib, phospholipase A2 inhibitors, recombinant erythropoietin, and monoclonal anti-interleukin antibodies such as canakinumab. The management of DME in a variety of clinical scenarios is also discussed- in newly diagnosed DME, refractory DME including after macular laser, and postoperatively after intraocular surgery. Results of long-term intravitreal triamcinolone for DME administered up to seven years after commencing treatment are considered in the context of the niche roles available for such agents in modern management of DME. This is alongside more widely used treatments available to the practitioner such as anti-VEGF agents like aflibercept(Eylea) and ranibizumab(Lucentis) which at present are the mainstay of pharmacological treatment of DME.

Advanced imaging and artificial intelligence for Barrett's esophagus:What we should and soon will do

Barrett’s esophagus(BE)is a well-established risk factor for esophageal adenocarcinoma.It is recommended that patients have regular endoscopic surveillance,with the ultimate goal of detecting early-stage neoplastic lesions before they can progress to invasive carcinoma.Detection of both dysplasia or early adenocarcinoma permits curative endoscopic treatments,and with this aim,thorough endoscopic assessment is crucial and improves outcomes.The burden of missed neoplasia in BE is still far from being negligible,likely due to inappropriate endoscopic surveillance.Over the last two decades,advanced imaging techniques,moving from traditional dye-spray chromoendoscopy to more practical virtual chromoendoscopy technologies,have been introduced with the aim to enhance neoplasia detection in BE.As witnessed in other fields,artificial intelligence(AI)has revolutionized the field of diagnostic endoscopy and is set to cover a pivotal role in BE as well.The aim of this commentary is to comprehensively summarize present evidence,recent research advances,and future perspectives regarding advanced imaging technology and AI in BE;the combination of computer-aided diagnosis to a widespread adoption of advanced imaging technologies is eagerly awaited.It will also provide a useful step-by-step approach for performing high-quality endoscopy in BE,in order to increase the diagnostic yield of endoscopy in clinical practice.

Partha Kar:科技与英国国家健康体系(NHS)--一张空头支票?

每次提到英国国家健康体系(NHS)的时候,"互用性(interoperability)""人工智能(AI)"和"科技(tech)"这些词层出不穷,但它们对于我们到底意味着什么?它们只是一些时髦的流行词,还是昙花一现的潮流?它们能否像天网,终结者及孤寂的未来世界般魔幻?或者是在暗示固守陈旧技术的NHS急需改变?一如既往,现实介于无以言表的热情与厌倦不堪的嘲弄之间。

International guideline on natural orifice specimen extraction surgery(NOSES)for colorectal cancer(2023 version)

Purpose In recent years,natural orifice specimen extraction surgery(NOSES)has gained widespread attention as an alternative approach.Although the safety and feasibility of NOSES have been well documented,many questions remain open for discussion.The aim of this guideline is to provide more evidence for the promotion of NOSES.Methods This guideline has been prepared by the CACA Committee of Colorectal Cancer Society and the International NOSES Alliance,based on the latest evidence.Results The guideline on NOSES for colorectal cancer include the definition,classification,technology requirement,indications,technical difficulties and clinical research.Conclusion The guideline provides a full introduction of the theoretical and technical aspects of NOSES for colorectal cancer which will beneficial to development of NOSES.

International consensus on natural orifice specimen extraction surgery(NOSES)for colorectal cancer

In recent years,natural orifice specimen extraction surgery(NOSES)in the treatment of colorectal cancer has attracted widespread attention.The potential benefits of NOSES including reduction in postoperative pain and wound complications,less use of postoperative analgesic,faster recovery of bowel function,shorter length of hospital stay,better cosmetic and psychological effect have been described in colorectal surgery.Despite significant decrease in surgical trauma of NOSES have been observed,the potential pitfalls of this technique have been demonstrated.Particularly,several issues including bacteriological concerns,oncological outcomes and patient selection are raised with this new technique.Therefore,it is urgent and necessary to reach a consensus as an industry guideline to standardize the implementation of NOSES in colorectal surgery.After three rounds of discussion by all members of the International Alliance of NOSES,the consensus is finally completed,which is also of great significance to the long-term progress of NOSES worldwide.

A European perspective on Digital Earth

The purpose of this paper is to contribute to the definition of a European perspective on Digital Earth(DE),identify some actions that can contribute to raise the awareness of DE in the European context and thus strengthen the European contribution to the International Society for Digital Earth(ISDE).The paper identifies opportunities and synergies with the current policy priorities in Europe(Europe 2020,Innovation Union and Digital Agenda)and highlights a number of key areas to advance the development of DE from a European perspective:(1)integrating scientific research into DE;(2)exploiting the Observation Web with human-centred sensing;and(3)governance,including the establishment of stronger linkages across the European landscape of funding streams and initiatives.The paper is offered also as a contribution to the development of this new vision of DE to be presented at the next International DE Conference in Perth,Australia,in August 2011.The global recognition of this new vision will then reinforce the European component and build a positive feedback loop for the further implementation of DE across the globe.

Partha Kar:COVID-19--现在是对糖尿病委托服务一视同仁的时候了

近期,有关COVID-19对糖尿病患者影响的数据引发了一系列讨论1。数据表明,糖尿病是COVID-19相关死亡的独立危险因素,其中1型糖尿病患者的危险性高于2型糖尿病。科学界试图破译这些结果,而糖尿病领域内的反应则从宽心到焦虑不等。

工作中照顾好我们自己:补充水分和按时用餐的重要性医院应该消除导致医生在工作日中用餐和饮水困难的任何障碍

作为医疗服务的提供者,我们很容易忘记在工作中照顾好自己。我们知道,稍作休息和规律饮水、用餐是保持"最优状态"的关键组成部分,这样有助于保持我们的能量、注意力和工作履职,并降低发生人为错误的风险。然而,在很多现代化医院中,面对现实中繁忙的工作往往难以实现。

Partha Kar: 2020年对糖尿病照护有什么意义?

我一直在思考过去十年中糖尿病照护方面的变化,以及未来十年我们可能看到的变化。2010年以来的变化简直令人震惊,无论哪一型糖尿病,治疗糖尿病的方法都发生了根本性变化。