Simon Butler-Manuel

Cerebral oedema following robotic surgery: a rare complication

IntroductionWe present an unusual complication following robotic assisted radical hysterectomy.Case reportA 51-year-old female with stage 1B1 cervical cancer underwent a robotic assisted radical hysterectomy. The procedure was prolonged with difficulties dissecting the left parametrium and vaginal fornix with persistent bleeding from the left vaginal vault. Post-operatively the patient was electively sedated and ventilated. Extubation was difficult due to patient agitation but achieved on day 2. Agitation persisted and a head CT scan was performed and a diagnosis of cerebral oedema was made.DiscussionFactors contributing to this case include prolonged operating time, prolonged Trendelenburg position with high pressures of CO2 pneumoperitoneum and excessive blood loss. These factors may contribute to poor cerebral venous outflow, increasing intracranial pressure leading to increased risk of cerebral oedema.ConclusionThe mechanics of robotic assistance may be used to reduce these risks by significantly reducing intra-abdominal pressure improving venous return.SummaryThe use of robotics in surgery has been increasing over the last 10xa0years, and the benefits have been well documented. We present an unusual complication following robotic assisted radical hysterectomy performed for cervical cancer.

HOX genes in ovarian cancer

The HOX genes are a family of homeodomain-containing transcription factors that determine cellular identity during development. Here we review a number of recent studies showing that HOX genes are strongly expressed in ovarian cancer, and that in some cases the expression of specific HOX genes is sufficient to confer a particular identity and phenotype upon cancer cells. We also review the recent advances in elucidating the different functions of HOX genes in ovarian cancer. A literature search was performed using the search terms HOX genes (including specific HOX genes), ovarian cancer and oncogenesis. Articles were accessed through searches performed in ISI Web of Knowledge, PubMed and ScienceDirect. Taken together, these studies have shown that HOX genes play a role in the oncogenesis of ovarian cancer and function in the inhibition of apoptosis, DNA repair and enhanced cell motility. The function of HOX genes in ovarian cancer oncogenesis supports their potential role as prognostic and diagnostic markers, and as therapeutic targets in this disease.

The prognostic significance of specific HOX gene expression patterns in ovarian cancer

HOX genes are vital for all aspects of mammalian growth and differentiation, and their dysregulated expression is related to ovarian carcinogenesis. The aim of the current study was to establish the prognostic value of HOX dysregulation as well as its role in platinum resistance. The potential to target HOX proteins through the HOX/PBX interaction was also explored in the context of platinum resistance. HOX gene expression was determined in ovarian cancer cell lines and primary EOCs by QPCR, and compared to expression in normal ovarian epithelium and fallopian tube tissue samples. Statistical analysis included one‐way ANOVA and t‐tests, using statistical software R and GraphPad. The analysis identified 36 of the 39 HOX genes as being overexpressed in high grade serous EOC compared to normal tissue. We detected a molecular HOX gene‐signature that predicted poor outcome. Overexpression of HOXB4 and HOXB9 was identified in high grade serous cell lines after platinum resistance developed. Targeting the HOX/PBX dimer with the HXR9 peptide enhanced the cytotoxicity of cisplatin in platinum‐resistant ovarian cancer. In conclusion, this study has shown the HOX genes are highly dysregulated in ovarian cancer with high expression of HOXA13, B6, C13, D1 and D13 being predictive of poor clinical outcome. Targeting the HOX/PBX dimer in platinum–resistant cancer represents a potentially new therapeutic option that should be further developed and tested in clinical trials.

Combined activity of oridonin and wogonin in advanced-stage ovarian cancer cells Sensitivity of ovarian cancer cells to phyto-active chemicals

The initial response rates of advanced-stage epithelial ovarian cancer to the chemotherapeutic agents carboplatin and paclitaxel are high. However, once drug resistance develops, further chemotherapy is less effective. The objective of this study is to investigate the anti-proliferative activity of the phyto-active chemicals (PACs) oridonin and wogonin in chemo-resistant epithelial ovarian cancer cells. Primary cell cultures from the ascitic fluid of three patients at diagnosis, two patients chemo-resistant to carboplatin and paclitaxel, and one patient treated with letrozole for breast cancer were studied and compared to the ovarian cancer cell lines A2780 and PTX10, by cell viability assay (MTS). Effects on cell cycle modulation and apoptosis were examined by flow cytometry and Western blot analysis (WB). WB was further conducted to investigate protein expressions altered by PACs. The results show that IC50 of the primary cultures ranged from 0.6 to 5.4xa0μg/ml for oridonin and 0.3–12.7xa0μg/ml for wogonin. The paclitaxel-resistant cell line PTX10 was more sensitive to each of the PACs than the chemo-sensitive cell line A2780. Of particular interest is that in combination, the two PACs were synergistic in their cytotoxicity to five of six of the primary cultures and to both the cell lines (combination indices of 0.39–0.95). The inhibition is attributable to apoptosis and cell cycle modulation induced by the PACs as demonstrated in A2780 and PTX10. Up-regulation of the functional p53 protein in A2780 and down-regulation of Akt protein in PTX10 have in part contributed to the apoptosis. These findings suggest that oridonin and wogonin may have activity in ovarian cancer following its development of resistance to carboplatin and paclitaxel.

First clinical experience of argon neutral plasma energy in gynaecological surgery in the UK

We describe the first in vivo use of neutral argon plasma energy in gynaecological surgery in the UK and the largest series worldwide. The use of PlasmaJet® (PJ) in different applications in 118 selected cases in a tertiary referral centre for gynaecological oncology and minimal access surgery was assessed. The effectiveness, ease of use, ergonomics and safety of PJ in gynaecological surgery is evaluated prospectively. Following this experience, we have devised a table of recommended power settings for different applications.

Robot assisted surgery in gynaecologic oncology – starting a program and initial learning curve from a UK tertiary referral centre: the Guildford perspective

The paper discusses the setup and evaluation of early data following the establishment of a robotic surgery programme in a UK gynaecological oncology cancer centre.

Prevalence of high‐grade CIN following mild dyskaryotic smears in different age groups

Objective:u2002 The new guidelines of the British Society of Colposcopy and Cervical Pathology suggest that women should be offered colposcopy after only one mildly dyskaryotic smear. This is expected to generate increased workload for the colposcopy clinics, at least in the short term. The main objective of this study was to estimate the incidence of high‐grade cervical intraepithelial neoplasia (CIN) in women with mildly dyskaryotic smears and investigate whether there is any variation in different age groups. The rationale was to determine whether we could reduce the burden on colposcopy services by prioritizing the mild dyskaryotic referrals by age, as we hypothesized that high‐grade CIN is less frequent in younger women.

Early experience of laparoscopically assisted radical vaginal hysterectomy (Coelio-Schauta) versus abdominal radical hysterectomy for early stage cervical cancer

The objective of this study was to compare outcomes of laparoscopically assisted radical vaginal hysterectomy (LARVH) vs. abdominal radical hysterectomy (RH) for early-stage cervical cancer. This is a retrospective study of all LARVH and RH procedures between January 2003 and June 2006 in our tertiary referral centre. Demographic, intraoperative and postoperative parameters in both groups were compared. Fourteen women (stage IA2–IB) underwent LARVH, and 12 women (stage IA2 to IB) had RH. All had clear excision margins. None of the laparoscopic procedures were converted into laparotomy. There have not been any recurrences in either group during the follow-up period. We conclude that LARVH and RH are equally efficacious surgical methods. The LARVH group had shorter hospital stay, reduced blood loss, shorter bladder recovery time, less postoperative complications but higher intraoperative injury rate in comparison to RH. This may reflect the learning curve of this new procedure.

Interval debulking surgery following neo-adjuvant chemotherapy for stage IVB ovarian cancer using neutral argon plasma (PlasmaJet™).

OBJECTIVEnWe present a novel surgical approach to ovarian cancer debulking using neutral argon plasma (PlasmaJet™).nnnCASE HISTORYnA 48 year-old woman diagnosed with FIGO stage IVB grade 3 serous epithelial ovarian carcinoma received three cycles of neoadjuvant chemotherapy with carboplatin and paclitaxel.nnnOPERATIVE TECHNIQUEnDissection and radical debulking surgery were performed using PlasmaJet™ as previously described [1,2]. This included diaphragmatic and abdominal peritoneal stripping, supra-colic omentectomy, tumour ablation on the small and large intestines and mesentery, pelvic and para-aortic lymphadenectomy.nnnRESULTSnThe only post-operative complication was a superficial wound breakdown, which healed by secondary intention. She remains well two years after surgery, with no sign of recurrence.nnnCONCLUSIONnIn this case, PlasmaJet™ facilitated diaphragmatic peritoneal stripping as well as dissection of tissue close to bowel and major vessels. Further study is required to assess whether this device can reduce the need for bowel resection while achieving complete cytoreduction.

Synchronous uterine artery embolization and laparoscopic myomectomy for massive uterine leiomyomas.

This report relates that preoperative uterine artery embolization and laparoscopic morcellation may be appropriate treatment for even the largest of leiomyomas. Size need not be a limiting factor for laparoscopic myomectomies.