The affect of radiotherapy on oropharyngeal bacterial flora was studied in the hope that this might help in controlling post-operative infections in previously irradiated patients. Eighty patients were included from whom swabs were taken before and at the end of irradiation, Swabs were also taken two weeks after treatment in the last 40 patients. Thirty healthy controls were included.It was found that coagulase positive Staphylococcus aureus, β-haemolytic streptococci, Candida albicans, B. proteus, and Pseudomonas aeruginosa, were significantly increased at the end of irradiation, while Klebsiella was increased significantly in the period after irradiation. Culture and sensitivity was performed for the organisms isolated in the last 40 patients.From this study it is evident that irradiation has a significant effect on oropharyngeal flora.

The closure of a massive abdominal wall defect is illustrated using a novel dynamic closure technique - the TopClosure® tension relief system. This system attaches to the abdominal wall immediately after laparotomy and allows for early approximation of the skin, avoiding an open abdomen and the complications associated with this. The technique in this case was employed after extensive resection of the abdominal wall for infected skin metastases of colonic adenocarcinoma and circumvented post-operative ventilation and open abdomen. Early recovery after such extensive surgery is important in terms of patient morbidity and mortality. In this case, primary surgery may not have been an acceptable risk to undertake without the option of Top Closure of the abdomen. We illustrate the technique of abdominal wall closure through a series of images of the procedure.

Transanal, hybrid natural orifice translumenal endoscopic surgery (NOTES) and NOTES-assisted natural orifice specimen extraction techniques hold promise as leaders in the field of natural orifice surgery. We report the feasibility of a novel NOTES assisted technique for unlimited length, clean, endolumenal proctocolectomy in a porcine model. This technique is a modification of a transanal intussusception and pull-through procedure recently published by our group. Rectal mobilization was achieved laparoscopically; this was followed by a transanal recto-rectal intussusception and pull-through (IPT). IPT was established in a stepwise fashion. First, the proximal margin of resection was attached laparoscopically to the shaft of the anvil of an end-to-end circular stapler with a ligature around the rectum. Second, this complex was pulled transanally to produce IPT. To achieve an unlimited-length proctocolectomy, the IPT step was repeated several times prior to bowel resection. This was facilitated by removing the ligature applied in the first step of this procedure. Once sequential IPT established the desired length of bowel to be resected, a second ligature was placed around the rectum approximating the proximal and distal resection margins. The specimen was resected and extracted by making a full-thickness incision through the 2 bowel walls. The anastomosis was achieved by deploying the stapler. The technique was found to be feasible. Peritoneal samples, collected after transanal specimen extraction, did not demonstrate bacterial growth. The minimally invasive nature of this evolving technique as well as its aseptic bowel manipulation has the potential to limit the complications associated with abdominal wall incision and surgical site infection.

Multiple modalities are currently employed in the treatment of high grade dysplasia and early esophageal carcinoma. While they are the subject of ongoing investigation, surgery remains the definitive modality for oncological resection. Esophagectomy, however, is traditionally a challenging surgical procedure and carries a significant incidence of morbidity and mortality. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are considerably less invasive alternatives to esophagectomy in the diagnosis and treatment of high grade dysplasia, early esophageal squamous cell carcinoma and adenocarcinoma. However, many early esophageal cancer patients, with favorable histology, who could benefit from endoscopic resection, are referred for formal esophagectomy due to lesion characteristics such as unfavorable lesion morphology or recurrence after previous endoscopic resection. In this study we present a novel, hybrid thoracoscopic transgastric endoluminal segmental esophagectomy with primary anastomosis for the potential treatment of high grade dysplasia and early esophageal cancer in a porcine ex vivo model as a proposed bridge between endoscopic resection and the relatively high mortality and morbidity formal esophagectomy procedure. The novel technique consists of thoracoscopic esophageal mobilization in addition to transgastric endoluminal segmental esophagectomy and anastomosis utilizing a standard circular stapler. The technique was found feasible in all experimental subjects. The minimally invasive nature of this novel procedure as well as the utility of basic surgical equipment and surgical skill is an important attribute of this method and can potentially make it a treatment option for many patients who would otherwise be referred for a formal esophagectomy.

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