Regulators of G-protein signaling (RGS) proteins are GTPaseactivating proteins (GAPs) that bind to G␣ subunits and attenuate G protein signaling, but where these events occur in the cell is not yet established. Here we investigated, by immunofluorescence labeling and deconvolution analysis, the site at which endogenous G␣-interacting protein (GAIP) (RGS19) binds to G␣i3-YFP and its fate after activation of ␦-opioid receptor (DOR). In the absence of agonist, GAIP is spatially segregated from G␣i3 and DOR in clathrin-coated domains (CCPs) of the cell membrane (PM), whereas G␣i3-YPF and DOR are located in non-clathrin-coated microdomains of the PM. Upon addition of agonist, G␣i3 partially colocalizes with GAIP in CCPs at the PM. When endocytosis is blocked by expression of a dynamin mutant [dyn(K44A)], there is a striking overlap in the distribution of DOR and G␣i3-YFP with GAIP in CCPs. Moreover, G␣i3-YFP and GAIP form a coprecipitable complex. Our results support a model whereby, after agonist addition, DOR and G␣i3 move together into CCPs where G␣i3 and GAIP meet and turn off G protein signaling. Subsequently, G␣i3 returns to non-clathrin-coated microdomains of the PM, GAIP remains stably associated with CCPs, and DOR is internalized via clathrin-coated vesicles. This constitutes a novel mechanism for regulation of G␣ signaling through spatial segregation of a GAP in clathrin-coated pits.

The addition of self-administered nitrous oxide offered significant benefits in the area of patient discomfort during flexible sigmoidoscopy. The availability of this agent is useful in clinical practice and may enhance compliance with a screening programme.

Background: Current guidelines suggest that patients should undergo colonoscopy after CT confirmed acute diverticulitis to outrule colorectal cancer (CRC). The aim of this study was to determine if flexible sigmoidoscopy (FS) could be a viable alternative to full colonoscopy following acute sigmoid diverticulitis.Methods: A retrospective study of 271 patients was performed who were diagnosed with acute sigmoid diverticulitis by CT and subsequently underwent full colonoscopy. Medical records, CT reports, endoscopy reports, and histopathological reports were reviewed.Results: Sigmoid diverticulosis was confirmed on colonoscopy in all patients. No colorectal malignancies were detected. Adenomatous polyps were found in 16 (5.9%) patients, of which three had polyps detected beyond the sigmoid colon. The overall proportion of abnormalities found beyond the sigmoid colon was 1.1% (n=3). Conclusion:The detection of CRC cancer in patients undergoing full colonoscopy following an episode of acute sigmoid diverticulitis is rare. Despite this, current guidelines still advocate for endoscopy due to the potentially serious consequences of a missed malignancy. However, given that the area of concern in these cases is the sigmoid colon, FS may be a feasible means of outruling malignancy in the absence of red flag features that would necessitate a full colonoscopy. Our results support this approach, with no CRC detected and a polyp detection rate equivalent to that of the general population. This offers numerous advantages to a full colonoscopy for the patient and health service by being a quicker, cheaper, safer procedure without the need for full bowel preparation or IV sedation.

No abstract

Pilonidal sinus disease (PSD) is a chronic inflammatory condition of the skin and subcutaneous tissue that typically arises from hair follicles in the natal cleft of the sacrococcygeal region [1]. The aetiology is debated but theorised to be a result of either the obstruction and subsequent inflammation of hair follicles, or acquired from hair penetrating through the skin into subcutaneous tissue [1,2]. This results in infection, abscess formation, chronic discharge and pain [2]. It is a common problem affecting 26/100,000 of the general population, with an incidence of 1.1% in young adult males [1,3]. It is a troublesome disease for patients, with negative impact on quality of life, mood, employment and self-image [4]. It also results in a significant burden for the healthcare service, with high rates of recurrence and readmission following surgery [5].

We present a rare case of a duplicated cystic duct encountered during an elective laparoscopic cholecystectomy in a patient with biliary colic. Prompt recognition of an intraoperative bile leak followed by thorough examination and recognition of the source allowed for timely and appropriate management of the affected patient with a satisfactory post-operative outcome. Our case is unique by the lack of availability of intraoperative cholangiogram at the time of surgery, which posed a significant diagnostic and therapeutic challenge, and by how aberrant anatomy was confirmed intraoperatively by reviewing prior cardiac magnetic resonance imaging. Unremarkable preoperative imaging does not rule out the presence of abnormal anatomy. Early involvement of a specialist hepatobiliary surgeon is essential in an unexplained bile leak, with a low threshold in converting to an open procedure if there is difficulty in clearly deciphering anatomy.

Background: Surgical trainees struggle to obtain experience in laparoscopic inguinal hernia repair (LIHR) due to a perceived steep learning curve. The purpose of this study was to compare outcomes in totally extraperitoneal (TEP) repair performed by surgical consultants and trainees under supervision as part of a standardised training regimen to assess the safety of residency training in this technique. Methods: A retrospective review of patients managed by TEP repair by either a consultant or a supervised trainee was performed. Demographic, perioperative and postoperative data were collected and compared. All trainees underwent a standardised approach to teaching TEP repair. Results: Trainees performed 133 procedures and consultants performed 121 procedures. Estimated blood loss was minimal in both cohorts. A significant difference was noted in mean operating time between consultants and trainees (33 vs. 50 min). However, it was also observed that the trainee mean operating time reduced significantly with experience (from 61 to 42 min). No statistically significant difference was demonstrated in postoperative complications, recurrence rate or length of stay. All trainees achieved the ability to complete a laparoscopic TEP repair under unscrubbed consultant supervision during a 1-year placement. Conclusion:With senior supervision and in the presence of a structured training regimen, trainees can safely and effectively perform LIHR, progressing to performing the procedure under unscrubbed consultant supervision. This is valuable information that can serve to inform the structure and direction of surgical training programmes as the ability to offer LIHR is increasingly becoming an expectation of consultant surgeons.

No abstract