Patient experiences of left-sided colorectal resection by robotic, conventional laparoscopic and open approaches: a qualitative study.

BACKGROUND: Robotic surgery (RS) is increasingly employed in colorectal surgical practice, widening the range of surgical techniques offered to patients. We investigated the perceptions of patients with colorectal cancer in relation to RS, open surgery (OS) and conventional laparoscopic surgery (CLS), to identify ideas or assumptions which, in the context of shared surgeon-patient decision-making, may affect the resultant choice of surgical technique. We also investigated salient factors affecting patients' perioperative experience, including those of RS patients, to guide improvements in care and preoperative patient preparation. METHODS: This study was conducted on patients who underwent resection of left-sided colorectal cancer at a large UK teaching hospital from November 2020 to July 2021. Purposive sampling was used to ensure a roughly equal proportion of patients who underwent RS, CLS and OS. The patients included in the study participated in semi-structured interviews six weeks postoperatively. The interview schedule allowed discussion around patients' experience of their surgery and postoperative recovery, and their perceptions of surgical techniques. Interview transcripts were coded manually using inductive thematic analysis, and analyst triangulation was employed to refine coding schemes and ensure reliability of emerging themes. RESULTS: Twenty-seven patients were recruited to the study; RS n = 9 (median age 69 [range 60-80] years); CLS n = 10 (median age 72 [range 32-82] years; OS n = 8 (median age 71 [range 60-75] years). Patients understood the technological benefits of RS but were concerned by a risk of technological failure causing patient harm. OS was understood to be associated with more pain and longer recovery than RS or CLS. Patients perceived CLS to be more technically challenging compared with OS. Less pain and smaller wounds than expected were significant positive factors in the experience of RS and CLS patients specifically. Complications and emotional impact were significant factors in the experience of all groups, for which many patients felt underprepared. CONCLUSIONS: Patients generally have a positive view of RS and technical innovation in surgery. Concerns mostly centred around failure of technology. Many patients felt unprepared for significant factors in their perioperative experience. Surgeons and healthcare providers should be prepared to address patients' perceptions and expectations of colorectal surgery preoperatively.

Comparison of robotic vs laparoscopic left-sided colorectal cancer resections.

Robotic assisted surgery (RAS) has become increasingly adopted in colorectal cancer surgery. This study aims to compare robotic and laparoscopic approaches to left sided colorectal resections in terms of surgical outcomeswith no formal enhanced recovery programme. All patients undergoing robotic or laparoscopic left sided or rectal (high and low anterior resection) cancer surgery at a single tertiary referral centre over 3 years were included.A total of 184 consecutive patients from July 2017 to December 2020 were included in this study, with 40.2% (n=74/184) undergoing RAS. The median age at time of surgery was 68 years (IQR 60-73 years). RAS had a significantly shorter length of median stay of 3 days, compared to 5 days in the conventional laparoscopic surgery (CLS) group (p<0.001). RAS had a significantly lower rate of conversion to open surgery (0% vs 16.4%, p<0.001). The median operative time was also shorter in RAS (308 minutes), compared to CLS (326 minutes, p=0.019). The overall rate of any complication was 16.8%, with the RAS experiencing a lower complication rate (12.2% vs 20.0%, p=0.041). There was no significant difference in anastomotic leak rates between the two groups (4.0% vs 5.5%, p=0.673), or in terms of complete resection (R0) (robotic 98.6%, laparoscopic 100%, p=0.095). Robotic left sided colorectal surgery delivers equivalent oncological resection compared to laparoscopic approaches, with the added benefits of reduced length of stay and lower rates of conversion to open surgery. This has both clinical and healthcare economic benefits.

Co-Registered In Situ Secondary Electron and Mass Spectral Imaging on the Helium Ion Microscope Demonstrated Using Lithium Titanate and Magnesium Oxide Nanoparticles.

The development of a high resolution elemental imaging platform combining coregistered secondary ion mass spectrometry and high resolution secondary electron imaging is reported. The basic instrument setup and operation are discussed and in situ image correlation is demonstrated on a lithium titanate and magnesium oxide nanoparticle mixture. The instrument uses both helium and neon ion beams generated by a gas field ion source to irradiate the sample. Both secondary electrons and secondary ions may be detected. Secondary ion mass spectrometry (SIMS) is performed using an in-house developed double focusing magnetic sector spectrometer with parallel detection. Spatial resolutions of 10 nm have been obtained in SIMS mode. Both the secondary electron and SIMS image data are very surface sensitive and have approximately the same information depth. While the spatial resolutions are approximately a factor of 10 different, switching between the different images modes may be done in situ and extremely rapidly, allowing for simple imaging of the same region of interest and excellent coregistration of data sets. The ability to correlate mass spectral images on the 10 nm scale with secondary electron images on the nanometer scale in situ has the potential to provide a step change in our understanding of nanoscale phenomena in fields from materials science to life science.

High-resolution high-sensitivity elemental imaging by secondary ion mass spectrometry: from traditional 2D and 3D imaging to correlative microscopy.

Secondary ion mass spectrometry (SIMS) constitutes an extremely sensitive technique for imaging surfaces in 2D and 3D. Apart from its excellent sensitivity and high lateral resolution (50 nm on state-of-the-art SIMS instruments), advantages of SIMS include high dynamic range and the ability to differentiate between isotopes. This paper first reviews the underlying principles of SIMS as well as the performance and applications of 2D and 3D SIMS elemental imaging. The prospects for further improving the capabilities of SIMS imaging are discussed. The lateral resolution in SIMS imaging when using the microprobe mode is limited by (i) the ion probe size, which is dependent on the brightness of the primary ion source, the quality of the optics of the primary ion column and the electric fields in the near sample region used to extract secondary ions; (ii) the sensitivity of the analysis as a reasonable secondary ion signal, which must be detected from very tiny voxel sizes and thus from a very limited number of sputtered atoms; and (iii) the physical dimensions of the collision cascade determining the origin of the sputtered ions with respect to the impact site of the incident primary ion probe. One interesting prospect is the use of SIMS-based correlative microscopy. In this approach SIMS is combined with various high-resolution microscopy techniques, so that elemental/chemical information at the highest sensitivity can be obtained with SIMS, while excellent spatial resolution is provided by overlaying the SIMS images with high-resolution images obtained by these microscopy techniques. Examples of this approach are given by presenting in situ combinations of SIMS with transmission electron microscopy (TEM), helium ion microscopy (HIM) and scanning probe microscopy (SPM).

Psychological needs of adult patients following renal transplantation and implications for care.

Previous work undertaken by the author has detailed factors that are known to contribute to psychological reactions experienced post renal transplantation by the recipient (Dowsett, 1991). Such information has thus prompted a more detailed investigation into identifying the emotional and psychological needs of adult renal transplant recipients and to establish whether the care received from health professionals and significant others is meeting the needs of these patients following renal transplantation.

Renal haemodynamics and prostaglandin synthesis in partial unilateral ureteric obstruction.

Haemodynamic changes in partial unilateral ureteric obstruction (PUUO) may be related to altered prostaglandin synthesis. In 12 dogs the left ureter was partially obstructed for 5 weeks. In six dogs the ureter was reimplanted into the bladder and to investigate the effect of this procedure on the contralateral side the other six animals underwent ipsilateral nephroureterectomy. Renal blood flow (RBF) was measured by the distribution of radiolabelled microspheres. Changes in urinary prostaglandin (PG) concentrations were validated by renin activity using angiotensin I. Reduced left RBF during obstruction was associated with increased thromboxane A2 synthesis (P < 0.01). Increased RBF to the non-obstructed side was associated with elevated PGE2 formation (P < 0.05). Elevated angiotensin I levels (P < 0.01) corresponded to maximal increases in PG synthesis. Reimplantation of the obstructed kidney did not exert a direct effect on contralateral RBF or PG concentration. Haemodynamic changes in PUUO in vivo are associated with alterations in renal PGs.

A comparison of SPECT and planar ventilation perfusion lung scanning.

In order to define the role of Single Photon Emission Computed Tomography (SPECT) in the diagnosis of pulmonary embolus; SPECT and Planar ventilation and perfusion lung studies were performed consecutively on eleven patients referred with suspected embolus. Three patients were shown to have 'high probability' ventilation perfusion mismatches. SPECT imaging allowed segmental localisation of the perfusion defect and revealed additional defects not seen on planar scans. SPECT lung study was performed with minimal technical difficulty and was well tolerated by all patients studied. SPECT is likely to become the method of choice for investigating patients referred with suspected pulmonary embolus.

Assessment of mammographic film processor performance in a hospital and mobile screening unit.

In contrast to the majority of mammographic breast screening programmes, film processing at this centre occurs on site in both hospital and mobile trailer units. Initial (1989) quality control (QC) sensitometric tests revealed a large variation in film processor performance in the mobile unit. The clinical significance of these variations was assessed and acceptance limits for processor performance determined. Abnormal mammograms were used as reference material and copied using high definition 35 mm film over a range of exposure settings. The copies were than matched with QC film density variation from the mobile unit. All films were subsequently ranked for spatial and contrast resolution. Optimal values for processing time of 2 min (equivalent to film transit time 3 min and developer time 46 s) and temperature of 36 degrees C were obtained. The widespread anomaly of reporting film transit time as processing time is highlighted. Use of mammogram copies as a means of measuring the influence of film processor variation is advocated. Careful monitoring of the mobile unit film processor performance has produced stable quality comparable with the hospital based unit. The advantages of on site film processing are outlined. The addition of a sensitometric step wedge to all mammography film stock as a means of assessing image quality is recommended.

Peripheral arteriovenous malformation: diagnosis and localization by intraarterial injection of technetium-99m-MAA.

Radionuclide angiography with technetium-99m-labeled macroaggregates of albumin (99mTc-MAA), was successful in a single patient with a lower limb arteriovenous (AV) malformation, not only in diagnosis and quantitation of AV shunting, but also in localizing the site of shunting. This information proved useful to the angiographer, permitting a carefully tailored examination of the area of interest. This technique may hold promise as a preliminary examination in patients with limb AV malformations prior to angiography.

Gold-195m: a steady-state imaging agent for venography that gives blood velocity measurement.

Gold-195m has found applications in first-pass studies for investigating both right and left ventricular activity as well as lung transit. Owing to its reasonably short half-life of 30 sec we have found it particularly useful for imaging leg veins up to and including the inferior vena cava. Its short half-life prevents recirculation activity from appearing, so continuous perfusion into a superficial foot vein and application of ankle tourniquets yield a steady-state image of the deep veins, with particularly good resolution. Its decay pattern along a vessel is very sensitive to blood velocity, so measurement of activity at various points on a vein in a computer static image can give velocity values that reveal abnormalities due to partial or complete thrombosis. The radiation dosimetry of 195mAu used in this way is lower than contrast and technetium-99m macroaggregated albumin [( 99mTc]MAA) venography, making it particularly useful for investigating deep vein thrombosis (DVT) in pregnancy.

Abnormal cardiac enzyme responses after strenuous exercise: alternative diagnostic aids.

Serial estimations of activities of creatine kinase and its MB isoenzyme, aspartate aminotransferase, alanine aminotransferase, and lactate dehydrogenase and of concentrations of alpha(1)-acid glycoprotein were performed in 15 healthy well-trained male marathon runners. Estimations were made initially within three days before a race and then one, 24, and 96 hours after the race. Technetium-99m pyrophosphate myocardial scintigraphy was carried out at the initial prerace assessment and repeated 48 to 96 hours after the race. None of the subjects developed cardiac symptoms during or after the race.Activities of creatine kinase and creatine kinase MB became maximal 24 hours after the race. One and 96 hours after the race two and five subjects, respectively, showed amounts of creatine kinase MB totalling 5% or more of total creatine kinase. Lactate dehydrogenase activity peaked at one hour after the race, and activities of aspartate and alanine aminotransferases peaked at 24 and 96 hours after the race, respectively. Activities of all these enzymes showed a significant increase from prerace values during the rest of the study. Electrocardiographic features noted were similar to those reported elsewhere in athletes under similar conditions. They included first-degree heart block, incomplete right bundle-branch block, left ventricular hypertrophy, pseudoischaemic T-wave changes, and early repolarisation of variant ST-segment elevations in precordial leads. Technetium-99m pyrophosphate myocardial scintigraphy did not show evidence of myocardial damage before or after the race. Alpha(1)-acid glycoprotein concentrations were normal throughout.These data suggest that reliance on standard enzyme estimations and electrocardiographic criteria may yield false-positive indicators of myocardial injury during prolonged strenuous exercise. Technetium-99m pyrophosphate scintigraphy and alpha(1)-acid glycoprotein measurements offer additional information and may usefully be employed in evaluating circulatory collapse associated with such exercise.

A comparison between monodisperse Tc-99m-labeled aerosol particles and Kr-81m for the assessment of lung function.

A quantitative method for study of the penetration and clearance of inhaled particles (5-micron Tc-99m-labeled polystyrene) in the human lung is described and compared with a Kr-81m technique for ventilation imaging. Volunteer healthy subjects and patients with chronic obstructive airway disease (COAD) were studied. Following inhalation of radioaerosol, data were recorded by a gamma-camera/computer system over a period of 6 hr. An aerosol penetration index (API) measures the proportion of aerosol reaching the peripheral region of the lung relative to that deposited in the larger central airways. A significant difference in the mean values of API for both groups was observed. Aerosol clearance rates from the whole lung and from central, intermediate and peripheral compartments of each lung field were studied. The healthy group showed a total clearance rate consistent with data from earlier work; the patients with COAD showed no clearance over the same period. Some healthy subjects were smokers, and differences in their penetration and clearance rates were evident, in spite of normal results from their conventional pulmonary function tests and Kr-81m ventilation studies. The aerosol technique, if carefully controlled, can be a more sensitive index for early lung abnormality than Kr-81m ventilation imaging.

Femoral head activity in Perthes' disease: clinical evaluation of a quantitative technique for estimating tracer uptake.

A method for quantifying the uptake of Tc-99m-labeled phosphate complexes in the femoral head has been clinically evaluated, being used specifically for studying the uptake of these bone-seeking agents in Perthes' disease. The analysis depends on the selection, by computer program, of a reliable reference area in the femoral shaft, which is then compared with the mean uptake from each femoral head. The femoral-head activity is then represented as an uptake ratio. These ratios, together with a fixed contour representing the uptake in the femoral-head regions, provide more clinical information than the radiograph or scintiphoto, particularly in the early stages of unilateral or bilateral femoral-head disease and during followup. No correlation has been found between these ratios and qualitative techniques for assessing Perthes' disease by radiograph. From the quantitative data so far obtained it is clear that osteotomy reduces the vascularity of the femoral head, and in certain cases this reduction persists for some years. Tc-99m-labeled diphosphonate compounds were used in more recent studies, and a significant increase in sensitivity was obtained, compared with earlier polyphosphate data.