Preceptorship in robotic colorectal surgery: experience from the Australian private sector.

This article describes a post-fellowship preceptorship training program to train sub-specialty colorectal surgeons in gaining proficiency in robotic colorectal surgery using a dual-surgeon model in the Australian private sector. The Australian colorectal surgeon faces challenges in gaining robotic colorectal surgery proficiency with limited exposure and experience in the public setting where the majority of general and colorectal surgery training is currently conducted. This training model uses graded exposure with a range of simulation training, wet lab training, and clinical operative cases to progress through both competency and proficiency in robotic colorectal surgery which is mutually beneficial to surgeons and patients alike. Ongoing audit of practice has shown no adverse impacts.

The National Aeronautics and Space Administration-task load index: NASA-TLX: evaluation of its use in surgery.

BACKGROUND: The technical difficulty an operation creates for a surgeon is difficult to measure. Current measures are poor surrogates. In both research and teaching settings it would be valuable to be able to accurately measure this degree of difficulty. The National Aeronautics and Space Administration Task Load Index (NASA TLX) is a multi-dimensional scale designed to obtain workload estimates relating to a task. This study aimed to evaluate the NASA TLX as an objective measure of technical difficulty of an operation. METHODS: Seven surgeons performed 127 pre-defined operations (minimally invasive right hemicolectomy & re-do bariatric surgery) and recorded a NASA TLX score after each operation. These scores were compared to numerous clinical parameters and the score was correlated with the subjective measure of whether the surgeon categorized the operation as "easy", "moderate" or "difficult". RESULTS: The NASA TLX score was significantly correlated with operative duration, blood loss, previous abdominal surgery and the surgeons' assessment of difficulty. It did not correlate with intra-operative or post-operative complications, conversion to open surgery or length of stay. CONCLUSIONS: The NASA TLX score provides a graded numerical score that that correlated significantly with the surgeon's assessment of the technical difficulty, and with operative duration, intra-operative blood loss and previous abdominal surgery. This novel application of this tool could be employed in both research and teaching settings to score surgical difficulty and monitor a trainee's proficiency over time.

Medullary colorectal carcinoma revisited: a clinical and pathological study of 102 cases.

AIM: Medullary carcinoma is a recently described subtype of mismatch repair deficient (MMRd) colorectal carcinoma (CRC) which, despite being poorly differentiated by traditional morphological criteria, has been reported to have a good prognosis. We investigated the pathological and clinical features of medullary CRC in an unselected cohort of CRCs undergoing surgical resection. METHODS: All CRCs resected within a single health district database from 1998 to 2012 were categorized prospectively and underwent retrospective review to identify 91 medullary CRCs, with 11 additional cases from 2013 to 2014. Strict criteria were employed to diagnose medullary carcinoma requiring both MMRd and greater than 90 % of the tumor to demonstrate typical morphology, including solid growth. The demographic and pathological features, as well as all-cause survival, were compared with other CRCs, and specifically to other MMRd CRCs. RESULTS: From 1998 to 2012, 91 of 3,295 CRCs (2.8 %) were of the medullary type. Medullary CRC was more likely to arise in females than males (3.3:1; p < 0.0001), the elderly (mean age 77 vs. 71 years; p < 0.001), and the right colon (86 %; p < 0.0001). All medullary CRCs demonstrated MMR deficiency (considered an inclusion criteria) and 86 % were BRAFV600E-mutated (p < 0.0001). Thirty-day mortality after resection was higher in medullary CRC (4.6 vs. 1.7 %; p = 0.049). On univariate analysis, survival was not better than well-differentiated or other MMRd tumors. However, using a multivariate model, a medullary phenotype was protective (hazard ratio of death 0.54, 95 % CI 0.30-0.96; p = 0.037). CONCLUSIONS: Medullary CRC is more common than previously reported, frequently presents with locally advanced disease, and may be associated with higher mortality at 30 days after resection. Despite this, when strict criteria are used for diagnosis, the overall survival is favorable when compared with CRCs with equivalent demographic and pathological characteristics.

A further investigation of combined mismatch repair and BRAFV600E mutation specific immunohistochemistry as a predictor of overall survival in colorectal carcinoma.

Mutation specific immunohistochemistry (IHC) is a promising new technique to detect the presence of the BRAFV600E mutation in colorectal carcinoma (CRC). When performed in conjunction with mismatch repair (MMR) IHC, BRAFV600E IHC can help to further triage genetic testing for Lynch Syndrome. In a cohort of 1426 patients undergoing surgery from 2004 to 2009 we recently demonstrated that the combination of MMR and BRAFV600E IHC holds promise as a prognostic marker in CRC, particularly because of its ability to identify the poor prognosis MMR proficient (MMRp) BRAFV600E mutant subgroup. We attempted to validate combined MMR and BRAFV600E IHC as a prognostic indicator in a separate cohort comprising consecutive CRC patients undergoing surgery from 1998 to 2003. IHC was performed on a tissue microarray containing tissue from 1109 patients with CRC. The 5 year survivals stratified by staining patterns were: MMRd/BRAFwt 64%, MMRd/BRAFV600E 64%, MMRp/BRAFwt 60% and MMRp/BRAFV600E 53%. Using the poor prognosis MMRp/BRAFV600E phenotype as baseline, univariate Cox regression modelling demonstrated the following hazard ratios for death: MMRd/BRAFwt HR = 0.71 (95%CI = 0.40-1.27), p = 0.31; MMRd/BRAFV600E HR = 0.74 (95%CI = 0.51-1.07), p = 0.11 and MMRp/BRAFwt HR = 0.79 (95%CI = 0.60-1.04), p = 0.09. Although the findings did not reach statistical significance, this study supports the potential role of combined MMR and BRAF IHC as prognostic markers in CRC.

Laparoscopy for colorectal malignancy.

Laparoscopy for colorectal pathology is technically demanding with a steep learning curve. In expert hands, there is no doubt that there is a place for laparoscopy in the operative armamentarium for the treatment of benign disease. The question of its application in the treatment of carcinoma is more difficult to address. The evidence available suggests that laparoscopic resection is a feasible and appropriate option for the treatment of colorectal carcinoma. The skill and technology to perform the procedure are developing apace, and level 1 evidence to support it is tantalizingly close. This paper will outline the development of the technique, the operative approach, and the available evidence for its use in the treatment of carcinoma.

Sacral nerve stimulation for faecal incontinence.

Faecal incontinence is a common problem. Conservative measures are effective in a significant proportion of patients. Failure of conservative management has until recently meant recourse to surgical intervention. Surgical treatment is often associated with disappointing results. Recently, sacral nerve stimulation (SNS) has been developed as a minimally invasive, effective technique for idiopathic and acquired faecal incontinence. The technique uses chronic low-level electrical stimulation of the sacral nerves, or neuromodulation, to produce a clinically beneficial effect on the distal colon and rectum, the pelvic floor and the anal sphincter complex. SNS is a 2-stage procedure: a diagnostic stage - temporary percutaneous nerve evaluation (PNE), and a therapeutic stage - permanent SNS. The predictive value of PNE is high, and the surgical trauma and morbidity of both procedures extremely low. The technique has been adapted from its original application in urinary dysfunction. It is almost impossible to produce level 1 evidence for this type of intervention; however, the results are superior to other interventions. Patient selection criteria are evolving, but there is a growing body of evidence that supports its use as first-line treatment for faecal incontinence in patients where conservative measures have failed.

Laparoscopy for rectal carcinoma: anterior resection.

Laparoscopic anterior resection is a technically demanding procedure with a steep learning curve. In expert hands, this procedure has a place in the operative armamentarium for the treatment of benign disease. Its application in the treatment of rectal carcinoma is more difficult to address. The evidence available suggests that laparoscopic anterior resection is a feasible and appropriate option for the treatment of rectal carcinoma. The skill and technology to perform the procedure are developing apace, and level 1 evidence to support its use is tantalizingly close. In this paper, we outline the development of the procedure, the operative approach, and the available evidence for its use in the treatment of rectal carcinoma.

Changing pattern of adrenalectomy at a tertiary referral centre 1970-2000.

BACKGROUND: In 1987, a report from this unit described the changing indications for open adrenalectomy over a 15-year period. The indications for adrenalectomy had switched from it being the principal therapeutic procedure used in advanced breast cancer in the early 1970s, to being predominately performed for Cushing's disease or incidental, asymptomatic, adrenal masses by the early 1980s. The aim of the present study was to evaluate the changes in the presentation and management of adrenal disease in the last 15 years and to compare these findings with our previously published results. METHODS: Information was gathered from a prospective database of all patients undergoing adrenalectomy in the University of Sydney Endocrine Surgical Unit at Royal North Shore Hospital from 1 January 1987 to 31 December 2000. Information was obtained on patient presentation, diagnostic investigations, indications for surgery, procedure performed and surgical outcomes. Prior to 1987, information was gathered by retrospective review of case notes of patients who had undergone adrenalectomy at Royal North Shore Hospital. During the period from 1 January 1970 to 31 December 2000, 236 patients underwent adrenalectomy. Excluding the 68 adrenalectomies performed for breast cancer, left 168 patients who underwent adrenalectomy for functional or non--functional masses. There were 97 (58%) women and 71 (42%) men, with a mean age of 48 years. RESULTS: Of the 168 patients, the principal indications for surgery were hyperaldosteronism (32%), phaeochromocytoma (20%), hypercortisolism (20%), incidentaloma (16%), carcinoma (6%) and other reasons (6%). Examination of the number of cases in each pathological group for the periods 1970-1986 and 1987-2000, revealed an 8-fold increase in the number of operations for hyper-aldosteronism, and a 3-fold increase in cases of phaeochromocytoma. The number of operations for the other pathological groups remained steady. The annual incidence of adrenalectomy in the hospital has steadily risen since 1990, with a linear increase in the adrenalectomy rate since the introduction of laparoscopic adrenalectomy in 1995. There were fewer complications in either the open or laparoscopic group since 1987 compared with the pre-1987 cohort. CONCLUSIONS: In the past 5 years, there has been a linear increase in the number of adrenalectomies performed in this unit for hyperaldosteronism and to a lesser extent phaeochromocytoma. This is a reflection of increased clinical awareness, improved diagnostic modalities and the advent of laparoscopic adrenalectomy.

Laparoscopic adrenalectomy: a 6-year experience of 59 cases.

BACKGROUND: The aims of this paper were to review our experience with laparoscopic transperitoneal adrenalectomy, report on outcomes in comparison with the published literature, and demonstrate any learning curve with the technique. METHODS: A review of our database and patient records was carried out for the period April 1995 to December 2000. Patient demographics, tumour characteristics, operating times, outcomes and lengths of stay were studied. Diagnostic tools, including a comparison between tumour size on computed tomography scanning and on pathological section were reviewed. A comprehensive literature review was conducted using MEDLINE. RESULTS: Indications for surgery included 33 patients with primary hyperaldosteronism (29 adenomas, 4 hyperplasias), 12 phaeochromo-cytomas, 7 cortisol-secreting adenomas, 4 non-secreting adenomas, 1 medullary cyst, 1 metastasis and 1 ganglioneuroma. The tumours ranged in size from 7 to 110 mm. All tumours were localized and lateralized preoperatively using standard techniques. Throughout the review period, six open procedures were undertaken electively, for various reasons. Three cases were converted to open procedures (5.1%). Thirty-eight left and 21 right procedures were undertaken. For all laparoscopic procedures, the average time in the operating theatre was 175.1 min. Men took 188.3 min compared with 165.7 min for women. Left-sided lesions took 178.72 min compared with 167.63 min for right-sided lesions. The average length of stay was 3.8 days. There was one wound infection, one blood transfusion and two readmissions: one for pain control in a patient with difficult home circumstances, and one patient suffered transient hypoadrenalism. CONCLUSION: The results achieved in our initial experience with this technique are comparable with the published literature. The results confirm that laparoscopic adrenalectomy is the method of choice for resection of benign adrenal pathology. The procedure has a learning curve and should be performed by a surgeon experienced in both open and laparoscopic adrenal surgery.