Procedural key steps in laparoscopic colorectal surgery, consensus through Delphi methodology.

BACKGROUND: While several procedural training curricula in laparoscopic colorectal surgery have been validated and published, none have focused on dividing surgical procedures into well-identified segments, which can be trained and assessed separately. This enables the surgeon and resident to focus on a specific segment, or combination of segments, of a procedure. Furthermore, it will provide a consistent and uniform method of training for residents rotating through different teaching hospitals. The goal of this study was to determine consensus on the key steps of laparoscopic right hemicolectomy and laparoscopic sigmoid colectomy among experts in our University Medical Center and affiliated hospitals. This will form the basis for the INVEST video-assisted side-by-side training curriculum. METHODS: The Delphi method was used for determining consensus on key steps of both procedures. A list of 31 steps for laparoscopic right hemicolectomy and 37 steps for laparoscopic sigmoid colectomy was compiled from textbooks and national and international guidelines. In an online questionnaire, 22 experts in 12 hospitals within our teaching region were invited to rate all steps on a Likert scale on importance for the procedure. RESULTS: Consensus was reached in two rounds. Sixteen experts agreed to participate. Of these 16 experts, 14 (88%) completed the questionnaire for both procedures. Of the 14 who completed the first round, 13 (93%) completed the second round. Cronbach's alpha was 0.79 for the right hemicolectomy and 0.91 for the sigmoid colectomy, showing high internal consistency between the experts. For the right hemicolectomy, 25 key steps were established; for the sigmoid colectomy, 24 key steps were established. CONCLUSION: Expert consensus on the key steps for laparoscopic right hemicolectomy and laparoscopic sigmoid colectomy was reached. These key steps will form the basis for a video-assisted teaching curriculum.

Ultrasound-Guided Quantitative Fluorescence Molecular Endoscopy for Monitoring Response in Patients with Esophageal Cancer Following Neoadjuvant Chemoradiotherapy.

PURPOSE: The ability to identify residual tumor tissues in patients with locally advanced esophageal cancer following neoadjuvant chemoradiotherapy (nCRT) is essential for monitoring the treatment response. Using the fluorescent tracer bevacizumab-800CW, we evaluated whether ultrasound-guided quantitative fluorescent molecular endoscopy (US-qFME), which combines quantitative fluorescence molecular endoscopy (qFME) with ultrasound-guided needle biopsy/single-fiber fluorescence (USNB/SFF), can be used to identify residual tumor tissues in patients following nCRT. EXPERIMENTAL DESIGN: Twenty patients received an additional endoscopy procedure the day before surgery. qFME was performed at the primary tumor site (PTS) and in healthy tissue to first establish the optimal tracer dose. USNB/SFF was then used to measure intrinsic fluorescence in the deeper PTS layers and lymph nodes (LN) suspected for metastasis. Finally, the intrinsic fluorescence and the tissue optical properties-specifically, the absorption and reduced scattering coefficients-were combined into a new parameter called omega. RESULTS: First, a 25-mg bevacizumab-800CW dose allowed for clear differentiation between the PTS and healthy tissue, with a target-to-background ratio (TBR) of 2.98 (IQR, 1.86-3.03). Moreover, we found a clear difference between the deeper esophageal PTS layers and suspected LN compared to healthy tissues, with TBR values of 2.18 and 2.17, respectively. Finally, our new parameter, omega, further improved the ability to differentiate between the PTS and healthy tissue. CONCLUSIONS: Combining bevacizumab-800CW with US-qFME may serve as a viable strategy for monitoring the response to nCRT in esophageal cancer and may help stratify patients regarding active surveillance versus surgery.

Case report of simultaneous presentation of pulmonary embolism and pericardial effusion following an oncological esophagectomy.

INTRODUCTION: This is the first reported case of simultaneous presentation of pulmonary embolism and pericardial effusion following esophagectomy. This case illustrates a diagnostic and therapeutic challenge exemplifying the difficulties arising from complex anticoagulant considerations in esophageal cancer. PATIENT CASE: A 72 year old male undergoes an oncological esophageal resection. Postoperatively the patient develops pulmonary embolism for which he is treated with Rivaroxaban. After starting Rivaroxaban the patient develops a large pericardial effusion. DISCUSSION: We suspect that the treatment of pulmonary embolism with Rivaroxaban had a causative role in the development of pericardial effusion. Based on literature we suspect that chemoradiotherapy increased susceptibility. CONCLUSION: Diagnosis and treatment of simultaneous pulmonary embolism and pericardial effusion remains a challenge. Special consideration should be taken when using Rivaroxaban in esophageal cancer patients; this should always be conducted in consultation with a coagulation specialist.