Comparison of ultrasound-guided transmuscular quadratus lumborum block catheter technique with surgical pre-peritoneal catheter for postoperative analgesia in abdominal surgery: a randomised controlled trial.

Following abdominal surgery, the provision of postoperative analgesia with local anaesthetic infusion through both transmuscular quadratus lumborum block and pre-peritoneal catheter have been described. This study compared these two methods of postoperative analgesia following laparotomy. Eighty-two patients 18-85 years of age scheduled to undergo elective surgery were randomly allocated to receive either transmuscular quadratus lumborum block or pre-peritoneal catheter block. In the transmuscular quadratus lumborum group, an 18-gauge Tuohy needle was passed through the quadratus lumborum muscle under ultrasound guidance to reach its anterior aspect. A 20-ml bolus of ropivacaine 0.375% was administered and catheters placed bilaterally. In the pre-peritoneal catheter group, 20 ml of ropivacaine 0.375% was infiltrated at each of three subcutaneous sub-fascial levels, and pre-peritoneal plane catheters were placed bilaterally. Both groups received an infusion of ropivacaine 0.2% at 5 ml.h-1 , continued up to 48 h along with a multimodal analgesic regime that included regular paracetamol and patient-controlled analgesia with fentanyl. The primary end-point was postoperative pain score on coughing, assessed using a numerical rating score (0-10). Secondary outcomes were pain score at rest, fentanyl usage until 48 h post-operation, satisfaction scores and costs. There was no treatment difference between the two groups for pain score on coughing (p = 0.24). In the transmuscular quadratus lumborum group, there was a reduction in numerical rating score at rest (p = 0.036) and satisfaction scores on days 1 and 30 (p = 0.004, p = 0.006, respectively), but fentanyl usage was similar. In the transmuscular quadratus lumborum group, the highest and lowest blocks observed in the recovery area were T4 and L1, respectively. The transmuscular quadratus lumborum technique cost 574.64 Australian dollars more per patient than the pre-peritoneal catheter technique.

Non-technical skills of surgical trainees and experienced surgeons.

BACKGROUND: In addition to technical expertise, surgical competence requires effective non-technical skills to ensure patient safety and maintenance of standards. Recently the Royal Australasian College of Surgeons implemented a new Surgical Education and Training (SET) curriculum that incorporated non-technical skills considered essential for a competent surgeon. This study sought to compare the non-technical skills of experienced surgeons who completed their training before the introduction of SET with the non-technical skills of more recent trainees. METHODS: Surgical trainees and experienced surgeons undertook a simulated scenario designed to challenge their non-technical skills. Scenarios were video recorded and participants were assessed using the Non-Technical Skills for Surgeons (NOTSS) scoring system. Participants were divided into subgroups according to years of experience and their NOTSS scores were compared. RESULTS: For most NOTSS elements, mean scores increased initially, peaking around the time of Fellowship, before decreasing roughly linearly over time. There was a significant downward trend in score with increasing years since being awarded Fellowship for six of the 12 NOTSS elements: considering options (score -0·015 units per year), implementing and reviewing decisions (-0·020 per year), establishing a shared understanding (-0·014 per year), setting and maintaining standards (-0·024 per year), supporting others (-0·031 per year) and coping with pressure (-0·015 per year). CONCLUSION: The drop in NOTSS score was unexpected and highlights that even experienced surgeons are not immune to deficiencies in non-technical skills. Consideration should be given to continuing professional development programmes focusing on non-technical skills, regardless of the level of professional experience.

Systematic review of skills transfer after surgical simulation-based training.

BACKGROUND: Simulation-based training assumes that skills are directly transferable to the patient-based setting, but few studies have correlated simulated performance with surgical performance. METHODS: A systematic search strategy was undertaken to find studies published since the last systematic review, published in 2007. Inclusion of articles was determined using a predetermined protocol, independent assessment by two reviewers and a final consensus decision. Studies that reported on the use of surgical simulation-based training and assessed the transferability of the acquired skills to a patient-based setting were included. RESULTS: Twenty-seven randomized clinical trials and seven non-randomized comparative studies were included. Fourteen studies investigated laparoscopic procedures, 13 endoscopic procedures and seven other procedures. These studies provided strong evidence that participants who reached proficiency in simulation-based training performed better in the patient-based setting than their counterparts who did not have simulation-based training. Simulation-based training was equally as effective as patient-based training for colonoscopy, laparoscopic camera navigation and endoscopic sinus surgery in the patient-based setting. CONCLUSION: These studies strengthen the evidence that simulation-based training, as part of a structured programme and incorporating predetermined proficiency levels, results in skills transfer to the operative setting.

The nursing and financial implications of laparoscopic colorectal surgery: data from a randomized controlled trial.

AIM: The issue of cost effectiveness of laparoscopic surgery remains uncertain and its impact on the ward nursing staff is unaddressed. This study investigated these issues using patients from a single centre admitted to a randomized controlled trial. METHOD: All patients recruited into the Australasian Laparoscopic Colon Cancer Study (ALCCaS) from The Queen Elizabeth Hospital between January 1999 and March 2005 were included in this study. Data relating to hospital cost were collated from the Hospital Patient Costing System. Nursing interventions were calculated in minutes per patient, using the excelcare Software database. RESULTS: Data from 97 patients were analysed (laparoscopy, 53; open surgery, 44). The median number of hours of nursing input per patient was 80 (27.5-907) h in the open surgery group and 58.5 (15-684.5) h in the laparoscopy group. This difference was further increased after exclusion of patients converted from laparoscopy to open surgery. The median total cost of the procedure was AUS $9698/£ 5631 (AUS $3862-90,397) in the open surgery group and AUS $10,951/£ 6219 (AUS$2337-66,237) in the laparoscopy group. CONCLUSION: These data suggest that laparoscopic colorectal surgery is equivalent in price to open surgery and there may be added benefits in reduced nursing intensity.

Australasian Laparoscopic Colon Cancer Study shows that elderly patients may benefit from lower postoperative complication rates following laparoscopic versus open resection.

BACKGROUND: A retrospective analysis of age-related postoperative morbidity in the Australia and New Zealand prospective randomized controlled trial comparing laparoscopic and open resection for right- and left-sided colonic cancer is presented. METHODS: A total of 592 eligible patients were entered and studied from 1998 to 2005. RESULTS: Data from 294 patients who underwent laparoscopic and 298 who had open colonic resection were analysed; 266 patients were aged less than 70 years and 326 were 70 years or older (mean(s.d.) 70.3(11.0) years). Forty-three laparoscopic operations (14.6 per cent) were converted to an open procedure. Fewer complications were reported for intention-to-treat laparoscopic resections compared with open procedures (P = 0.002), owing primarily to a lower rate in patients aged 70 years or more (P = 0.002). Fewer patients in the laparoscopic group experienced any complication (P = 0.035), especially patients aged 70 years or above (P = 0.019). CONCLUSION: Treatment choices for colonic cancer depend principally upon disease-free survival; however, patients aged 70 years or over should have rigorous preoperative investigation to avoid conversion and should be considered for laparoscopic colonic resection. REGISTRATION NUMBER: NCT00202111 (http://www.clinicaltrials.gov).

Laparoscopically assisted colectomy: a study of risk factors and predictors of open conversion.

BACKGROUND: Conversion to an open procedure during laparoscopically assisted colorectal resection may be necessary because of technical, patient, or pathologic factors. Recent literature has indicated that converted patients may have poorer outcomes than those undergoing open or completed laparoscopically assisted procedure. This study aimed to audit the authors' experience with laparoscopically assisted colectomy and to assess the clinical outcomes of patients undergoing conversion. METHODS: All laparoscopic right hemicolectomies or anterior resections performed at seven South Australian hospitals from 1997 to 2006 were reviewed. Data pertaining to patient sex, age, American Society of Anesthesiology (ASA) score, pathology, operative outcomes including operating time, conversion, reason for conversion, length of hospital stay, and intra- and postoperative complications were analyzed. RESULTS: Laparoscopic anterior resection had a higher rate of open conversion than laparoscopic right hemicolectomy (18.7% vs 10.4%; p = 0.028). In the right hemicolectomy group, none of the investigated risk factors for conversion were statistically significant, and the morbidity rates for the two groups were similar. The median hospital stay was significantly longer in the anterior resection group (p < 0.001), and the wound morbidity rate was higher in the converted group (12.8% vs 3.0%; p = 0.022). Age older than 75 years and a high ASA status were independent risk factors for conversion in anterior resection. CONCLUSIONS: Conversion of laparoscopic anterior resection to open procedure is associated with higher wound morbidity and a longer hospital stay. The authors recommend that surgeons carefully consider the selection of patients 75 years of age or older and high ASA status for laparoscopic anterior resection.

Receptor protein tyrosine kinase EphB4 is up-regulated in colon cancer.

BACKGROUND: We have used commercially available cDNA arrays to identify EphB4 as a gene that is up-regulated in colon cancer tissue when compared with matched normal tissue from the same patient. RESULTS: Quantitative RT-PCR analysis of the expression of the EphB4 gene has shown that its expression is increased in 82% of tumour samples when compared with the matched normal tissue from the same patient. Using immunohistochemistry and Western analysis techniques with an EphB4-specific antibody, we also show that this receptor is expressed in the epithelial cells of the tumour tissue and either not at all, or in only low levels, in the normal tissue. CONCLUSION: The results presented here supports the emerging idea that Eph receptors play a role in tumour formation and suggests that further elucidation of this signalling pathway may identify useful targets for cancer treatment therapies.

Dipeptidase 1: a candidate tumor-specific molecular marker in colorectal carcinoma.

The aim of this study was to identify tumor-specific markers for the detection of rare disseminated colorectal tumor cells in peripheral venous blood and in intra-peritoneal saline lavage samples collected before and after resection of colorectal tumors. Using cDNA micro-array screening, we found dipeptidase 1 (DPEP1) to be highly expressed in colon tumors compared to matched normal mucosa. Relative reverse transcriptase (RT)-PCR showed that DPEP1 was over-expressed by >/=2 fold in colon tumor compared to normal colonic mucosal tissue in 56/68 (82%) patients. Using immunobead RT-PCR, a technique that first enriches for epithelial cells, we found DPEP1 positive cells in intra-peritoneal lavage and venous blood samples from 15/38 (39%) colorectal cancer cases. This is the first report of DPEP1 as a marker for disseminated colon tumor cells.

The activity of caspase-3-like proteases is elevated during the development of colorectal carcinoma.

Activated caspase-3-like proteases promote apoptotic cell death by cleaving cellular substrates. Caspase-3-like activity was measured in colonic carcinomas and in matched normal colonic mucosa from 31 patients and was significantly elevated in 25/ 31 colonic carcinomas and adenomas when compared to normal mucosa (P < 0.0001). Caspase-3-like activity was much higher in normal mucosa and tumours of female subjects than of males (P < 0.0001). No correlation was obtained between caspase-3-like activity and location of the tumour, tumour grade, stage, or patient age. The marked increase in caspase-3-like activity in colorectal carcinomas may reflect an increase in the proportion of cells undergoing spontaneous apoptosis.

The effect of lavage on intraabdominal cell burden.

BACKGROUND: Abdominal lavage is a common surgical practice, but few studies have been conducted to assess its efficacy at removing cells from the abdominal cavity, particularly during laparoscopic surgery. METHODS: After three 12-mm trocars were inserted into six female 30-kg pigs at the umbilicus left and right iliac fossae, the abdomen was insufflated with carbon dioxide. The pelvis of each pigs was injected with 6 million radiolabeled LIM 1215 cells. Then the abdominal cavity was irrigated with either 500 ml 0.9% saline, 500 ml 10% betadine solution, or 1 L 0.9% saline. A maximum of 5 L of solution was used for each animal. The lavage fluid was suctioned into separate containers after each aliquot, and each container was measured for radioactivity. RESULTS: Significantly greater numbers of cells were removed by lavage by the first to third lavage cycle; however, after four lavage cycles, relatively few cells were removed by each further cycle. No difference was observed between 500-ml and 1-L aliquots. Additionally, the mechanical efficacy of 0.9% saline and 10% betadine solution appeared similar. CONCLUSION: These findings suggest that optimal lavage consists of four irrigation/suction cycles utilizing 500-ml aliquots.

Hematogenous spread as a mechanism for the generation of abdominal wound metastases following laparoscopy.

BACKGROUND: We designed this study to determine whether hematogenous spread has a role in the etiology of port site metastases following laparoscopic surgery. METHODS: The study design had two parts. In experiment 1, two groups (n = 30) of male Dark Agouti rats were studied. Under general anesthesia, the first group (20 rats) underwent 15 mins of laparoscopic insufflation, followed by an injection of a suspension of 105 Dark Agouti mammary adenocarcinoma (DAMA) cells into the internal jugular vein and a further 15-mins period of insufflation. The laparoscopic ports were then removed, and the wounds were closed and marked. In the second group (n = 10), the procedure was identical except that a 2.5-cm midline laparotomy was performed 15 mins after the commencement of anesthesia and insufflation was not used. The laparotomy was closed in two layers. In experiment 2, one group (n = 4) was studied. The study protocol was identical to the first laparoscopic group except that a larger number of 106 DAMA cells were injected. All rats in both experiments were killed 15 days later, and the injection site, laparoscopy wounds, and laparotomy wound were examined histologically by a blinded histopathologist. RESULTS: In experiment 1, one port site tumor was detected in the laparoscopic group and no wound metastases were found in the laparotomy group. Postoperative weight loss was significantly less in the laparoscopic group (p < 0.001). In experiment 2, no port site metastases were detected. CONCLUSION: Although hematogenous spread is a possible mechanism in the development of port site metastases, judging from the low number of port site metastases in this study as compared to previous reports using this tumor model, this mechanism is unlikely to be a major contributor to the problem of wound metastasis following laparoscopy.

Variables in the spread of tumor cells to trocars and port sites during operative laparoscopy.

BACKGROUND: Port-site recurrences have delayed the uptake of laparoscopic colectomy, but the etiology of these is incompletely understood. These studies were designed to investigate variables such as the size of the tumor inoculum and the volume and pressure of the insufflated gas during operative laparoscopy that might affect the deposition of these cells in relation to trocars and port sites. METHODS: Radiolabeled human colon cancer cells were injected into the peritoneal cavity of pigs. Three trocars were inserted, and the abdomen was insufflated with carbon dioxide. The movement of cells within the abdomen was traced on a gamma camera. After 2 h, the trocars were removed and the port sites excised. Two studies were performed. In the first study, tumor inocula were varied from 1.5 x 10(5) to 120 x 10(5). In the second study, insufflation pressure was varied, with pressures 0, 4, 8 and 12 mmHg were studied. RESULTS: When larger tumor inocula were injected, the contamination of both trocars (p = 0.005, Kendall's rank correlation) and trocar sites (p = 0.04, Kendall's rank correlation) increased. The deposition of cells on a trocar site was linked to contamination of its trocar (p = 0.03, chi-square), but the contamination of trocars did not always result in trocar-site contamination (p = 0.5, chi-square). Increased volumes of gas insufflation caused increased intraabdominal movement of tumour cells (p = 0.01, Kendall's rank correlation), although this did not lead to greater contamination of trocars or port sites (p = 0.82, Kendall's rank correlation). Decreased insufflation pressures resulted in increased contamination of trocars and port sites (p = 0.01, Kendall's rank correlation). CONCLUSIONS: If clinical situations parallel this study, strategies such as increasing insufflation pressure, reducing episodes of desufflation and gas leaks, and using frequent intraabdominal lavage may help to reduce the numbers of viable tumor cells displaced to port sites during laparoscopic surgery for intraabdominal malignancy. This may reduce the rate of port-site metastases.

Toothpick injuries to the gastrointestinal tract.

Perforation of the gastrointestinal tract by toothpicks is an uncommon but well described occurrence. Five cases treated by the authors over the past 5 years are described. This series emphasizes the fact that plain abdominal and chest radiology is unhelpful in establishing the diagnosis. Risk factors identified are the wearing of dentures and previous abdominal surgery.

The treatment of internal fistulae that complicate diverticular disease of the sigmoid colon by laparoscopically assisted colectomy.

Seven patients with internal fistulae complicating colonic diverticular disease were treated by laparoscopic assisted colectomy over a 24-month period. Prospective review of these patients was carried out to ascertain efficacy of the treatment. No intraoperative complications were encountered and return of gastrointestinal function was apparent within two days in all cases. Postoperative hospital stay was limited to an average of 4.7 days. No long-term complication or fistula recurrence has been noted in the mean 11-month follow-up period. This study indicates laparoscopic assisted colectomy is an effective means of treatment for diverticular fistulae.

Early postoperative perforation of the terminal ileum following total colectomy for fulminant colitis.

Perforation of the ileum following total colectomy for Crohn's colitis is an uncommon entity which was fully described in 1970 by Hawke and Turnbull. Few reports have appeared since that time. A review of the clinical and pathological aspects of two cases of ileal perforation soon after colectomy for Crohn's colitis reveals a marked similarity to the original description of this entity.

A novel method of rectal occlusion during anterior resection of the rectum.

An inexpensive and effective method of rectal occlusion during low anterior resection using a commercially available cable tie is described. Its use facilitates cross stapling of the rectum distal to the tumour.

Ischiorectal fossa block decreases posthemorrhoidectomy pain: randomized, prospective, double-blind clinical trial.

PURPOSE: Hemorrhoidectomy can be associated with severe pain in the immediate postoperative period. The aim of this study was to assess the efficacy of a preemptive local anesthetic, ischiorectal fossa block, in the reduction of pain and analgesic requirements after hemorrhoidectomy. METHODS: All patients were suitable for an established day surgery hemorrhoidectomy protocol. Immediately before surgery patients were randomly assigned either to receive (Group 1) or not receive (Group 2) the local anesthetic block. All other aspects of surgery and anesthesia were standardized. Nursing staff assessed pain at 30 minutes and 2, 4, and 24 hours postoperatively using a visual analog scale (1-10, where 1 represented no pain and 10 represented the worst pain imaginable). Analgesic requirements also were recorded at these times. Both the patients and the nursing staff were blinded to which local anesthetic protocol had been used. RESULTS: Twenty patients were enrolled in the trial. Ten patients were randomly assigned to Group I and ten to Group 2. Mean pain scores for Group 1 (anal block) at 0.5, 2, 4, and 24 hours were 1.5, 1.8, 2.1, and 2.5, respectively, compared with Group 2, with mean pain scores of 3.4, 3.4, 3.9, and 5.1. These differences were statistically significant. Patients in Group 1 used less analgesia in the first 24 hours postoperatively than those in Group 2. CONCLUSION: The use of a preemptive local anesthetic, ischiorectal fossa block, is associated with a significant decrease in pain and analgesia requirements after hemorrhoidectomy.

Laparoscopic-assisted colonoscopic polypectomy: technique and preliminary experience.

BACKGROUND: The majority of colonic polyps found at endoscopy are suitable for diathermy snare excision via colonoscope. Due to location or size, some are deemed unsafe to treat in this manner and therefore require colectomy. This study describes the technique and early results of a laparoscopic-assisted colonoscopic polypectomy technique that can be used to manage such polyps and thereby avoid laparotomy and colectomy. METHODS: Colonoscopy with simultaneous laparoscopy was utilized to locate the site of the polyp. The colon was mobilized, if required, and the polyp resected by electrosurgical snare via the colonoscope while the serosal aspect of the colon was monitored laparoscopically. RESULTS: The technique has been tried successfully in six patients. Three polyps were in the cecum and three were within the left colon. The size of the polyps ranged from 3 to 7 cm. All polyps were benign on histological examination. The patients were discharged on the day following the procedure. There were no complications. CONCLUSIONS: The combination of laparoscopy with colonoscopic resection of a select group of large polyps represents a safe alternative to colonic resection.

A comparison of Southern blot and polymerase chain reaction as techniques to identify loss of DNA heterozygosity in colorectal cancer.

Alterations in the tumour suppressor gene p53 have been found in a wide variety of tumours. The variable number tandem repeat present at the YNZ22 locus is a highly polymorphic marker closely linked to the p53 gene. Examination for loss of heterozygosity at the YNZ22 locus has been carried out by Southern blot or polymerase chain reaction (PCR). A comparison of these techniques shows a 100% concordance rate in normal tissue but a 90.9% rate in tumour tissue. Both false positive and false negative results were obtained. This must be considered in the interpretation of studies using PCR for this purpose.

The influence of age of template DNA derived from archival tissue on the outcome of the polymerase chain reaction.

The analysis of DNA from archival tumour tissue for molecular alterations has been facilitated by the use of the polymerase chain reaction (PCR). Degradation of tissue prior to fixation and the nature of the fixative used influence successful amplification from archival tissue. Age of the archival tissue may also be a factor. To determine if this was so, DNA was extracted from 30 archival specimens of spleen spanning a 15 year period. Polymerase chain reaction was performed on all specimens using primers for exon 2 (307 bp) and exon 9 (1278 bp) of the hypoxanthine phosphoribosyl transferase (HPRT) gene. It was not possible to show that the age of archival tissue had an influence on the capacity to amplify exon 2 of the HPRT gene. It was not possible to amplify exon 9 of the HPRT gene from archival tissue.