Colorectal cancer patients under the age of 50 experience delays in primary care leading to emergency diagnoses: a population-based study.

AIM: The incidence of colorectal cancer in the under 50s is increasing. In this national population-based study we aim to show that missed opportunities for diagnosis in primary care are leading to referral delays and emergency diagnoses in young patients. METHOD: We compared the interval before diagnosis, presenting symptom(s) and the odds ratio (OR) of an emergency diagnosis for those under the age of 50 with older patients sourced from the cancer registry with linkage to a national database of primary-care records. RESULTS: The study included 7315 patients, of whom 508 (6.9%) were aged under 50 years, 1168 (16.0%) were aged 50-59, 2294 (31.4%) were aged 60-69 and 3345 (45.7%) were aged 70-79 years. Young patients were more likely to present with abdominal pain and via an emergency, and had the lowest percentage of early stage cancer. They experienced a longer interval between referral and diagnosis (12.5 days) than those aged 60-69, reflecting the higher proportion of referrals via the nonurgent pathway (33.3%). The OR of an emergency diagnosis did not differ with age if a red-flag symptom was noted at presentation, but increased significantly for young patients if the symptom was nonspecific. CONCLUSION: Young patients present to primary care with symptoms outside the national referral guidelines, increasing the likelihood of an emergency diagnosis.

Delays in referral from primary care are associated with a worse survival in patients with esophagogastric cancer.

NICE referral guidelines for suspected cancer were introduced to improve prognosis by reducing referral delays. However, over 20% of patients with esophagogastric cancer experience three or more consultations before referral. In this retrospective cohort study, we hypothesize that such a delay is associated with a worse survival compared with patients referred earlier. By utilizing Clinical Practice Research Datalink, a national primary care linked database, the first presentation, referral date, a number of consultations before referral and stage for esophagogastric cancer patients were determined. The risk of a referral after one or two consultations compared with three or more consultations was calculated for age and the presence of symptom fulfilling the NICE criteria. The risk of death according to the number of consultations before referral was determined, while accounting for stage and surgical management. 1307 patients were included. Patients referred after one (HR 0.80 95% CI 0.68-0.93 p = 0.005) or two consultations (HR 0.81 95% CI 0.67-0.98 p = 0.034) demonstrated significantly improved prognosis compared with those referred later. The risk of death was also lower for patients who underwent a resection, were younger or had an earlier stage at diagnosis. Those presenting with a symptom fulfilling the NICE criteria (OR 0.27 95% CI 0.21-0.35 p < 0.0001) were more likely to be referred earlier. This is the first study to demonstrate an association between a delay in referral and worse prognosis in esophagogastric patients. These findings should prompt further research to reduce primary care delays.

Complications after discharge and delays in adjuvant chemotherapy following colonic resection: a cohort study of linked primary and secondary care data.

AIM: By understanding the reasons for delays in adjuvant chemotherapy (AC) after colonic resection, there is the potential to improve patient outcome. The aim of this study is to determine the extent and impact of complications after hospital discharge on delays to AC. METHOD: The study cohort included patients from Hospital Episode Statistics (HES) who had a colorectal cancer resection; linkage to primary care data was provided by the Clinical Practice Research Datalink (CPRD). Complications during the index hospital stay (from HES) and after discharge (from CPRD) were compared. The risk of late AC treatment (8 weeks or later) following a complication, stoma at the index procedure or emergency admission was described after accounting for age and Charlson score. A Cox hazards model determined the association of these factors with overall survival (OS). RESULTS: A total of 1266 patients underwent AC following colon cancer resection, of whom 598 (47.2%) received treatment within 8 weeks. Patients receiving late AC had a significantly higher proportion of re-operations (7.0% vs 3.3% P < 0.005) and wound infections (5.5% vs 3.7% P = 0.042), with 96% of the latter only being noted in CPRD. In multivariate analysis, the risk of AC delay significantly increased following a complication (OR 1.53, 95% CI 1.16-2.03, P = 0.003) or a stoma at the index operation. AC delay was associated with worse OS [hazard ratio (HR) 1.44, 95% CI 1.16-1.79, P = 0.001], as was an emergency admission (HR 1.59, 95% CI 1.21-1.98, P < 0.0005). However, the presence of a complication did not independently reduce OS (HR 1.15, 95%CI 0.89-1.48, P = 0.295). CONCLUSION: The true extent and impact of complications following colonic resection is underestimated when only secondary care data are used.

Colorectal surgery and enhanced recovery: Impact of a simulation-based care pathway training curriculum.

BACKGROUND: The aim was to determine whether a simulation-based care pathway approach (CPA) curriculum could improve compliance for enhanced recovery programs (ERP), and residents' participation in laparoscopic colorectal surgery (LCS). Indeed, trainee surgeons have limited access to LCS as primary operator, and ERP have improved patients' outcomes in colorectal surgery (CS). METHODS: All residents of our department were trained in a simulation-based CPA: perioperative training consisted in virtual patients built according to guidelines in both ERP and CS, whilst intraoperative training involved a virtual reality simulator curriculum. Twenty consecutive patients undergoing CS were prospectively included before (n=10) and after (n=10) the training. All demographic and perioperative data were prospectively collected, including compliance for ERP. Residents' participation as primary operator in LCS was measured. RESULTS: Five residents (PGY 4-7) were enrolled. None had performed LCS as primary operator. Overall satisfaction and usefulness were both rated 4.5/5, usefulness of pre-, post- and intraoperative training was rated 5/5, 4.5/5 and 4/5, respectively. Residents' participation in LCS significantly improved after the training (0% (0-100) vs. 82.5% (10-100); P=0.006). Pre- and intraoperative data were comparable between groups. Postoperative morbidity was also comparable. Compliance for ERP improved at Day 2 in post-training patients (3 (30%) vs. 8 (80%); P=0.035). Length of stay was not modified. CONCLUSIONS: A simulated CPA curriculum to training in LCS and ERP was correctly implemented. It seemed to improve compliance for ERP, and promoted residents participation as primary operator without adversely altering patients' outcomes.

Identification and management of the ilio-inguinal and ilio-hypogastric nerves in open inguinal hernia repair: benefits of self-gripping mesh.

PURPOSE: A large randomized, multicenter European study recently reported a reduction in early pain after open inguinal surgery when self-gripping mesh was used compared with sutured Lichtenstein repair. This secondary exploratory study is focused on the influence of nerve identification and handling on post-operative pain. METHODS: Post-operative VAS pain data and Surgical Pain Scores (SPS) from 507 patients included in this study were analyzed according to whether inguinal nerves were preserved or resected during surgery to investigate whether identification and peri-operative nerve handling impact post-operative pain. RESULTS: Preservation of the ilio-hypogastric nerve during Lichtenstein mesh repair with suture fixation was associated with significantly more post-operative pain compared with resection at each follow-up (p ≤ 0.003). This difference was not significant with self-gripping mesh repair. The decrease from baseline in post-operative VAS and SPS scores were significantly greater after self-gripping mesh repair compared to Lichtenstein repair at 1 year, but only when the ilio-hypogastric nerve was preserved (VAS scores, p = 0.009; SPS scores, p = 0.015). No such difference was observed with the ilio-inguinal nerve. When self-gripping mesh was used, preservation of the ilio-hypogastric nerve was associated with significantly greater decreases in post-operative pain (change in VAS score from baseline) compared with Lichtenstein repair at each follow-up (p ≤ 0.018). CONCLUSIONS: The ilio-hypogastric nerve is in danger of being traumatized during Lichtenstein mesh repair with suture fixation. The use of self-gripping mesh was shown to reduce the level of post-operative pain when the ilio-hypogastric nerve was preserved. Resection of the ilio-hypogastric nerve during Lichtenstein repair eliminates this difference.

Utilisation and outcomes of case-based discussion in otolaryngology training.

OBJECTIVES: To assess the reliability, validity and outcomes of Case-based Discussion (CBD) in otolaryngology training. DESIGN: Retrospective database analysis. SETTING: National electronic database. PARTICIPANTS: North London otolaryngology trainees. MAIN OUTCOME MEASURES: We tested the tool's reliability along with its capacity to denote trainee progress. A score was calculated (cS) and compared across core (CT) and specialty trainees (ST) at all levels. The number of items rated as "development required" (D) was also examined. RESULTS: One thousand four hundred and fifty-six CBDs were submitted by 46 trainees from 2007 to 2013, averaging 13.6 per trainee per year. Items relating to knowledge, management and judgement were more popular (98% usage), and better predictors of cS compared to other parameters (rs: +0.74, +0.70 and +0.72, respectively). CBD was found to be reliable (Cronbach's α = 0.848) and highly sensitive (99%), yet not specific. cS was significantly higher in ST than CT (95.3% ± 0.6 versus 88.7% ± 1.3). pS showed a similar pattern (3.15 ± 0.4 versus 2.0 ± 0.05) (P < 0.001). cS and pS increased from CT1 to ST8 (rs: +0.60 and +0.34, respectively). The number of D-rated items decreased with increasing year of training. CONCLUSION: Case-based discussion is a reliable and valid tool in otolaryngology training. It is highly sensitive but not specific. Trainees should be encouraged to use it at all levels.

Randomized clinical trial comparing self-gripping mesh with suture fixation of lightweight polypropylene mesh in open inguinal hernia repair.

BACKGROUND: Postoperative pain is an important adverse event following inguinal hernia repair. The aim of this trial was to compare postoperative pain within the first 3 months and 1 year after surgery in patients undergoing open mesh inguinal hernia repair using either a self-gripping lightweight polyester mesh or a polypropylene lightweight mesh fixed with sutures. METHODS: Adult men undergoing Lichtenstein repair for primary inguinal hernia were randomized to ProGrip™ self-gripping mesh or standard sutured lightweight polypropylene mesh. RESULTS: In total 557 men were included in the final analysis (self-gripping mesh 270, sutured mesh 287). Early postoperative pain scores were lower with self-gripping mesh than with sutured lightweight mesh: mean visual analogue pain score relative to baseline +1·3 and +8·6 respectively at discharge (P = 0·033), and mean surgical pain scale score relative to baseline +4·2 and +9·7 respectively on day 7 (P = 0·027). There was no significant difference in mid-term (1 month) and long-term (3 months and 1 year) pain scores between the groups. Surgery was significantly quicker with self-gripping mesh (mean difference 7·6 min; P < 0·001). There were no significant differences in reported mesh handling, analgesic consumption, other wound complications, patient satisfaction or hernia recurrence between the groups. CONCLUSION: Self-gripping mesh for open inguinal hernia repair was well tolerated and reduced early postoperative pain (within the first week), without increasing the risk of early recurrence. It did not reduce chronic pain. REGISTRATION NUMBER: NCT00827944 (http://www.clinicaltrials.gov).

Does direct observation of procedural skills reflect trainee's progress in otolaryngology?

BACKGROUND: UK surgical trainees are required to undertake work-based assessments each year in order to progress in their training. Direct Observation of Procedural Skills (DOPS) is one of these assessments. We aim to investigate the validity of DOPS in assessing otolaryngology trainees at all levels. METHODS: A retrospective search of the portfolios of all otolaryngology trainees in North Thames was carried out to identify otolaryngology-specific DOPS. A score (Cs) was calculated for each DOPS based on the percentage of satisfactorily-rated items. The overall performance rating (Ps) was analysed as a separate variable and compared with Cs. The Ps and Cs results were then compared across trainee grades and levels within each grade: Core trainees (CT1-CT2) and specialty trainees (ST3-ST8). RESULTS: Seven hundred and sixty-seven otolaryngology DOPS were completed between August 2008 and September 2013. The tool was found to be reliable and internally consistent. Trainees in ST grade had higher Cs and Ps scores than CT grade (P < 0.001). Pairwise comparison showed that both Cs and Ps increased from CT1 to ST3 (P = 0.005) but not from ST4 onwards (P = 0.198). CONCLUSIONS: Otolaryngology DOPS is a useful tool in assessing otolaryngology trainees especially from CT1-ST3 level. DOPS can also differentiate between junior and senior trainees. However, it was not able to demonstrate progress at levels above ST3, most likely due to the simplicity of the procedures which trainees tend to master in the first few years of training.

The impact of shortened postgraduate surgical training on colorectal cancer outcome.

BACKGROUND: Shortened postgraduate surgical training reforms, known as Calman, have altered delivery of surgical training in the UK with reduced working hours and training time aiming to produce a more subspecialised workforce. AIMS: This study aims to compare rectal cancer surgical outcomes of Calman-trained consultants in a single institution to published data. Additionally, the study compared colorectal cancer surgical outcome between Calman-trained consultants (CTCs) and non-Calman consultants (NCTCs) in a national dataset. METHODS: Local dataset Clinicopathological outcome of rectal cancer resection undertaken by CTCs in a single institution (2006-2010) were compared against NCTC counterparts. National dataset All elective colorectal cancer resections between 2004 and 2008 in English NHS hospitals were included. CTCs (present from 2004 onwards) were compared to NCTCs (present prior to 2004). Outcome measures included 30-day in-hospital mortality, reoperation and readmission rates. RESULTS: Local dataset One hundred thirteen patients were operated under five CTC. The 30-day in-hospital mortality for CTCs (1%) was favourable compared to published rates (3-5%). Local recurrence rate (4.4%) was comparable to NCTC (3.6%). National dataset Between 2004 and 2008, 44,106 patients underwent elective colorectal resection. Multiple regression demonstrated CTC patients had a reduced length of stay and reduced reoperation rate. No difference in mortality and unplanned readmission rates were seen. CONCLUSION: CTCs have similar safety outcome to NCTCs for colorectal cancer resection procedures. Further work is needed to assess the impact of further training reductions on clinical outcome.

Neoadjuvant chemotherapy and primary-first approach for rectal cancer with synchronous liver metastases.

AIM: Up to a quarter of patients with rectal cancer have synchronous liver metastases at the time of diagnosis. This is a predictor of poor outcome. There are no standardized guidelines for treatment. We reviewed the outcomes of our patients with synchronous rectal liver metastases treated with a curative intent by neoadjuvant chemotherapy with or without chemoradiotherapy followed by resection of the primary tumour and then liver metastases. METHOD: Between 2004 and 2012, patients who presented with rectal cancer and synchronous liver metastasis were treated with curative intent with peri-operative systemic chemotherapy as the first line of treatment. Responders to chemotherapy underwent resection of the primary tumour with or without preoperative chemoradiotherapy followed by hepatic resection. RESULTS: Fifty-three rectal cancer patients with 152 synchronous liver lesions were identified. After a median follow-up of 29.6 months, the median survival was 41.4 months. Overall survival was 59.0% at 3 years and 39.0% at 5 years. CONCLUSION: Rectal resection before hepatic resection combined with neoadjuvant chemotherapy is associated with promising clinical outcome. It allows downstaging of liver lesions and removal of the primary tumour before the progression of further micrometastases. Furthermore, patients who do not respond to chemotherapy can be identified and may avoid major surgical intervention.

How should perineal wounds be closed following abdominoperineal resection in patients post radiotherapy--primary closure or flap repair? Best evidence topic (BET).

This best evidence topic was investigated according to a described protocol. The question posed was: should the irradiated perineal wound following abdominoperineal resection (APR) be closed with primary repair or a myocutaneous flap. Using the reported search 364 papers were found of which eight represented the best evidence to answer the clinical question. The conclusion drawn is that there is some limited evidence for recommending flap closure in abdominoperineal resection post radiotherapy. The best evidence available was from a systematic review of cohort studies and case series. Although no meta-analysis was performed, overall wound healing was improved using flap closure with a low frequency of flap necrosis. Other studies providing evidence were case-control series or cohort studies. Three papers prospectively compared vertical rectus abdominus muscle (VRAM) flap with primary closure; two of which demonstrated statistically significant improvement in complication rates with flap closure. Two retrospective case control series showed significant improvement in major wound complication rates in the flap group. Two studies retrospectively compared gracilis flap repair with primary closure and showed significantly lower incidence of major perineal complications. Most studies suffered from significant limitations, small sample sizes and no direct comparisons between matched groups with respect to type of anatomic flap, wound size, tumour recurrence or radiation dose. Whilst there is evidence that myocutaneous flap closure following APR in radiotherapy patients can reduce wound related complications, prospective randomized controlled trials are warranted.

Clinical outcome following Doppler-guided haemorrhoidal artery ligation: a systematic review.

AIM: Doppler-guided haemorrhoidal artery ligation (DGHL) has experienced wider uptake and has recently received National Institute for Health and Clinical Excellence (NICE) approval in the UK. A systematic review of the literature was conducted to assess its safety and efficacy. METHOD: This review was conducted in keeping with PRISMA guidelines. MEDLINE, EMBASE, Google Scholar and Cochrane Library databases were searched. Studies describing DGHL as a primary procedure and reporting clinical outcome were considered. Primary end-points were recurrence and postoperative pain. Secondary end-points included operation time, complications and reintervention rates. Studies were scored for quality with either Jadad score or NICE scoring guidelines. RESULTS: Twenty-eight studies including 2904 patients were included in the final analysis. They were of poor overall quality. Recurrence ranged between 3% and 60% (pooled recurrence rate 17.5%), with the highest rates for grade IV haemorrhoids. Postoperative analgesia was required in 0-38% of patients. Overall postoperative complication rates were low, with an overall bleeding rate of 5% and an overall reintervention rate of 6.4%. The operation time ranged from 19 to 35 min. CONCLUSION: DGHL is safe and efficacious with a low level of postoperative pain. It can be safely considered for primary treatment of grade II and III haemorrhoids.

The STAR score: a method for auditing clinical records.

INTRODUCTION: Adequate medical note keeping is critical in delivering high quality healthcare. However, there are few robust tools available for the auditing of notes. The aim of this paper was to describe the design, validation and implementation of a novel scoring tool to objectively assess surgical notes. METHODS: An initial 'path finding' study was performed to evaluate the quality of note keeping using the CRABEL scoring tool. The findings prompted the development of the Surgical Tool for Auditing Records (STAR) as an alternative. STAR was validated using inter-rater reliability analysis. An audit cycle of surgical notes using STAR was performed. The results were analysed and a structured form for the completion of surgical notes was introduced to see if the quality improved in the next audit cycle using STAR. An education exercise was conducted and all participants said the exercise would change their practice, with 25% implementing major changes. RESULTS: Statistical analysis of STAR showed that it is reliable (Cronbach's α = 0.959). On completing the audit cycle, there was an overall increase in the STAR score from 83.344% to 97.675% (p < 0.001) with significant improvements in the documentation of the initial clerking from 59.0% to 96.5% (p < 0.001) and subsequent entries from 78.4% to 96.1% (p < 0.001). CONCLUSIONS: The authors believe in the value of STAR as an effective, reliable and reproducible tool. Coupled with the application of structured forms to note keeping, it can significantly improve the quality of surgical documentation and can be implemented universally.

Randomized controlled multicenter international clinical trial of self-gripping Parietex™ ProGrip™ polyester mesh versus lightweight polypropylene mesh in open inguinal hernia repair: interim results at 3 months.

PURPOSE: To compare clinical outcomes following sutureless Parietex™ ProGrip™ mesh repair to traditional Lichtenstein repair with lightweight polypropylene mesh secured with sutures. METHODS: This is a 3-month interim report of a 1-year multicenter international study. Three hundred and two patients were randomized; 153 were treated with Lichtenstein repair (L group) and 149 with Parietex™ ProGrip™ precut mesh (P group) with or without fixation. The primary outcome measure was postoperative pain using the visual analog scale (VAS, 0-150 mm); other outcomes were assessed prior to surgery and up to 3 months postoperatively. RESULTS: Compared to baseline, pain score was lower in the P group at discharge (-10%) and at 7 days (-13%), while pain increased in the L group at discharge (+39%) and at 7 days (+21%). The difference between groups was significant at both time points (P = 0.007 and P = 0.039, respectively). In the P group, patients without fixation suffered less pain compared to those with single-suture fixation (1 month: -20.9 vs. -6.15%, P = 0.02; 3 months: -24.3 vs. -7.7%, P = 0.01). The infection rate was significantly lower in the P group during the 3-month follow-up (2.0 vs. 7.2%, P = 0.032). Surgery duration was significantly shorter in the P group (32.4 vs. 39.1 min; P < 0.001). No recurrence was observed at 3 months in both groups. CONCLUSIONS: Surgery duration, early postoperative, pain and infection rates were significantly reduced with self-gripping polyester mesh compared to Lichtenstein repair with polypropylene mesh. The use of fixation increased postoperative pain in the P group. The absence of early recurrence highlights the gripping efficiency effect.

Dynamic Magnetic Resonance Imaging Demonstrates the Integrity of Perineal Reconstruction following Cylindrical Abdominoperineal Excision with Reconstruction of the Pelvic Floor Using Porcine Collagen.

A 72-year-old female presented with a six-month history of increased frequency of defecation, rectal bleeding, and severe rectal pain. Digital rectal examination and endoscopy revealed a low rectal lesion lying anteriorly. This was confirmed histologically as adenocarcinoma. Radiological staging was consistent with a T(3)N(2) rectal tumour. Following long-course chemoradiotherapy repeat staging did not identify any metastatic disease. She underwent a laparoscopic cylindrical abdominoperineal excision with en bloc resection of the coccyx and posterior wall of the vagina with a negative circumferential resection margin. The perineal defect was reconstructed with Permacol (biological implant, Covidien) mesh. She had no clinical evidence of a perineal hernia at serial followup. Dynamic MRI images of the pelvic floor obtained during valsalva at 10 months revealed an intact pelvic floor. A control case that had undergone a conventional abdominoperineal excision with primary perineal closure without clinical evidence of herniation was also imaged. This confirmed subclinical perineal herniation with significant downward migration of the bowel and bladder below the pubococcygeal line. We eagerly await further evidence supporting a role for dynamic MR imaging in assessing the integrity of a reconstructed pelvic floor following cylindrical abdominoperineal excision.

Robotic vs. laparoscopic Roux-en-Y gastric bypass in morbidly obese patients: systematic review and pooled analysis.

BACKGROUND: The aim of this study was to provide pooled analysis of individually small trials comparing robotic Roux-en-Y gastric bypass (RRYGB) with standard laparoscopic RYGB (LRYGB). METHODS: A systematic literature search of Medline, Embase and Cochrane Library databases was performed. Primary outcome measures were the incidence of anastomotic leak and stricture. Secondary outcome measures were post-operative complications, operative time and length of hospital stay. RESULTS: Seven relevant studies of 1686 patients were included in this analysis. There was a significantly reduced incidence of anastomotic stricture in the robotic group (POR = 0.43; 95% CI = 0.19 to 0.98; p = 0.04). There was no significant difference between robotic and laparoscopic groups for anastomotic leak, post-operative complications, operative time and length of hospital stay. CONCLUSION: The incidence of anastomotic stricture was reduced with RRYGB compared with LRYGB over a minimum follow-up period of 6 months, thus demonstrating the potential benefit of RRYGB.

Prognostic biomarkers in squamous cell carcinoma of the anus: a systematic review.

BACKGROUND: recent decades have seen combination chemoradiotherapy become the standard treatment for anal squamous cell carcinoma (SCC). However, the burden of this disease continues to rise, with only 10% of patients with metastatic disease surviving >2 years. Further insight into tumour characteristics and molecular biology may identify novel therapeutic targets. This systematic review examines current prognostic markers in SCC of the anus. METHODS: an extensive literature search was performed to identify studies reporting on biomarkers in anal cancer in the context of clinical outcome following treatment primarily with chemoradiotherapy. RESULTS: in all, 21 studies were included. A total of 29 biomarkers were studied belonging to 9 different functional classes. Of these biomarkers, 13 were found to have an association with outcome in at least one study. The tumour-suppressor genes p53 and p21 were the only markers shown to be of prognostic value in more than one study. CONCLUSIONS: an array of biomarkers have been identified that correlate with survival following chemoradiotherapy in anal cancer. However, investigators are yet to identify a biomarker that has the ability to consistently predict outcome in this disease. Further studies are needed to elucidate whether these candidate biomarkers demonstrate their optimum value when they serve as targets for new therapeutic strategies.

Prognostic significance of circulating tumour cells following surgical resection of colorectal cancers: a systematic review.

BACKGROUND: The role of adjuvant chemotherapy after resection of colorectal cancers (CRCs) is well understood for patients with stage-I or stage-III disease. Its efficacy for those with stage-II disease remains much less clear. Many investigators have sought to identify prognostic markers that might clarify which patients have the highest risk of recurrence and would, therefore, be most likely to benefit from chemotherapy. This systematic review examines evidence for the use of peripherally sampled, circulating tumour cells (CTCs) as such a prognostic marker. METHODS: A comprehensive literature search was used to identify studies reporting on the significance of CTCs in the postoperative blood of CRC patients. RESULTS: Fourteen studies satisfied the inclusion criteria. Six of the nine studies that took blood samples 24 h or more postoperatively found detection of postoperative CTCs to be an independent predictor of cancer recurrence. CONCLUSION: The presence of CTCs in peripheral blood at least 24 h after resection of CRCs is an independent prognostic marker of recurrence. Further studies are needed to clarify the optimal time point for blood sampling and determine the benefit of chemotherapy in CTC-positive patients with stage-II disease.

Development of a virtual reality training curriculum for laparoscopic cholecystectomy.

BACKGROUND: Training within a proficiency-based virtual reality (VR) curriculum may reduce errors during real surgical procedures. This study used a scientific methodology for development of a VR training curriculum for laparoscopic cholecystectomy. METHODS: Inexperienced (had performed fewer than ten laparoscopic cholecystectomies), intermediate (20-50) and experienced (more than 100) surgeons were recruited. Construct validity was defined as the ability to differentiate between the three levels of experience, based on simulator-derived metrics for nine basic skills, four procedural tasks and full laparoscopic cholecystectomy on a high-fidelity VR simulator. Inexperienced subjects performed ten repetitions for learning curve analysis. Proficiency measures were based on the performance of experienced surgeons. RESULTS: Thirty inexperienced, 11 intermediate and 16 experienced operators were recruited. Eight of nine basic skills and three of four procedural tasks were found to be construct valid. The full procedure revealed significant intergroup differences for time (1541, 673 and 816 s; P = 0.002), movements (1021, 595 and 638; P = 0.006) and path length (2038, 1235 and 1303 cm; P = 0.033). Learning curves plateaued between the second and ninth sessions. CONCLUSION: This study shows that it is possible to define and develop a whole-procedure VR training curriculum for laparoscopic cholecystectomy using structured scientific methodology.