Assessment of the Safety and Effectiveness of Colorectal Robotic-Assisted Surgery: The First 50 Consecutive Cases at a Single Centre.

BACKGROUND: Colorectal robotic-assisted-surgery (RAS) is a novel technology with scarce real-world evidence. The aim of this retrospective review was to ascertain the safety and effectiveness of colorectal RAS. METHODS: The da Vinci® Xi™ robot system (Intuitive Surgical, Inc., Sunnyvale, CA, USA) was used to perform the first 50 colorectal resections in our centre. Outcomes regarding safety and efficacy were analysed and learning curves (LC) were plotted using RStudio. RESULTS: The median patient age and BMI were 65 years (IQR, 50.25-76.5) and 28.3kg/m2 (IQR, 25.2-30.7), respectively, and 27 patients were female. Malignancy (66%) followed by rectal prolapse (18%) was the most frequent diagnosis, and all malignant tumours were completely resected. High anterior resection was the most frequently performed operation (36%). The median operative time was 256.5 minutes (IQR, 202.2-332.8). Twenty-seven patients had anastomosis (54%), a stoma was formed in 7 (14%) and 7 anastomoses required defunctioning loop ileostomy (14%). Two unexpected intra-operative events occurred, and neither required conversion to an open procedure. Thirty-eight complications occurred in 21 patients, and most were minor by the Clavien-Dindo classification: CD 1 (17, 44.7%) or 2 (11, 28.9%). Moreover, 5 patients developed an anastomotic leak (14.7%), 5 developed infections (10%), 2 required transfusions (4%) and 3 needed re-operation (6%). There was no 30-day mortality and the readmission rate was 8%. The median length of stay in hospital was 6 days (IQR,4-8). All resections, except for low anterior resections, resulted in a significantly longer stay compared to rectopexies. Finally, projections from LCs indicated that outcome optimization can be achieved after experience with 33-39 cases. CONCLUSIONS: Colorectal RAS in our centre was both safe and effective. In the initial 50 cases, there was no 30-day mortality and no need for conversion to an open surgery. The readmission and complication (>CD 2) rates were 8% and 20%, respectively.

A narrative review of the use of alcohol during the Covid-19 pandemic; effects and implications.

The Covid-19 pandemic created an environment wherein stress and isolation could increase alcohol consumption. The effects of alcohol consumption on Covid-19 susceptibility and the impact of the Covid-19 pandemic on alcohol use, related harms and services were explored.Search terms were inputted to Medline and Embase databases, with relevant published papers written in English chosen.Alcohol ingestion both increased and decreased throughout the population globally, however, the overall trend was an increase. Risk factors for this included female sex, young age, family conflicts, unemployment, mental health disorders, substance misuse and lack of support. Alcohol misuse was found to be an aggravator of domestic violence and worsening mental health. It exacerbated the risk of contracting SARS-CoV-2 and worsened the Covid-19 infection severity, with >10 drinks/week increasing the acute respiratory distress syndrome (ARDS) risk similarly to established risk factors. This was attributed to the immunosuppressive and disinhibition effects of alcohol. Therefore, healthcare professionals should provide support to vulnerable groups, encouraging stress reduction, healthy habits, limiting alcohol consumption (<5 drinks/week) and promoting coping techniques. Self-help tools that monitor individual alcohol intake and psychosocial interventions in a primary care setting can also be employed. Finally, governing bodies should inform the public of the risks of alcohol ingestion during the Covid-19 pandemic.Thus, the Covid-19 pandemic could create a cycle whereby alcohol misuse could become a risk factor for Covid-19 infection and the Covid-19 pandemic could become a risk factor for alcohol misuse. Healthcare professionals should counsel people on alcohol misuse risk and protective factors.

Clinical practice guidelines on the use of deep brain stimulation for the treatment of obsessive-compulsive disorder: systematic review.

BACKGROUND: Deep brain stimulation (DBS) has been proposed to improve symptoms of obsessive-compulsive disorder (OCD) but is not yet an established therapy. AIMS: To identify relevant guidelines and assess their recommendations for the use of DBS in OCD. METHOD: Medline, Embase, American Psychiatric Association PsycInfo and Scopus were searched, as were websites of relevant societies and guideline development organisations. The review was based on the PRISMA recommendations, and the search strategy was verified by a medical librarian. The protocol was developed and registered with PROSPERO (CRD42022353715). The guidelines were assessed for quality using the AGREE II instrument. RESULTS: Nine guidelines were identified. Three guidelines scored >80% on AGREE II. 'Scope and Purpose' and 'Editorial Independence' were the highest scoring domains, but 'Applicability' scores were low. Eight guidelines recommended that DBS is used after all other treatment options have failed to alleviate OCD symptoms. One guideline did not recommend DBS beyond a research setting. Only one guideline performed a cost-effectiveness analysis; the other eight did not provide details on safe or effective DBS protocols. CONCLUSION: Despite a very limited evidence base, eight of the nine identified guidelines supported the use of DBS for OCD as a last line of therapy; however, multiple aspects of DBS provision were not addressed.

Enfortumab vedotin and pembrolizumab as monotherapies and combination treatment in locally advanced or metastatic urothelial carcinoma: A narrative review.

Background: Bladder cancer is the 10th most common cancer globally. The majority of bladder cancers are urothelial carcinomas (UCs), which, if locally advanced or metastatic, carry poor long-term prognosis. Cancer cells can evade the immune system by expressing the programmed cell death ligand 1 protein (PD-L1). Programmed cell death ligand 1 protein binds to programmed cell death protein 1 (PD-1) on T cells, inhibiting their antitumor action. Bladder tumor cells also overexpress nectin-4, a cell adhesion polypeptide that contributes to metastasis, worsening prognosis. Current platinum-based chemotherapy treatments are suboptimal. This review aimed to assess novel treatments for locally advanced or metastatic UC that specifically target PD-L1 or nectin-4, namely, the PD-1 inhibitor pembrolizumab and the anti-nectin-4 antibody-drug conjugate enfortumab vedotin (EV). Materials and methods: Relevant English-language peer-reviewed articles and conference abstracts from the last 5 years were identified through MEDLINE and EMBASE database searches. A narrative review was performed, with key results outlined below. Results: Pembrolizumab was demonstrated to be superior to chemotherapy as a second-line treatment for platinum-unresponsive participants in the KEYNOTE-045 trial, resulting in its Food and Drug Administration (FDA) approval. Enfortumab vedotin therapy resulted in superior outcomes compared with chemotherapy in the EV-301 trial, resulting in FDA approval for its use for patients with locally advanced or metastatic UC who had previously undergone treatment with platinum-based chemotherapy and PD-1/PD-L1 inhibitors. Positive preliminary results for pembrolizumab and EV combination therapy have led to FDA approval in patients with locally advanced or metastatic UC who are not eligible for platinum chemotherapy. Conclusions: Pembrolizumab and EV represent novel treatment options for patients with locally advanced or metastatic UC with documented superior outcomes and tolerability as compared with standard chemotherapy.