Assessment of the Quality of Patient-Oriented Internet Information on Fluorescence Imaging in Surgery.

BACKGROUND: In the digital age, patients are increasingly turning to the Internet to seek medical information to aid in their decision-making process before undergoing medical treatments. Fluorescence imaging is an emerging technological tool that holds promise in enhancing intra-operative decision-making during surgical procedures. This study aims to evaluate the quality of patient information available online regarding fluorescence imaging in surgery and assesses whether it adequately supports informed decision-making. METHOD: The term "patient information on fluorescence imaging in surgery" was searched on Google. The websites that fulfilled the inclusion criteria were assessed using 2 scoring instruments. DISCERN was used to evaluate the reliability of consumer health information. QUEST was used to assess authorship, tone, conflict of interest and complementarity. RESULTS: Out of the 50 websites identified from the initial search, 10 fulfilled the inclusion criteria. Only two of these websites were updated in the last two years. The definition of fluorescence imaging was stated in only 50% of the websites. Although all websites mentioned the benefits of fluorescence imaging, none mentioned potential risks. Assessment by DISCERN showed that 30% of the websites were rated low and 70% were rated moderate. With QUEST, the websites demonstrated an average score of 62.5%. CONCLUSION: This study highlights the importance of providing patients with accurate and balanced information about medical technologies and procedures they may undergo. Fluorescence imaging in surgery is a promising technology that can potentially improve surgical outcomes. However, patients need to be well-informed about its benefits and limitations in order to make informed decisions about their healthcare.

The rise of robotic colorectal surgery: better for patients and better for surgeons.

Robotic colorectal surgery represents a major technological advancement in the treatment of patients with colorectal disease. Several recent randomized controlled trials comparing robotic colorectal surgery with laparoscopic surgery have demonstrated improved short-term patient outcomes in the robotic group. Whilst the primary focus of research in robotic surgery has been on patient outcomes, the robotic platform also provides unparalleled benefits for the surgeon, including improved ergonomics and surgeon comfort, with the potential to reduce occupational injuries and prolong career longevity. It is becoming clear that robotic surgical systems improve patient outcomes and may provide significant benefits to the surgical workforce.

Sigmoid Diverticulitis in a Tight Spot: An Atypical Presentation Within a Ventral Hernia.

Ventral hernia and acute diverticulitis may present with similar symptoms posing difficulty in clinical diagnosis. Rarely, complicated sigmoid diverticulitis is found within an irreducible ventral hernia sac in the emergency setting. Intraoperative decision on the appropriate surgical option depends on the surgeon's experience and the patient's clinical state. We present a case of a middle-aged female who came in with infraumbilical hernia containing necrotic sigmoid diverticulitis. Her surgical history was cesarean section and total abdominal hysterectomy with a re-look laparotomy. She had an emergency exploration of the hernia through a midline incision, excision of the necrotic diverticulum, and the formation of loop colostomy at the site of the hernia. Post-operative recovery was uneventful and she has been scheduled for an elective sigmoid colectomy and reversal of the stoma. This study highlights that complicated sigmoid diverticulitis can rarely present as an irreducible ventral hernia and that less is often more in safely getting patients out of trouble in an emergency.

Fluorescence imaging in colorectal surgery.

BACKGROUND: Fluorescent imaging is an emerging technological tool that can guide surgeons during surgery by highlighting anatomical structures and pathology, and help with intraoperative decision making. METHODS: A comprehensive review of published literature was performed using the search terms "fluorescence", "imaging" and "colorectal surgery" in PubMed. Only clinical trials that were published in English were included in this review. Ex vivo and animal studies were excluded. RESULTS: This review demonstrates the use of fluorescence imaging in colorectal surgery in four areas: (1) assessment of tissue perfusion and vasculature; (2) assessment of tumour; (3) lymphatic drainage and (4) identification of the urinary tract. The most commonly used fluorescent dyes are nonspecific, such as indocyanine green and methylene blue, but there is increasing interest in the development of specific fluorescently labelled molecular markers. CONCLUSION: Fluorescence imaging is a potentially useful tool for colorectal surgery. Early studies on fluorescence imaging have been promising but larger scale randomised controlled trials are warranted to demonstrate the effectiveness and benefits of using fluorescence imaging routinely. The development of molecular dyes that are specific to targets could significantly increase the potential use of fluorescence imaging during surgery.

Methylene blue fluorescence of the ureter during colorectal surgery.

BACKGROUND: Iatrogenic ureteric injury is a serious complication of colorectal surgery. Incidence is estimated to be between 0.3 and 1.5%. Of all ureteric injuries, 9% occur during colorectal procedures. Ureteric stents are utilised as a method to reduce the risk of injury; however, these are not without risk and do not guarantee prevention of injury. Fluorescence is a safe and effective alternative for intraoperative ureteric localisation. This proof of principle study aims to assess the use of methylene blue to fluoresce the ureter during colorectal surgery. METHOD: Patients undergoing elective colorectal surgery were included in this open label, non-randomised study. Methylene blue was administered intravenously at varying doses (0.25-1 mg/kg) over 5 min, 10-15 min prior to entering 'ureteric territory.' Fluorescence was assessed using the PINPOINT Deep Red laparoscopic system at fixed time points by the surgeon and an independent observer. RESULTS: 42 patients received methylene blue; 2 patients were excluded from analysis. Of the 69 ureters assessed, 64 were seen under fluorescence. Of these, 14 were not visible under white light. 50 ureters were observed with both fluorescence and white light with 14 of these being seen earlier with fluorescence. In ten cases, fluorescence revealed the ureter to be in a different location than suspected. CONCLUSION: Fluorescence is a promising method to allow visualisation of the ureter, where it is not identified easily under standard operative conditions, thereby improving safety and reducing operative time and difficulty.

Intraoperative identification and analysis of lymph nodes at laparoscopic colorectal cancer surgery using fluorescence imaging combined with rapid OSNA pathological assessment.

BACKGROUND: Standard surgical practice for colorectal cancer involves resection of the primary lesion and all draining lymph nodes. Accurate intraoperative assessment of nodal status could allow stratified resectional extent. One-step nucleic acid (OSNA) can provide a rapid method of interrogating nodal tissue, whilst near-infrared (NIR) laparoscopy together with indocyanine green (ICG) can identify relevant nodal tissue intraoperatively. METHODS: ICG was administered around the tumour endoscopically prior to the operation. Fluorescent nodes identified by NIR were marked and submitted for whole-node OSNA analysis. Further fresh lymph nodes dissected from the standard resection specimen were examined and analysed by both conventional histology and OSNA. In addition, the status of the fluorescent nodes was compared to that of non-ICG nodes to assess their predictive value. RESULTS: Sixteen patients were recruited with a total final lymph node count of 287. 78 fresh lymph nodes were identified on fresh dissection for both histological and OSNA assessment with an analytical concordance rate of 98.7% (77/78). OSNA sensitivity was 1 (0.81-1, 95% CI) and specificity 0.98 (0.91-1, 95% CI). Six patients had a total of nine nodes identified intraoperatively by ICG fluorescence. Of these nine nodes, one was positive for metastasis on OSNA. OSNA analysis of the ICG-labelled node matched the final histological nodal stage in 3/6 patients (two being N0 and one N1). The final pathological nodal stage of the other three was N1 or N2, while the ICG nodes were negative. CONCLUSION: OSNA is highly concordant with standard histology, although only a minority of nodes identifiable by full pathological analysis were found for OSNA on fresh dissection. OSNA can be combined with NIR and ICG lymphatic mapping to provide intraoperative assessment of nodal tissue in patients with colorectal cancer.

Assessment of the Quality of Patient-Orientated Information on Surgery for Crohn's Disease on the Internet.

BACKGROUND: The Internet is a vast resource for patients to search for health information on the treatment of Crohn's disease. OBJECTIVE: This study examines the quality of Web sites that provide information to adults regarding Crohn's disease, including treatment options and surgery. DESIGN: Two search engines (Google and Yahoo) and the search terms "surgery for Crohn's disease" were used. The first 50 sites of each search were assessed. Sites that fulfilled the inclusion criteria were evaluated for content and scored by using the DISCERN instrument, which evaluates the quality of health information on treatment choices. RESULTS: One hundred sites were examined, of which 13 were duplicates. Sixty-two sites provided patient-orientated information. The other sites included 7 scientific articles, 3 blogs, 2 links, 6 forums, 3 video links, and 4 dead links. Of the 62 Web sites that provided patient information for adults, only 15 (24.2%) had been updated within the past 2 years. Only 9 (14.5%) were affiliated with hospitals and clinics. The majority of sites (33, 53.2%) were associated with private companies with commercial interests. Only half of the Web sites provided details on treatment options, and most Web sites did not provide any information on symptoms and procedure details. Just 5 Web sites (8.1%) described the risks of surgery, and only 7 (11.3%) provided any information on the timescale for recovery. Overall, only 1 Web site (1.6%) was identified as being "good" or "excellent" with the use of the DISCERN criteria. LIMITATIONS: Although the internet is constantly evolving, this study captures data at a specific time point. Search results may vary depending on geographical location. This study only assessed English language websites. CONCLUSIONS: The quality of patient information on surgery for Crohn's disease is highly variable and generally poor. There is potential for the Internet to provide valuable information, and clinicians should identify high-quality Web sites to guide their patients.

Stem cell differentiation and lumen formation in colorectal cancer cell lines and primary tumors.

Single cancer stem-like cells (CSC) from colorectal cancers can be functionally identified by their ability to form large lumen-containing colonies in three-dimensional Matrigel cultures. These colonies contain the three types of differentiated colorectal epithelial cells, and single cells obtained from them can reproduce themselves and form tumors efficiently in immunodeficient mice. In this study, we show how hypoxia affects these CSC-derived lumens to control differentiation of stem-like cells and enterocytes via the homeobox gene CDX1. Lumens were identified by F-actin staining and they expressed many characteristics associated with normal differentiated intestinal epithelium, including brush border enzymes, polarization, and tight junctions. RNA interference-mediated silencing of CDX1 reduced lumen formation. Inhibitory effects of hypoxia on lumen formation and stem cell differentiation, including suppression of CDX1 expression, could be mimicked by inhibiting prolyl-hydroxylases that activate HIF1, suggesting that HIF1 is a critical mediator of the effects of hypoxia in this setting. Cell line-derived lumens were phenotypically indistinguishable from colorectal tumor glandular structures used by pathologists to grade tumor differentiation. Parallel results to those obtained with established cell lines were seen with primary cultures from fresh tumors. This in vitro approach to functional characterization of CSCs and their differentiation offers a valid model to study colorectal tumor differentiation and differentiation of colorectal CSCs, with additional uses to enable high-throughput screening for novel anticancer compounds.

Assessment of the quality of patient-orientated Internet information on surgery for diverticular disease.

BACKGROUND: The Internet is a vast resource available for patients to obtain health information. OBJECTIVE: This study examines the quality of Web sites that provide information on diverticular disease, treatment options, and surgery. DESIGN: Two search engines (Google and Yahoo) and the search terms "surgery and diverticular disease" and "surgery and diverticulitis" were used. The first 50 sites of each search were assessed. Sites that fulfilled the inclusion criteria were evaluated for content and scored by using the DISCERN instrument, which evaluates the quality of health information on treatment choices. RESULTS: Two hundred sites were examined, of which 60 (30%) provided patient-orientated information. 50 sites (25%) were duplicated, 7 (3.5%) were links, 10 (5%) were advertisements, 14 (7%) were resources for clinicians, 9 (4.5%) were message forums, 27 (13.5%) were articles, and 15 (7.5%) were dead links. Of the 60 Web sites that provided patient information, only 10 (16.7%) had been updated within the past 2 years. Seventeen (28.3%) sites were affiliated with hospitals and clinics, but another 17 (28.3%) sites were associated with private companies with commercial interests. Although most Web sites contained information on symptoms, complications, investigations, and treatment options of diverticular disease, 20 (33.3%) did not describe any of the risks of surgery, and 45 (75%) did not provide information on the timescale of recovery postoperatively. Eighteen sites did not provide balanced information on treatment options; of these, 7 were biased toward medical treatment and 6 focused on laparoscopic surgery. Overall, only 22 (36.7%) were identified as being "good" or "excellent" with the use of the DISCERN criteria. CONCLUSIONS: The quality of patient information on surgery for diverticular disease is highly variable, and Web sites that are sponsored by private companies may be biased in discussing treatment options. There is potential for the Internet to provide valuable information, and clinicians should guide patients to access high-quality Web sites.

What is the potential of oligodendrocyte progenitor cells to successfully treat human spinal cord injury?

BACKGROUND: Spinal cord injury is a serious and debilitating condition, affecting millions of people worldwide. Long seen as a permanent injury, recent advances in stem cell research have brought closer the possibility of repairing the spinal cord. One such approach involves injecting oligodendrocyte progenitor cells, derived from human embryonic stem cells, into the injured spinal cord in the hope that they will initiate repair. A phase I clinical trial of this therapy was started in mid 2010 and is currently underway. DISCUSSION: The theory underlying this approach is that these myelinating progenitors will phenotypically replace myelin lost during injury whilst helping to promote a repair environment in the lesion. However, the importance of demyelination in the pathogenesis of human spinal cord injury is a contentious issue and a body of literature suggests that it is only a minor factor in the overall injury process. SUMMARY: This review examines the validity of the theory underpinning the on-going clinical trial as well as analysing published data from animal models and finally discussing issues surrounding safety and purity in order to assess the potential of this approach to successfully treat acute human spinal cord injury.

Regulation of self-renewal and differentiation by the intestinal stem cell niche.

The gastrointestinal epithelium is a highly organised tissue that is constantly being renewed. In order to maintain homeostasis, the balance between intestinal stem cell (ISC) self-renewal and differentiation must be carefully regulated. In this review, we describe how the intestinal stem cell niche provides a unique environment to regulate self-renewal and differentiation of ISCs. It has traditionally been believed that the mesenchymal myofibroblasts play an important role in the crosstalk between ISCs and the niche. However, recent evidence in Drosophila and in vertebrates suggests that epithelial cells also contribute to the niche. We discuss the multiple signalling pathways that are utilised to regulate stemness within the niche, including members of the Wnt, BMP and Hedgehog pathways, and how aberrations in these signals lead to disruption of the normal crypt-villus axis. Finally, we also discuss how CDX1 and inhibition of the Notch pathway are important in specifying enterocyte and goblet cell differentiation respectively.