Development of a procedure-specific tool for skill assessment in left- and right-sided laparoscopic complete mesocolic excision.

AIM: To (1) develop an assessment tool for laparoscopic complete mesocolic excision (LCME) and (2) report evidence of its content validity. METHOD: Assessment statements were revealed through (1) semi-structured expert interviews and (2) consensus by the Delphi method, both involving an expert panel of five LCME surgeons. All experts were interviewed and then asked to rate LCME describing statements from 1 (strongly disagree) to 5 (strongly agree). Responses were returned anonymously to the panel until consensus was reached. Statements were directly included as content in the assessment tool if ≥60% of the experts responded "agree" or "strongly agree" (ratings 4 and 5), with the remaining responses being "neither agree nor disagree" (rating 3). Interclass correlation coefficient (ICC) was calculated for expert agreement evaluation. All included statements were subsequently reformulated as tool items and approved by the experts. RESULTS: Four Delphi rounds were performed to reach consensus. Disagreement was reported for statements describing instrument handling around pancreas; visualisation of landmarks before inferior mesenteric artery ligation; lymphadenectomy around the inferior mesenteric artery, and division of the terminal ileum and transverse colon. ICC in the last Delphi-round was 0.84. The final tool content included 73 statements, converted to 48 right- and 40 left-sided items for LCME assessment. CONCLUSION: A procedure-specific, video-based tool, named complete mesocolic excision competency assessment tool (CMECAT), has been developed for LCME skill assessment. In the future, we hope it can facilitate assessment of LCME surgeons, resulting in improved patient outcome after colon cancer surgery.

Going, gonad, gone. Gender inequalities in the management of gonadal torsion: a cohort study.

Gonadal torsion (when the gonad twists on its ligamentous supports) is a surgical emergency in both men and women. Prompt management is essential to preserve gonadal function. Our aim was to compare the timeliness with which men and women who underwent surgery for suspected gonadal torsion are managed. All adult patients who underwent surgery for suspected gonadal torsion between 1/4/16 and 31/3/18 were reviewed and the following times recorded: symptom onset; hospital presentation; gynaecological/surgical review; decision for theatre; and knife-to-skin (KTS). The surgical procedure(s) and intra-operative findings were also documented. In total, 31 women (mean age 29.4 ± 7.1yrs) and 49 men (mean age 23.2 ± 7.0yrs) were identified. Women waited significantly longer than men at every stage (p < 0.01). Time intervals between hospital presentation and review, review and decision for theatre, and decision and KTS were 1.6 (1.2-2.6 hrs), 0.3 (0.0-0.9 hrs) and 1.7 (1.5-2.5 hrs) for men and 4.3 (3.1-15.3 hrs), 10.3 hrs (2.4-20.7 hrs) and 4.7 (2.3-9.3 hrs) for women, respectively. Torsion was confirmed in 20 (64.5%) women and 25 (51.0%) men. Intraoperatively, 13(65%) ovaries were reportedly necrotic compared to only 6 (24%) testes (p = 0.0076). All necrotic gonads were removed despite conservative surgery being recommended practice during the study period. Women with suspected gonadal torsion received suboptimal care compared to their male counterparts, which has potentially catastrophic consequences for the subsequent fertility of this predominantly young population.

A prospective case control study of functional outcomes and related quality of life after colectomy for neoplasia.

AIM: Our aim was to assess bowel function and its effect on overall quality of life (QOL) when compared to healthy controls after colectomy. METHODS: Patients undergoing resection of colorectal neoplasia were recruited pre-operatively and followed up at 6 and 12 months, to assess 'early' bowel function. Patients who underwent surgery 2 to 4 years previously were recruited for assessment of 'intermediate' bowel function. Healthy relatives were recruited as controls. The Memorial Sloan-Kettering Cancer Centre and EQ-5D questionnaires were used to assess bowel function and QOL, respectively. Statistical assessment included regression analyses, parametric and non-parametric tests. The association between QOL and Memorial Sloan-Kettering Cancer Centre (MSKCC) scores was evaluated using Spearman's rank correlation. RESULTS: Ninety-one patients were recruited for assessment of 'early' and 85 for 'intermediate' bowel function. There were 85 controls. Patients had a significantly higher number of bowel movements at each follow-up (p < 0.001). At 12 months after surgery, patients reported difficulty with gas-stool discrimination. The 'intermediate' group were found to have lower scores for flatus control (<0.001) and total frequency score (p 0.03), indicating worse function. Patients with higher total MSKCC scores, no symptoms of urgency and those able to control flatus reported better QOL (p 0.006, 0.007 and 0.005, respectively) at 6 and 12 months. Gas-stool differentiation and complete evacuation correlated with better QOL in the 'intermediate' bowel function group (p 0.02 and 0.02, respectively). CONCLUSION: Colonic resection adversely affects elements of bowel function up to 4 years after surgery. Good colonic function, represented by higher MSKCC scores, correlates with better QOL.

Operative time and outcome of enhanced recovery after surgery after laparoscopic colorectal surgery.

BACKGROUND AND OBJECTIVES: Combining laparoscopy and enhanced recovery provides benefit to short-term outcomes after colorectal surgery. Advances in training and techniques have allowed surgeons to operate on cases that are technically challenging and associated with prolonged operative time. Laparoscopic techniques improve the outcome of enhanced recovery after colorectal surgery; however, there are no specifications on the effect of prolonged operations on the outcome. The objective was to elucidate the impact of prolonged surgery and blood loss on the outcome of enhanced recovery after surgery after laparoscopic colorectal surgery. METHODS: Four-hundred patients who underwent elective colorectal resection on enhanced recovery after surgery in Yeovil District Hospital between 2002 and 2009 were retrospectively reviewed. Delayed discharge was defined as a prolonged length of stay beyond the mean in this series (≥8 days). RESULTS: Three-hundred eighty-five patients were included. Median operative time was 180 minutes with a median blood loss of 100 mL. Conversion was not associated with a prolonged length of stay. Operative time and blood loss correlated with length of stay in a stepwise fashion. There were 2 cutoff points of operative time at 160 minutes and 300 minutes (5 hours), where risk of prolonged stay increased significantly (odds ratio [OR] 2.02; 95% confidence interval [CI], 1.05-3.90; P = .027), and blood loss of >500 mL (OR 3.114; 95% CI, 1.501-6.462, P = .002). CONCLUSIONS: Total operative timing impacts negatively on the outcome of enhanced recovery after laparoscopic colorectal resections with increased risk of delayed discharge seen after ∼2.5 hours and 5-hour duration.

A systematic review regarding the feasibility and safety of endoscopic full thickness resection (EFTR) for colonic lesions.

PURPOSE: This review summarizes the published methods of colonic EFTR, examining data on feasibility and safety. Due to the introduction of bowel cancer screening programs, there is an increasing incidence of complex colonic polyps and early colonic cancer that requires segmental colectomy. Traditional radical surgery is associated with significant morbidity, and there is a need for alternative treatments. METHODS: Systematic literature search identified articles describing EFTR techniques of colon, published between 1990 and 2012. Complication rates, anastomotic bursting pressures, procedure duration, specimen size and quality, and postmortem findings were analyzed. RESULTS: Five research groups reported four EFTR techniques using endoscopic stapling devices, T-tags, compression closure, or laparoscopic assistance for defect closure before or after specimen resection. A total of 113 procedures were performed in 99 porcine models, with an overall success rate of 89 and 4 % mortality. The intraoperative complication rate was 22 % (0-67 %). Post-resection closure methods more commonly resulted in failure to close the defect (5-55 %) and a high incidence of abnormal findings at postmortem examination (84 %). Significant heterogeneity was observed in procedure duration (median or mean 3-233 min) and size of the excised specimen (median or mean 1.7-3.6 cm). Anastomotic bursting pressures and specimen quality were poorly documented. CONCLUSIONS: The technique of EFTR is developing, but the inability to close the resection defect reliably is a major obstacle. The review highlights the challenges that need to be addressed in future preclinical studies.

Full-thickness laparoendoscopic excision in the stomach: the FLEx technique.

BACKGROUND: The authors describe the initial validation of a novel full-thickness laparoendoscopic excision (FLEx) technique for the stomach. METHODS: The technique was studied in seven 50-kg pigs. Secure full-thickness excision was ensured by inversion excision target with a 1-cm circumferential margin using laparoendoscopically placed brace bars passed intraluminally from the outside of the stomach, laparoscopic oversewing of the site of inversion, and endoscopic full-thickness excision using a dual scope approach. Pigs were sacrificed either immediately (n = 3) or between 7 and 10 days after surgery (n = 4). RESULTS: The procedure achieved uncomplicated full-thickness excision in every case. Median procedure duration was 227 minutes (range = 210-245 minutes). Median specimen diameter was 5.5 cm (range = 2.5-8 cm). Investigative autopsy confirmed technical sufficiency in all animals. Median site bursting pressure was 130 mm Hg (range = 120-160 mm Hg). CONCLUSIONS: The FLEx technique proved useful for excision of small localized lesions of the stomach in this animal study.

How will health-care organizations meet venous thromboembolism targets?

Health-care organizations need to develop a strategy to ensure that all hospitalized patients receive appropriate thromboprophylaxis. This review describes an evidence-based model which could improve service delivery, meet national targets, save money and reduce the incidence of hospital-acquired venous thromboembolism.