Randomized clinical trial of accelerated enhanced recovery after minimally invasive colorectal cancer surgery (RecoverMI trial).

BACKGROUND: Minimally invasive surgery (MIS) and enhanced recovery protocols (ERPs) have improved postoperative recovery and shortened length of hospital stay (LOS). Telemedicine technology has potential to improve outcomes and patient experience further. This study was designed to determine whether the combination of MIS, ERP and a structured telemedicine programme (TeleRecovery) could shorten total 30-day LOS by 50 per cent. METHODS: This was a phase II prospective RCT at a large academic medical centre. Eligible patients aged 18-80 years undergoing minimally invasive colorectal resection using an ERP were randomized after surgery. The experimental arm (RecoverMI) included accelerated discharge on postoperative day (POD) 1 with or without evidence of bowel function and a televideoconference on POD 2. The control arm was standard postoperative care. The primary endpoint was total 30-day LOS (postoperative stay plus readmission/emergency department/observation days). Secondary endpoints included patient-reported outcomes measured by EQ-5D-5L™, Brief Pain Inventory (BPI) and a satisfaction questionnaire. RESULTS: Thirty patients were randomized after robotic (21 patients) or laparoscopic (9) colectomy, including 14 patients in the RecoverMI arm. Median 30-day total LOS was 28·3 (i.q.r. 23·7-43·6) h in the RecoverMI arm and 51·5 (43·8-67·0) h in the control arm (P = 0·041). There were no differences in severe adverse events or EQ-5D-5L™ score between the study arms. The BPI revealed low pain scores regardless of treatment arm. Satisfaction was high in both arms. CONCLUSION: In patients having surgery for colorectal neoplasms, the trimodal combination of MIS, ERP and TeleRecovery can reduce 30-day LOS while preserving patients' quality of life and satisfaction. Registration number: NCT02613728 ( https://clinicaltrials.gov).

ANTECEDENTES: La cirugía mínimamente invasiva (minimally invasive surgery, MIS) y los protocolos de recuperación intensificada (enhanced recovery protocols, ERP) han mejorado la recuperación postoperatoria y acortan la duración de la estancia (length of stay, LOS). La tecnología de la telemedicina tiene potencial para mejorar aún más los resultados y la experiencia del paciente. Este estudio se diseñó para determinar si la combinación de MIS, ERP y un programa estructurado de telemedicina (TeleRecovery) podría acortar la LOS total a los 30 días en un 50%. MÉTODOS: Se efectuó un ensayo controlado aleatorizado, prospectivo, de fase II en un gran centro médico académico. Los pacientes elegibles de 18-80 años de edad que se sometieron a resección colorrectal MIS mediante ERP se asignaron al azar después de la resección quirúrgica. El brazo experimental (RecoverMI) incluyó el alta acelerada en el día 1 del postoperatorio (postoperative day, POD) con o sin evidencia de recuperación del tránsito intestinal y una televideoconferencia en el día 2 POD. Los pacientes en el grupo control recibieron los cuidados postoperatorios habituales. El criterio de valoración principal fue la LOS total (estancia postoperatoria más reingreso/estancia en urgencias/días de observación) a los 30 días. Los criterios de valoración secundarios incluyeron los resultados referidos por los pacientes medidos por los cuestionarios EQ-5D-5L, el Cuestionario Breve del Dolor (Brief Pain Inventory, BPI) y un cuestionario de satisfacción. RESULTADOS: Treinta pacientes fueron aleatorizados después de una colectomía robótica (21) o laparoscópica (9), incluidos 14 pacientes en el grupo de RecoverMI. La mediana de la LOS total a los 30 días fue de 28,3 horas (rango intercuartílico, RIQ 23,7-43,6) en el grupo de RecoverMI y de 51,5 horas (RIQ 43,8-67,0) en el grupo control (P = 0,04). No hubo diferencias entre los grupos de estudio en los eventos adversos graves o en las puntuaciones del EQ-5D-5L. El BPI mostró puntuaciones bajas de dolor independientemente del grupo de tratamiento. La satisfacción fue alta en ambos grupos. CONCLUSIÓN: Entre los pacientes que se someten a cirugía por cáncer colorrectal, la combinación trimodal de MIS, ERP y TeleRecovery puede reducir la LOS a los 30 días, preservando la calidad de vida y la satisfacción del paciente.

Output factors for blocked fields.

This study investigates the output from blocked treatment fields with 6 MV and 18 MV photons. Square fields, defined by collimators, were blocked down to smaller symmetrical square, rectangular and asymmetrical rectangular fields using blocks on a tray beneath the collimators. Up to 7.5% difference was found between the output measured for the blocked field and the output calculated using a collimator output factor for the surface field size. A method is described by which output factors for the blocked fields can be measured and used in practice. Three methods of approximating these output factors are also presented.

Results of treatment of carcinoma of the uterine cervix using the Newcastle afterloading technique.

Eighty-seven patients with carcinoma of the uterine cervix were seen between 1 August 1977 and 31 December 1985. Seventy-one patients were treated radically. A combination of intracavitary radiotherapy, using the Newcastle manual afterloading technique, and external-beam radiotherapy was used. The actuarial 4-year survival for all Stage 1 cervical carcinomas was 84.9%. For Stage 2 cancers the actuarial local control rate was 71.1% and the survival 49.2% and for Stage 3 cancers the 4-year actuarial local control rate was 24.3% and the survival 14.8%. Complications of treatment were confined to the bowel and bladder and occurred in 11.5% of cases. The results of treatment of Stage 1 cancer suggest that the intracavitary technique gives a satisfactory distribution of radiation. The results of treatment of more advanced cases are disappointing and suggest that improvements are possible for some patients (i.e. wedge malalignment patients). There is sufficient flexibility in the technique for it to be applied satisfactorily for most anatomical situations.

Gynaecological treatments using the Selectron remote afterloading system.

The Manchester method of gynaecological treatment using radium 226, ovoids and a flexible intrauterine tube has been used in many centres. In Newcastle, the Manchester technique was used until 1971, when a manually afterloaded system (MAS) using caesium 137 and two source trains was introduced. In 1985, the MAS was replaced by the Selectron remote afterloading system (RAS), which also uses caesium-137 sources. The dosimetry of this remote system has been designed to produce the same shape of isodose distributions as the MAS, but shorter treatment times. The applicator design and the dosimetry of the system used in Newcastle are discussed. Dose rates achieved by the RAS are more than double those currently produced by the MAS, and a reduction in prescribed dose of 10-20% is being made. The percentage of ward staff receiving monthly doses of more than 0.2 mSv has fallen from 78% to 18% since the introduction of the remote afterloading system. The almost-cylindrical isodose distributions facilitate matching of external beam treatments using a central lead wedge to the intracavitary treatments, and work is in progress to develop this technique.

Stability of the human body investigated by sway magnetometry.

A new technique using a pre-calibrated magnetometer has been used to investigate the stability of the human body. Transducer coils were attached to a belt which was worn by the subject. Sway was measured over 30 s periods with eyes open and eyes closed. For 10 normal subjects, the mean sway speed was 3.6 +/- 0.9 mm/s with eyes open, and 5.3 +/- 1.5 mm/s with eyes closed. The mean ratio for eyes open to eyes closed was 0.68 +/- 0.10. The test was simple to perform and gave reproducible results.