The Introduction of Magtrace® Lymphatic Tracer for Axillary Sentinel Node Biopsy for Breast Cancer in a Rural Scottish District General Hospital: Initial Experience, Perspectives, Outcomes and Learning Curves.

BACKGROUND: Magtrace is a supraparamagnetic iron lymphatic tracer that has had increasing use in sentinel node biopsy (SNB) for breast cancer and has theoretical logistical benefits in centres where nanocolloid use may be associated with such issues. We describe our initial experience with the introduction of Magtrace into our routine practice by dual localisation with nanocolloid, comparing performance, and concordance. MATERIALS AND METHODS: This was prospective study of the first patients undergoing axillary SNB using Magtrace in a single centre. These patients had dual localisation with nanocolloid and Magtrace. Subjective global assessments of Magtrace and nanocolloid performance as well as objective signal strength and anatomical concordance were compared across multiple timepoints in the operative journey. RESULTS: A total of 30 consecutive patients underwent SNB within the timeframe of this study. While there were no failed SNB, 8 issues were reported including 4 issues of perceived imperfect localisation on global assessment. No patient had a failed or abandoned SNB, and only 1 case had a potential challenge in subsequent management after histopathological examination of the retrieved nodes. The majority of these issues occurred in the first half of the study period. There was overall weak to moderate positive correlation between Magtrace and nanocolloid signals of the retrieved sentinel nodes (Spearman's ρ = 0.392, P = .043). CONCLUSION: This study suggests that introducing Magtrace was feasible and safe in the context of a rural breast cancer service. A possible strategy to ameliorate the learning curve associated with these procedures is the routine dual localisation in the initial phases of performing Magtrace localisation.

Robotic-assisted surgery for left-sided colon and rectal resections is associated with reduction in the postoperative surgical stress response and improved short-term outcomes: a cohort study.

INTRODUCTION: There is growing evidence that the use of robotic-assisted surgery (RAS) in colorectal cancer resections is associated with improved short-term outcomes when compared to laparoscopic surgery (LS) or open surgery (OS), possibly through a reduced systemic inflammatory response (SIR). Serum C-reactive protein (CRP) is a sensitive SIR biomarker and its utility in the early identification of post-operative complications has been validated in a variety of surgical procedures. There remains a paucity of studies characterising post-operative SIR in RAS. METHODS: Retrospective study of a prospectively collected database of consecutive patients undergoing OS, LS and RAS for left-sided and rectal cancer in a single high-volume unit. Patient and disease characteristics, post-operative CRP levels, and clinical outcomes were reviewed, and their relationships explored within binary logistic regression and propensity scores matched models. RESULTS: A total of 1031 patients were included (483 OS, 376 LS, and 172 RAS). RAS and LS were associated with lower CRP levels across the first 4 post-operative days (p < 0.001) as well as reduced complications and length of stay compared to OS in unadjusted analyses. In binary logistic regression models, RAS was independently associated with lower CRP levels at Day 3 post-operatively (OR 0.35, 95% CI 0.21-0.59, p < 0.001) and a reduction in the rate of all complications (OR 0.39, 95% CI 0.26-0.56, p < 0.001) and major complications (OR 0.5, 95% CI 0.26-0.95, p = 0.036). Within a propensity scores matched model comparing LS versus RAS specifically, RAS was associated with lower post-operative CRP levels in the first two post-operative days, a lower proportion of patients with a CRP ≥ 150 mg/L at Day 3 (20.9% versus 30.5%, p = 0.036) and a lower rate of all complications (34.7% versus 46.7%, p = 0.033). CONCLUSIONS: The present observational study shows that an RAS approach was associated with lower postoperative SIR, and a better postoperative complications profile.

A Paper-Based Simulation Model for Teaching Inguinal Hernia Anatomy.

BACKGROUND: Inguinal hernias remain a challenging area of learning for medical students due to its relatively complex anatomy. Modern curriculum delivery methods are conventionally limited to didactic lectures and demonstration of anatomy intraoperatively. These strategies have limitations; lectures are inherently descriptive and based on 2-dimensional models, while intraoperative teaching is often unstructured and opportunistic. METHODS: A paper-based model was developed comprising three overlapping paper panels simulating the anatomical layers of the inguinal canal which can be modified readily to further simulate various hernia pathologies and their surgical repair. These models were incorporated into a timetabled structured learning session for 3rd- and 4th-year medical students. Learners responded to fully anonymised surveys before and after the learning session. FINDINGS: A total of 45 students participated in these sessions over a period of 6 months. Pre-learning session mean ratings for the learners' confidence in their understanding of the layers of the inguinal canal, identifying indirect and direct inguinal hernias and in naming the contents of the inguinal canal were 2.5, 3.3 and 2.9, while post-learning session mean ratings were 8.0, 9.4 and 8.2, respectively. Paired samples Student's t-tests for all three questions were statistically significant (p < 0.001). The mean rating for usefulness of the session was 9.6/10. Free comments from students emphasised the models' usefulness as a visual learning aid. DISCUSSION AND CONCLUSION: Our novel, low-cost paper model was associated with an improvement in learners' perceived knowledge and understanding of inguinal canal anatomy and pathology.

Dr Google - assessing the reliability and readability of information on general surgical procedures found via search engines.

BACKGROUND: The most common general surgical emergency operations are laparoscopic appendicectomy, laparoscopic cholecystectomy, hernia repair, hemorrhoidectomy and colectomy. Patients commonly perform an internet search for more information prior to undergoing surgery, which can lead to an inappropriate understanding of their procedure. The aim is to assess the quality of information available on three of the most used search engines. METHODS: A search was conducted on Google.com, Bing.com and Yahoo.com using the terms related to laparoscopic appendicectomy, laparoscopic cholecystectomy, hemorrhoidectomy, hernia repair and colectomy. First 20 results from each search engine were collected for evaluation. Results were excluded if they were sponsored, duplicates, academic publications, advertisements, forums, audiovisual tools, social media or any non-English information. Included results were assessed for reliability using DISCERN and JAMA benchmark score. Readability was assessed using Flesch Reading Ease (FRE) Score and Simple Measure of Gobbledygook (SMOG). RESULTS: Hundred and ninety-seven websites were analysed, 44.7% were published by institutions, 34.5% by health websites and 20.8% by independent surgeons. Mean DISCERN scores for Institutions was 54.6 ± 11.3, independent surgeons 45.9 ± 11.4 and health websites 58.7 ± 10.3. Mean JAMA score for Institutions was 1.0 ± 1.0, independent surgeons 0.1 ± 0.4 and health websites 1.7 ± 1.1. FRE scores for institutions was 51.6 ± 10.3, independent surgeons 40.9 ± 10.2, and health websites 45.7 ± 12.3. SMOG scores were 9.8 ± 1.5 for institutions, 11.4 ± 1.6 for independent surgeons and 10.6 ± 1.7 for health websites. CONCLUSION: Health information on common general surgical procedures found on search engines are generally fair to good quality but still above the suggested reading level of the population. Information on surgical procedures should be written at recommended reading level of 13-14 years old.

A novel model for hands-on laparoscopic pelvic surgery training on Genelyn-embalmed body: an initial feasibility study.

The human donor body provides a well-accepted ex vivo model for laparoscopic surgical training. Unembalmed, or fresh-frozen, bodies comprise high-fidelity models. However, their short life span and high cost relatively limit the hands-on training benefits. In contrast, soft embalmed body of donors has a relatively longer usability without compromising tissue flexibility. This study reports the initial experience of the utility and feasibility of human donor Genelyn-embalmed body as a novel soft-embalmed cadaveric model for laparoscopic surgical training. An expert laparoscopic surgeon, who organised many fresh-frozen body donor courses, performed deep laparoscopic pelvic dissection and laparoscopic surgical tasks including suturing and electrosurgery on a single Genelyn-embalmed body. The three sessions were performed over a course of 3 weeks. The body was fully embalmed using the Genelyn technique. The technique consisted of a single-point closed arterial perfusion of embalming solution via the carotid artery with no further exposure to or immersion in embalming fluids thereafter. The donor's Genelyn-embalmed body provided a feasible model for laparoscopic surgical training. Initial experience shows evidence of this model being feasible and realistic. There was reproducibility of these qualities across a minimum of 3 weeks in this single-donor study. Initial experience shows that donor's Genelyn-embalmed body provides a novel model for laparoscopic surgical training, which possesses fidelity and is feasible for laparoscopic training. While further studies are needed to validate these findings, this technical note provides perspectives from an expert trainer regarding this model and provides a photographic and videographic atlas of this model's use in laparoscopy.

Weight loss in adults following bariatric surgery, a systematic review of preoperative behavioural predictors.

Bariatric surgery is effective in treating obesity in many cases, yet as many as 50% of patients may not achieve the desired weight reduction. Preoperative modifiable behavioural factors could help patient selection and intervention design to improve outcomes. Medline, EMBASE, Cochrane Library and PsychINFO were searched to identify studies published between 1 January 2008 and 14 February 2019 reporting on preoperative modifiable behavioural factors associated with postoperative weight loss, with minimum 2 years follow-up. A total of 6888 articles were screened, 34 met the inclusion criteria. Maladaptive eating behaviours (MEB), preoperative weight loss (PWL), and tobacco use were reported 21, 18, and 3 times respectively. Physical activity and substance abuse were each reported once. Most articles on PWL (72.2%) and MEB (52.4%) reported no association. Positive associations were reported in 22.2% and 14.3% of articles for PWL and MEB respectively. Negative associations were reported in 5.6% and 33.3% of articles for PWL and MEB, respectively. Marked heterogeneity in outcome reporting hindered quantitative synthesis. The current paucity of evidence amenable to synthesis leads to ongoing uncertainty regarding the size and direction of association between PWL and MEB with outcomes following bariatric surgery. Long-term studies with common reporting of outcomes are needed.

Inflammatory reaction to fish oil coated polypropylene mesh used for laparoscopic incisional hernia repair: a case report.

BACKGROUND: Polypropylene meshes are widely used in hernia repairs. Hernia meshes have been developed incorporating coatings of active agents. One commercially available mesh has a fish oil coating which is promoted as having anti-inflammatory properties. We report a case, a symptomatic foreign body granuloma reaction associated with a fish oil coated polypropylene mesh, which required eventual mesh explantation. CASE PRESENTATION: A 61-year old lady with previous peptic ulcer disease underwent a laparoscopic intraperitoneal placement of mesh for incisional hernia utilising a fish oil coated polypropylene mesh. The patient presented 3 months after the procedure complaining of dyspepsia and pain at the operative site. There was no discharge. The patient was managed conservatively. She presented 10 months post-operatively with progressively worsening symptoms and a hard palpable mass in the epigastrium. Abdominal laparoscopy revealed dense adhesive disease around the mesh with exudates. Adhesiolysis, mesh explantation and a partial gastrectomy was performed. Histopathological examination revealed a foreign body granuloma formation to the mesh. CONCLUSION: In-vivo studies looking at intraperitoneal mesh placement with fish oil coatings including data on surgical outcomes such as fistula and adhesive characteristics are scarce in the literature. Further monitoring and studies are required to investigate the safety and efficacy profile of this mesh type in in-vivo models.

Determining Surgical Complications in the Overweight (DISCOVER): a multicentre observational cohort study to evaluate the role of obesity as a risk factor for postoperative complications in general surgery.

INTRODUCTION: Obesity is increasingly prevalent among patients undergoing surgery. Conflicting evidence exists regarding the impact of obesity on postoperative complications. This multicentre study aims to determine whether obesity is associated with increased postoperative complications following general surgery. METHODS AND ANALYSIS: This prospective, multicentre cohort study will be performed utilising a collaborative methodology. Consecutive adults undergoing open or laparoscopic, elective or emergency, gastrointestinal, bariatric or hepatobiliary surgery will be included. Day case patients will be excluded. The primary end point will be the overall 30-day major complication rate (Clavien-Dindo grade III-V complications). Data will be collected to risk-adjust outcomes for potential confounding factors, such as preoperative cardiac risk. This study will be disseminated through structured medical student networks using established collaborative methodology. The study will be powered to detect a two-percentage point increase in the major postoperative complication rate in obese versus non-obese patients. ETHICS AND DISSEMINATION: Following appropriate assessment, an exemption from full ethics committee review has been received, and the study will be registered as a clinical audit or service evaluation at each participating hospital. Dissemination will take place through national and local research collaborative networks.

Resonance metallic ureteric stent in a case of ketamine bladder induced bilateral ureteric obstruction with one year follow up.

INTRODUCTION: Upper urinary tract occlusion is well recognized in patients with chronic ketamine abuse. The mechanism is generally unknown, but the ulcerative cystitis contracture may be responsible for obstruction. We present the first reported use of the Resonance metallic ureteric stent in the management ureteric obstruction caused by ketamine-induced uropathy. PRESENTATION OF CASE: A 31-year-old lady with one-year history of recreational ketamine abuse presented with symptoms related to drug-induced ulcerative cystitis over twelve-months. She presented with acute renal failure with bilateral pyonephrosis and sepsis, and was initially treated with bilateral nephrostomy insertions and antegrade stenting. The J stents recovered the renal function, but the patient suffered from recurrent urinary tract infections (UTI's) with the prosthesis in-situ. The patient successfully underwent bilateral insertion of 12cm 6.0 French Cook Resonance metallic ureteric stents. One year following the placement of the metallic stents, the patient maintained optimal renal function with no episode of UTI. DISCUSSION: Ketamine induced uropathy is a well documented complication of chronic drug-induced ulcerative cystitis. The mechanical strength and inert property of metallic ureteric stents make it an ideal device to manage this problematic benign cause of ureteric obstruction. CONCLUSION: This is the first reported case of therapeutic bilateral metallic ureteric stents in the management of patients with ketamine induced uropathy with one year follow up.