Getting to grips with endoscopy - Learning endoscopic surgical skills induces bi-hemispheric plasticity of the grasping network.

Endoscopic surgery requires skilled bimanual use of complex instruments that extend the peri-personal workspace. To delineate brain structures involved in learning such surgical skills, 48 medical students without surgical experience were randomly assigned to five training sessions on a virtual-reality endoscopy simulator or to a non-training group. Brain activity was probed with functional MRI while participants performed endoscopic tasks. Repeated task performance in the scanner was sufficient to enhance task-related activity in left ventral premotor cortex (PMv) and the anterior Intraparietal Sulcus (aIPS). Simulator training induced additional increases in task-related activation in right PMv and aIPS and reduced effective connectivity from left to right PMv. Skill improvement after training scaled with stronger task-related activation of the lateral left primary motor hand area (M1-HAND). The results suggest that a bilateral fronto-parietal grasping network and left M1-HAND are engaged in bimanual learning of tool-based manipulations in an extended peri-personal space.

A research agenda for the European Association for Endoscopic Surgeons (EAES).

INTRODUCTION: The European Association of Endoscopic Surgeons (EAES) conducted this study aiming to identify the top research questions which are relevant to surgeons in Minimal Access Surgery (MAS). This is in order to promote and link research questions to the current clinical practice in MAS in Europe. METHODS: Using a systematic methodology, (modified Delphi), the EAES members and leadership teams were surveyed to obtain consensus on the top research priorities in MAS. The responses were categorized and redistributed to the membership to rate the level of importance of each research question. The data were reported as the weighted average score with a scale from 1 (lowest agreement) to 5 (highest agreement). RESULTS: In total, 324 of 2580 (12.5%) of the EAES members and the leaders responded to the survey and contributed to the final consensus. The ranked responses over the 80th percentile identified 39 research priorities with rating ranged from 4.22 to 3.67. The top five highest ranking research priorities in the EAES were centered on improving training in MAS, laparoscopic surgery for benign upper gastrointestinal conditions, integration of novel technology in OR, translational and basic science research in bariatric surgery and investigating the role of MAS in rectal cancer. CONCLUSION: An EAES research agenda was developed using a systematic methodology and can be used to focus MAS research. This study was commissioned by the European Association for Endoscopic Surgery (EAES).

[Limited evidence for best treatment of uncomplicated gallbladder stones]. / Begrænset evidens for bedste behandling af ukompliceret galdestenssygdom

Gallbladder stones will rarely lead to colic pain attacks and even more seldom to complications. A conservative watchful waiting strategy may be an alternative to cholecystectomy for uncomplicated symptomatic gallbladder stone disease. Evidence for whether the optimal treatment should be cholecystectomy or watchful waiting is weak. This narrative-condensed review critically analyses current evidence with special focus on epidemiological risk factors of developing symptoms or complications related to gallbladder stones. The evidence for treatment is discussed.

[Median arcuate ligament syndrome]. / Truncus coeliacus-kompressionssyndrom.

The median arcuate ligament syndrome is a rare entity and poorly described in Danish literature. The syndrome is a diagnosis of exclusion and is characterized by chronic abdominal pain, postprandial pain and weight loss. It is believed that the median arcuate ligament, being a fibrous structure of diaphragm, compresses the coeliac trunk thus causing stenosis and malperfusion of the gastrointestinal organs. Until recently, there has been some reluctance to consider intervention with revascularization or ligament release. Within the latest decade minimally invasive techniques, including laparoscopic release of the median arcuate ligament, have shown promising results.

Limited success in patients treated with transanal haemorrhoidal dearterialisation.

INTRODUCTION: Transanal haemorrhoidal dearterialisation (THD) is a novel non-excisional technique based on suture closure of the haemorrhoidal arterial flow feeding the haemorrhoidal plexus. The primary objective of this study was to report the first Danish experience with THD. METHODS: The study was a single-centre, non-controlled retrospective study that comprised consecutive patients from a two-year period. Prior to the study start, THD was introduced in our surgical department as the standard treatment of Grade III-IV haemorrhoids. All patients were clinically examined 4-6 weeks post-operatively. Additionally, a structured telephone interview was conducted within two years after the THD operation. RESULTS: During the study period (from January 2011 to January 2013), 93 patients underwent a THD procedure. Twenty patients were exluded from the study which left 73 patients for analysis. Treatment success was obtained in 47 patients (64%) after a median follow-up period of nine months (range 1-24 months). CONCLUSION: We found a relatively low success rate of 64% in patients undergoing THD. Our findings may, in part, reflect a learning curve, patient selection, or that a low success rate is associated with the use of THD per se. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

[Mortality during admission in a surgical department].

A review of patient charts in 322 in-hospital deaths in one surgical unit from July 1 2010 to June 31 2011. Overall mortality was 2.9%, with terminal cancer patients, patients unsolvable at admission and patients declining treatment comprising 35.7% of patients dying. Most fatalities (169/53%) were after acute admission (median age 78 years, 61%, ASA score > 2). Stratification of in-hospital mortality in surgical patients is feasible and meaningful. A measurable reduction in surgical mortality is probably only possible in the group of patients with acute admissions.

Non-radiographic intraoperative fluorescent cholangiography is feasible.

INTRODUCTION: Intraoperative fluorescent cholangiography (IFC) with concomitant fluorescent angiography was recently developed for non-invasive identification of the anatomy during laparoscopic cholecystectomy. The objective of this study was to assess the time required for routine-use of IFC and to evaluate the success rate of the procedures. MATERIAL AND METHODS: A total of 35 patients scheduled for laparoscopic cholecystectomy and operated by the same surgeon were consecutively enrolled. A standardised protocol with IFC including angiography was performed during laparoscopic cholecystectomy. Intraoperative time and exposure of predefined anatomical structures were recorded. RESULTS: The median time used for IFC was 2.6 minutes (range: 1.5-11.4 minutes) corresponding to a median of 6.2% (range: 3.0-15.2%) of the operation time. The junction between the cystic duct, the common bile duct and the common hepatic duct was identified by IFC in all patients. In 29 of the 35 patients (83%; 95% confidence interval: 71-96%), the cystic artery was visualised by fluorescent angiography. No adverse effects or complications were recorded. CONCLUSION: Routine-use of IFC with fluorescent angiography during laparoscopic cholecystectomy is feasible and associated with an acceptable time expenditure and a satisfactory success-rate. FUNDING: Not relevant. TRIAL REGISTRATION: The Regional Ethics Committee approved the study (J. No. H-3-2013-FSP45). The study is registered with clinicaltrials.gov (ID: NCT02136095).

Less tachycardia during transnasal versus conventional gastroscopy.

INTRODUCTION: Transnasal endoscopy is well tolerated, but physiological benefits compared with conventional gastroscopy have not been studied in detail. The aims of this randomised study were to evaluate cardiopulmonary features, patient tolerance, and the endoscopist's evaluation of transnasal versus conventional endoscopy. MATERIAL AND METHODS: Patients were randomized to either a conventionally sized transoral (50 patients) or to a transnasal endoscopy (48 patients). Pulse rate and oxygen saturation were registered as well as the patient's tolerance and the endoscopist's evaluation of the procedure. RESULTS: The success rate for transnasal gastroscopy was 77%, mainly because of nasal stenosis. The per- and post-endoscopy pulse rates of the conventional group were elevated compared with those of the transnasal group (p = 0.04 and p = 0.02). Procedural discomfort in the two groups was similar, but significantly fewer transnasal patients reported gagging (p < 0.01). The endoscopists evaluated the technical features as good even if they did not reach those of conventional gastroscopy (p < 0.05). CONCLUSION: In this study, transnasal gastroscopy was technically inferior to conventional gastroscopy. There was no benefit in terms of patient comfort, except for less gagging. A lower stress response was indicated by significantly lower pulse rates during transnasal than during conventional gastroscopy, but the clinical relevance of this finding needs to be further investigated.

Warm-up in a virtual reality environment improves performance in the operating room.

OBJECTIVE: To assess the impact of warm-up on laparoscopic performance in the operating room (OR). BACKGROUND: Implementation of simulation-based training into clinical practice remains limited despite evidence to show that the improvement in skills is transferred to the OR. The aim of this study was to evaluate the impact of a short virtual reality warm-up training program on laparoscopic performance in the OP. METHODS: Sixteen Laparoscopic Cholecystectomies were performed by 8 surgeons in the OR. Participants were randomized to a group which received a preprocedure warm-up using a virtual reality simulator and no warm-up group. After the initial laparoscopic cholecystectomy all surgeons served as their own controls by performing another procedure with or without preoperative warm-up. All OR procedures were videotaped and assessed by 2 independent observers using the generic OSATS global rating scale (from 7 to 35). RESULTS: There was significantly better surgical performance on the laparoscopic Cholecystectomy following preoperative warm-up, median 28.5 (range = 18.5-32.0) versus median 19.25 (range = 15-31.5), P = 0.042. The results demonstrated excellent reliability of the assessment tool used (Cronbach's alpha = 0.92). CONCLUSION: This study showed a significant beneficial impact of warm-up on laparoscopic performance in the OP. The suggested program is short, easy to perform, and therefore realistic to implement in the daily life in a busy surgical department. This will potentially improve the procedural outcome and contribute to improved patient safety and better utilization of OR resources.

Randomized clinical trial comparing oral prednisone (50 mg) with placebo before laparoscopic cholecystectomy.

BACKGROUND: Intravenous administration of dexamethasone 90 min before laparoscopic cholecystectomy improves surgical outcome but may be impractical. The objective of this study was to assess the clinical efficacy of oral self-administration of prednisone 2 h before ambulatory laparoscopic cholecystectomy. METHODS: In a double-blind placebo-controlled study, 200 patients were randomized to oral administration of prednisone (50 mg) or placebo 2 h before laparoscopic cholecystectomy. Patients received a similar standardized anaesthetic, surgical, and analgesic treatment. The primary outcome was pain 24 h after surgery and secondary outcomes were fatigue and malaise 24 h after surgery. Outcome parameters were registered before operation, on the day of operation, and the following two days. Analgesic and antiemetic requirements were registered, and nausea and vomiting were assessed twice within the first 24 h. Side-effects and 30-day follow-up for morbidity were registered. RESULTS: Data from 184 patients were available for statistical analysis. There were no significant differences in side-effects or complications between the surgical groups (P > 0.05). No significant intergroup differences in 24-h pain, fatigue or malaise scores or any other variables were found (P > 0.05). CONCLUSION: There is no important clinical gain of preoperative oral steroid administration compared with placebo in patients undergoing laparoscopic cholecystectomy.

[What happens to gallstone patients discharged without cholecystectomy? Follow-up of 222 consecutive patients with initially untreated gallstones]. / Hvad sker der hos personer med galdeblaeresten, hvis de ikke får foretaget kolecystektomi? Opfølgning af 222 konsekutive patienter med initialt ubehandlet galdestenssygdom.

INTRODUCTION: The aim of this study was to investigate the cholecystectomy rate and rate of gallstone-related complications in patients formerly seen and discharged without operation from the Clinic for Day-Surgery, Glostrup University Hospital, Denmark. MATERIALS AND METHODS: From January 2000 to December 2002 a total of 222 patients with gallstones were discharged without operation (lap. cholecystectomy) from the day-surgery clinic. All admittances and surgical procedures in the follow-up period were identified by reading patient files and strategic searches in the National Patient Register in which all operations in Denmark are registered. RESULTS: The median follow-up period was 37 months (range 5-62 months). 25% of patients were operated in the follow-up period (cholecystectomy, n = 54, gallstone ileus, n=1). 13% had gallstone-related complications in the follow-up period. 9 patients had one or more endoscopic retrograde cholangiographies. There was no mortality or serious surgical complications. CONCLUSION: There is a lack of objective criteria for cholecystectomy in symptomatic cholecystolithiasis. The national guidelines in Denmark advocate cholecystectomy only in patients with socially disabling pain attacks. These guidelines are followed in our department and the strategy seems acceptable and patient-friendly, although the optimal treatment strategy for patients with symptomatic gallstone disease is still unknown.

The impact of objective assessment and constructive feedback on improvement of laparoscopic performance in the operating room.

OBJECTIVES: The study was carried out to demonstrate the impact of assessment and constructive feedback on improvement of laparoscopic performance in the operating room (OR). DESIGN: Sixteen surgical trainees performed a laparoscopic cholecystectomy in the OR. The participants were then divided into two groups. The procedure performed by group 1 was assessed by an experienced surgeon, and detailed and constructive feedback was provided to each trainee. Group 2 received no feedback. Subsequently, all subjects performed a new laparoscopic cholecystectomy in the OR. Both operative procedures were recorded on videotapes and assessed by two independent and blinded observers using a validated scoring system. MAIN OUTCOME MEASURES: Error and economy of movements score assessed during the laparoscopic procedures in the OR. RESULTS: No differences in baseline assessments were found between the two groups (t-test, p > 0.5). Surgeons, who received feedback (group 1) made significantly greater improvement in their time to complete the following procedure (independent sample t-test, p = 0.022), error (t-test, p = 0.003) and economy of movement scores (t-test, p < 0.001). CONCLUSIONS: Surgeons who received constructive feedback made significantly greater improvement in their performance in the OR compared with those in the control group. The study provides objective evidence that assessment is beneficial for surgical training and should be implemented in the educational programmes in the future.

[Laparoscopic colorectal surgery in Denmark 2004-2005]. / Laparoskopisk kolorektal kirurgi i Danmark 2004-2005.

INTRODUCTION: The postoperative course following colorectal surgery has improved since the introduction of "fast track surgery", and laparoscopic surgery will probably optimize the results further. The aim of this study was to evaluate the implementation of laparoscopic colorectal surgery in Denmark. MATERIALS AND METHODS: The number of laparoscopic colorectal resections performed in the period between 1 January 2004 and 1 November 2005 was obtained from the National Patient Register of the National Board of Health. RESULTS: A total of 441 laparoscopic colorectal resections were performed. 350 of these were colonic resections without creation of a stoma. These operations were performed in 23 departments, of which only 5 performed more than 20 laparoscopic resections. The median length of stay was 5 days, with a mean of 6.7 days after laparoscopic colon resection. CONCLUSION: It is not appropriate that so many departments have started using this advanced laparoscopic procedure, due to the high learning curve, cost considerations and need for international consensus. It is proposed that the treatment be coordinated nationwide in order to optimise research and clinical results.

[Diagnostic laparoscopy under local anaesthesia]. / Diagnostisk laparoskopi under lokal anaestesi.

Laparoscopy under local anaesthesia (LULA) is a safe, feasible and well-tolerated procedure. LULA has been successfully used for such outpatient gynaecological procedures as diagnosis of chronic pelvic pain and sterilisation. Single studies have indicated that LULA can be performed for diagnosis of possible intra-abdominal catastrophe in ICU patients, appendectomy and preperitoneal inguinal hernia repair. LULA in abdominal surgery for diagnosis of conditions presenting with acute lower abdominal pain is being introduced at our institution. This paper describes the possible applications of LULA in current practice as well as the technical aspects of the procedure.

ECG changes during endoscopic retrograde cholangio-pancreatography and coronary artery disease.

OBJECTIVE: Myocardial ischaemia has been described during endoscopic retrograde cholangio-pancreatography (ERCP), but the pathogenesis remains unclear. The aim of the present study was to evaluate whether coronary artery disease was present in patients with ST-segment changes during ERCP. MATERIAL AND METHODS: Forty patients were monitored with a Holter tape recorder during ERCP. Patients with ST-segment deviation during ERCP subsequently underwent a standard exercise ECG test. RESULTS: Twelve patients developed signs of myocardial ischaemia during ERCP (30%) and 9 had concomitant tachycardia. None had a cardiac history or cardiorespiratory symptoms. Ten of the 12 patients did an exercise test and one patient developed silent ischaemia. Subsequent coronary angiography showed no evidence of coronary artery disease. CONCLUSIONS: No signs of existing coronary artery disease were found in patients developing ST deviation during ERCP when evaluated with a 12-lead exercise ECG test. Further studies should evaluate other mechanisms responsible for myocardial ischaemia during ERCP.

[Treatment of gallstone pancreatitis in Denmark]. / Behandlingen af galdestenspankreatitis i Danmark.

INTRODUCTION: The aim of the study was to describe the treatment of gallstone pancreatitis in Denmark and to compare it to the recommendations given in the National Reference Programme for the treatment of patients with gallstone disease. MATERIALS AND METHODS: A questionnaire was sent to the 42 general surgical hospital departments in Denmark. RESULTS: All of the departments returned the questionnaire. All of them treated patients with gallstone pancreatitis; 40 of them performed laparoscopic cholecystectomy. The severity of gallstone pancreatitis was estimated in 29 departments. In patients with mild gallstone pancreatitis, 6 departments used ERCP in the evaluation of choledocholithiasis. In patients with mild gallstone pancreatitis who did not undergo an ERCP procedure with sphincterotomy, 13 departments performed laparoscopic cholecystectomy during the same admission after an acute attack. DISCUSSION: In agreement with the recommendations given in the National Reference Programme, the majority of Danish surgical departments used laparoscopic cholecystectomy in the treatment of patients with gallstone pancreatitis who had not undergone ERCP with sphincterotomy. To avoid the high recurrence of gallstone pancreatitis, laparoscopic cholecystectomy during the same admission is recommended. This recommendation was, however, followed by less than half of the surgical departments.

Objective assessment of gastrointestinal endoscopy skills using a virtual reality simulator.

BACKGROUND: This study was carried out to validate the role of virtual reality computer simulation as a method of assessment of psychomotor skills in gastrointestinal endoscopy. We aimed to investigate whether the GI Mentor II computer system (Simbionix Ltd.) was able to differentiate between subjects with different experience with GI endoscopy. METHODS: Twenty-eight subjects were included in the study. They were divided into 3 groups according to their experience with GI endoscopy: experienced [group 1, performed > 200 endoscopic procedures, (n = 8)] residents [group 2, performed < 50 endoscopic procedures, (n = 10)] and medical students [group 3, never performed GI endoscopy, (n = 10)]. All participants received identical pretest instruction on the simulator. Assessment of endoscopic skills was performed during a simulated colonoscopy and was based on parameters measured by the computer system: time, percentage of mucosa surface examined, efficiency of screening, time with a clear view, excessive local pressure, pain, time with pain, loop formation, and total time with a loop. RESULTS: Significant differences in performance existed between surgeons in the 3 groups. Experienced surgeons demonstrated best performance parameters, followed by the residents and the medical students. Significant differences in time (Kruskal-Wallis test, P < 0.001), percentage of mucosa surface examined (P = 0.001), efficiency of screening (P = 0.001), time with a clear view (P = 0.001), pain experienced (P = 0.004), time with pain (P = 0.012), loop formation (P < 0.001), time with a loop (P < 0.001), and excessive local pressure (P = 0.001) were demonstrated. Significant differences existed between group 1 and 2 and 1 and 3 (Mann-Whitney test, P < 0.05). Differences between groups 2 and 3 did not reach statistical significance (P > 0.05). CONCLUSIONS: The VR simulator was able to differentiate between subjects with different endoscopic experience. This indicates that the GI Mentor measures skills relevant for gastrointestinal endoscopy and can be used in training programs as an assessment tool.