Impact of standardising indocyanine green fluorescence angiography technique for visual and quantitative interpretation on interuser variability in colorectal surgery.

AIM/BACKGROUND: Intra-operative colonic perfusion assessment via indocyanine green fluorescence angiography (ICGFA) aims to address malperfusion-related anastomotic complications; however, its interpretation suffers interuser variability (IUV), especially early in ICGFA experience. This work assesses the impact of a protocol developed for both operator-based judgement and computational development on interpretation consistency, focusing on senior surgeons yet to start using ICGFA. METHODS: Experienced and junior gastrointestinal surgeons were invited to complete an ICGFA-experience questionnaire. They subsequently interpreted nine operative ICGFA videos regarding perfusion sufficiency of a surgically prepared distal colon during laparoscopic anterior resection by indicating their preferred site of proximal transection using an online annotation platform (mindstamp.com). Six ICGFA videos had been prepared with a clinical standardisation protocol controlling camera and patient positioning of which three each had monochrome near infrared (NIR) and overlay display. Three others were non-standardised controls with synchronous NIR and overlay picture-in-picture display. Differences in transection level between different cohorts were assessed for intraclass correlation coefficient (ICC) via ImageJ and IBM SPSS. RESULTS: 58 clinicians (12 ICGFA experts, 46 ICGFA inexperienced of whom 23 were either finished or within one year of finishing training and 23 were junior trainees) participated as per power calculations. 63% felt that ICGFA should be routinely deployed with 57% believing interpretative competence requires 11-50 cases. Transection level concordance was generally good (ICC = 0.869) across all videos and levels of expertise (0.833-0.915). However, poor agreement was evident with the standardised protocol videos for overlay presentation (0.208-0.345). Similarly, poor agreement was seen for the monochrome display (0.392-0.517), except for those who were trained but ICG inexperienced (0.877) although even here agreement was less than with unstandardised videos (0.943). CONCLUSION: Colorectal ICGFA acquisition and display standardisation impacts IUV with this specific protocol tending to diminish surgeon interpretation consistency. ICGFA video recording for computational development may require dedicated protocols.

Pelvic Vascular Malformations and Recurrent Rectal Prolapse in a Patient With Maffucci Syndrome: A Diagnostic and Therapeutic Challenge.

Maffucci syndrome is an extremely rare congenital condition characterized by the development of multiple enchondromas and haemangiomas, primarily on the extremities, and an association with various tumors. Colonic and pelvic floor function has never been explored in patients with Maffucci syndrome. We report a case illustrating the challenges in managing colonic and pelvic floor dysfunction in a female patient secondary to vascular malformations as part of Maffucci syndrome.

A novel digital rectoscope for the triage of lower gastrointestinal symptoms in primary care: a prospective multicentre feasibility study.

BACKGROUND: Access to community rectoscopy might help to ease the burden on hospital services and reduce costs for the NHS. To assess this, a prospective multicentre observational phase I feasibility study of a novel digital rectoscope and telestration software for the triage of lower gastrointestinal (GI) symptoms was undertaken. AIM: To determine if digital rectoscopy is feasible, acceptable, and clinically safe. DESIGN & SETTING: Evaluation of clinician case reports and patient questionnaires from patients recruited from five primary care centres. METHOD: Adults meeting 2-week wait (2WW) criteria for suspected lower GI cancer, suspected new diagnosis, or flare-up of inflammatory bowel disease (IBD) were enrolled. Examinations were performed by primary care practitioners using the LumenEye rectoscope. The CHiP platform allowed immediate remote review by secondary care. A prospective analysis was performed of patient and clinician experiences, diagnostic accuracy, and cost. RESULTS: A total of 114 patients were recruited and 110 underwent the procedure (46 [42%] females and 64 [58%] males). No serious adverse events were reported. Eighty-two (74.5%) patients reported that examination was more comfortable than expected, while 104 (94.5%) felt the intervention was most convenient if delivered in the community. Clinicians were confident of their assessment in 100 (87.7%) examinations. Forty-eight (42.1%) patients subsequently underwent colonoscopy, flexible sigmoidoscopy, or computed tomography virtual colonoscopy (CTVC). The overall sensitivity and specificity of LumenEye in identifying rectal pathology was 90.0% and 88.9%. It was 100% and 100% for cancer, and 83.3% and 97.8% for polyps. Following LumenEye examination, 19 (17.3%) patients were discharged, with projected savings of 11 305 GBP. CONCLUSION: Digital rectoscopy in primary care is safe, acceptable, and can reduce referrals. A phase III randomised controlled trial is indicated to define its utility in reducing the burden on hospital diagnostic services.

A prospective analysis of sleep deprivation and disturbance in surgical patients.

INTRODUCTION: Sleep deprivation has a potentially deleterious effect on postoperative recovery. The aim of our prospective study was to identify the factors contributing to postoperative sleep deprivation and disturbance in order to recommend improvements in postoperative care. METHODS: 102 consecutive patients attending for elective general and orthopaedic surgery were interviewed preoperatively (baseline) and postoperatively on their duration of sleep, number of wakenings during the night, factors contributing to sleep loss and the use of analgesia and night sedation. RESULTS: Patients woke up a median of 5 times in the first postoperative night compared to a median of 3 times preoperatively (p = 0.01). Pain was the predominant factor preventing sleep, affecting 39% of patients preoperatively and 48% of patients on the first postoperative day. Other factors included noise from other patients and nursing staff, and using the toilet. Analgesia was taken by more than 90% of patients in the first two days, this number gradually reducing over the postoperative period. On the other hand, in the first two postoperative days, only about 5% of patients had night sedation. DISCUSSION AND CONCLUSIONS: Apart from highlighting the need for effective pain management postoperatively, we believe that our study supports the drive towards single bed bays, where steps can be taken to minimize the impact of environmental factors on sleep.

Probiotics in the management of gastrointestinal disease: analysis of the attitudes and prescribing practices of gastroenterologists and surgeons.

OBJECTIVE: Probiotics are increasingly advocated in the management of various gastrointestinal disorders. The aim of this study was to investigate the current attitudes and prescribing practices of surgeons and gastroenterologists for probiotics in the treatment of gastrointestinal disorders. METHODS: A questionnaire was designed to look at the frequency of probiotic prescribing, types of probiotics used, indications for and duration of treatment and clinicians' experiences with probiotic use. A total of 220 questionnaires were mailed to consultant gastroenterologists and surgeons practicing in the UK. RESULTS: The overall response rate was 80.5%, of which 69.5% of respondents said they recommended or prescribed probiotic food supplements to their patients, including 53.4% of surgeons and 80.8% of gastroenterologists (P = 0.00013). The most popular probiotic supplements among surgeons were probiotic-containing yoghurt and drinks (79.5% and 71.8%, respectively), whereas VSL#3 was more popular with gastroenterologists (83.3%). The most popular indications were irritable bowel syndrome (70.7% of prescribers) and pouchitis (67.5% of prescribers). Many respondents prescribed long-term probiotics. Most consultants had been prescribing probiotics for a period of 1 to 5 years. CONCLUSION: Probiotics are popular among gastroenterologists and surgeons in the UK for the treatment of gastrointestinal disorders. Further evidence to support their routine use, by way of large, well-designed randomized controlled trials, is necessary.

Significant rectal bleeding as a complication of a fecal collecting device: report of a case.

We report the case of 65-year-old man who developed massive rectal bleeding associated with the use of a fecal collecting device: the Flexi-Seal Fecal Management System. A colonoscopy showed an acute laceration of the anterior rectal wall mucosa, 6 cm from the anal verge, with active bleeding. The tear was most likely the result of an acute event, such as sudden movement of the device within the rectum or trauma sustained during insertion. Massive transfusion was required, and surgical endoscopic treatment was necessary to ensure hemostasis. This is, to our knowledge, the first such case to be reported.

Does an ileoanal pouch offer a better quality of life than a permanent ileostomy for patients with ulcerative colitis?

Although an ileoanal pouch is frequently offered to patients with ulcerative colitis, it is still not clear to what extent this operation offers advantages over a permanent ileostomy. The aim of this study was to determine whether patients with a pouch have less morbidity and a better quality of life than a matched group of patients with a Brooke ileostomy. Nineteen patients (12 males and 7 females, median age 41 years) who had undergone total colectomy and ileoanal pouch formation for ulcerative colitis were individually matched with patients who had had a panproctocolectomy and ileostomy; patients were matched for disease process, sex, age, socioeconomic status, and time since surgery. Quality of life was assessed using the Short-Form 36 version 2 questionnaire, the inflammatory bowel disease questionnaire, and a few additional questions on perception of body image. The scores were compared using the nonparametric Wilcoxon signed-rank test for paired samples. The number and type of postoperative complications, as well as the number of operative stages, were recorded prospectively. Restorative proctocolectomy was associated with a significantly better perception of body image than a permanent stoma, although quality of life in general was similar in both groups. Patients with a pouch had more long-term complications than patients with an ileostomy within the same period of time (52.6% vs. 26.3%). The median number of stages for pouch construction was two, compared to a median of one stage for an ileostomy (P<0.0001). Because of the high long-term complication rate and the relatively small quality-of-life advantage associated with restorative proctocolectomy, patients need to be counseled thoroughly before agreeing to this operation.

Patient generated index: new instrument for measuring quality of life in patients with rectal cancer.

The objective of this study was to assess the validity and responsiveness of a new quality of life instrument, the Patient Generated Index (PGI), in patients with rectal cancer. Thirty-three patients with rectal cancer were administered the PGI, the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaires QLQ-C30 and QLQ-CR38, and the Medical Outcomes Study short form SF-36 questionnaire preoperatively and at 3 months postoperatively. The PGI was assessed in this group of patients for validity and responsiveness. PGI scores achieved significant correlations with a number of domains on the three quality of life (QOL) questionnaires. Stepwise regression analysis showed that 91.3% of the variation in PGI scores could be explained by three health-related QOL variables alone: pain, role limitations due to physical problems, and a global rating of health and QOL. The mean PGI score showed significant improvement 3 months following surgery. The PGI was found to be more responsive to change than the SF-36, the QLQ-C30, or the QLQ-CR38 items except the micturition item. The PGI assesses the extent to which the expectations of patients suffering from rectal cancer are matched by reality; and it satisfies the criteria of validity and responsiveness of this instrument for this cancer. Further studies are needed to determine its psychometric properties in other areas of surgery and oncology. If these studies support our findings, we believe that patient-centered measures such as the PGI may provide a meaningful assessment of the outcome of surgery for patients with cancer.