Impact of low anterior resection syndrome (LARS) on the quality of life and treatment options of LARS - A cross sectional study.

PURPOSE: The purpose of this study was to assess the relationship between the low anterior resection syndrome (LARS) and quality of life (QOL). Furthermore, in patients with major LARS, therapeutic management options were explored. METHODS: A cohort of surviving patients, who underwent a low anterior resection for rectal cancer after long course of radiochemotherapy, were identified. These patients were treated in Ghent University Hospital between 2006 and 2016. QOL was assessed using the European Organization for Research and Treatment of Cancer Quality Of Life questionnaire-C30 and the bowel function using the LARS-score. The relationship between LARS and QOL was analysed. Patients with major LARS (≥30 points) were contacted to explore their therapeutic management of LARS. RESULTS: 69% of the participants had major LARS. QOL was closely associated with LARS. Significant differences were found between those with and without LARS in the global health status (p ≤ 0.001) and in the following functional scales: physical (p ≤ 0.001), role (p ≤ 0.001), cognitive (p = 0.04) and social (p ≤ 0.001). Patients with major LARS experienced more diarrhea (p ≤ 0.001), fatigue (p = 0.002), insomnia (p ≤ 0.001) and pain (p = 0.02), compared to patient with no/minor LARS. Most patients tried dietary regimens (71%), medication (71%) and incontinence material (63.8%) in an attempt to manage their LARS and found some of them useful. The level of the anastomosis (low) was a significant risk factor for major LARS (p=0.03). CONCLUSION: More than half of the patients in this cohort still suffered from major LARS. Patients confronted with major LARS had a lower QOL than patients with no/minor LARS. Currently, there is no gold standard for the management of LARS. Patients manage it through trial and error.

Left-handedness in cardiac surgery: who's right?

There is a paucity of literature describing potential issues related to lateral hand dominance in general and cardiac surgery. Nonetheless, during surgical training left-handedness can produce difficulties in the operating room that are not always understood or accepted by supervising right-handed surgeons. These problems can be easily overcome by practice and anticipation. This report aims to address laterality related issues in cardiac surgery and provide insight into techniques that may aid the left handed surgeon in a right handed dominated surgical environment. An ergonomically different approach, more convenient for the left-handed trainee, may facilitate learning, enhance confidence and increase surgeon satisfaction both for the trainer and trainee.

Do sociodemographic features, pain sensitivity or pain catastrophizing relate to clinic-based adherence to physiotherapy in people suffering from chronic spinal pain? Secondary analysis of a randomized clinical trial.

PURPOSE: Examining whether socio-demographic variables, pain or functionality are related to the degree of clinic-based therapy adherence in patients suffering from nonspecific chronic spinal pain (nCSP). DESIGN: Secondary analysis of a randomized clinical trial. SETTING: University hospital of Ghent and Brussels. METHODS: Dutch speakers, 18-65 years old, experiencing nCSP for at least 3 months. 120 participants were randomly allocated to two interventional groups, of which 94 completed all therapy sessions. MAIN OUTCOME MEASURES: Degree of clinic-based adherence, defined as the amount of completed therapy sessions. RESULTS: Demographic data (sex, age or education) were not significantly associated with adherence in the total sample or the neuroscience group. For the traditional physiotherapy group, educational level was associated with attendance of at least 50% of the therapy sessions. Regarding pain-, belief- and function-related measures, only the association between change in kinesiophobia and adherence was significant for the traditional physiotherapy group. CONCLUSIONS: Factors related to therapy adherence in the total group or the neuroscience group could not be found. Educational level and change in kinesiophobia were however related to therapy adherence in the traditional physiotherapy group.

Safety and preliminary efficacy of electrostatic precipitation during pressurized intraperitoneal aerosol chemotherapy (PIPAC) for unresectable carcinomatosis.

INTRODUCTION: Pressurized intraperitoneal aerosol chemotherapy (PIPAC) was recently introduced to treat unresectable peritoneal metastases. Adding an electrostatic field may enhance charged droplet precipitation and tissue penetration, resulting in improved anticancer efficacy. We report for the first time its safety and preliminary efficacy. MATERIALS AND METHODS: Patients underwent PIPAC combined with an electrostatic field, using the Ultravision™ apparatus. Adverse events were scored with the Common Terminology Criteria. Treatment response was assessed after more than one PIPAC, using clinical symptoms, tumor markers, CT imaging and histological regression. RESULTS: Forty-eight patients (median age, 61 y) with diverse primary tumors underwent 135 procedures (median per patient, 3). Most (65.2%) were treated as outpatient. Twenty-eight (58.3%) patients received concomitant chemotherapy. The most frequent treatment-related toxicities were anemia (grade 1 to 3, 13 [9.6%]), ileus (grade 1 to 3, 5 [3.7%]), anorexia (grade 1 to 3, 6 [4.4%]), nausea (grade 1 to 3, 5 [3.7%]) and vomiting (grade 1 to 3, 7 [5.2%]). There was no grade 4 or 5 morbidity. Twenty (41.7%) patients did not complete three treatments, mainly because of disease progression (n = 13). After two procedures, there were one responder and 8 non-responders. After three treatments, we observed 11 responders, two patients with stable disease, and 15 non-responders. All but one patient with therapy response received simultaneous chemotherapy. CONCLUSION: Electrostatic precipitation during PIPAC is well tolerated and safe. After three procedures and concomitant chemotherapy, response or stable disease is achieved in approximately half of cases. These findings warrant prospective trials in homogeneous patient cohorts.

Metabolic surgery in patients over 60 years old: short- and long-term results.

PURPOSE: Laparoscopic Roux-en-Y gastric bypass can treat obesity related comorbidities and can prolong life expectancy. It remains unclear whether this type of surgery is also indicated in obese patients with advanced age. MATERIALS AND METHODS: In this retrospective monocentric study, we investigated the morbidity and outcomes of weight and metabolic control of bariatric surgery in patients older than 60 years and compared these findings with those of younger patients. RESULTS: At 18 months after RY gastric bypass, weight losses of respectively 30 ± 11% and 34 ± 9% of total initial body weight were measured in the older and younger patients (p < 0.05). After 12 months, HbA1c dropped below 6.5% in 89% of patients younger and in 81% of patients older than 60 (p = 0.11). There was no mortality in either group, but there were significantly more complications and there was a longer hospital stay in the older patients. CONCLUSION: RY gastric bypass comes with a significantly higher morbidity and hospital stay in older patients, but weight loss and improvement of DM are similar as in the younger patients.

Simultaneous Parenchyma-Preserving Liver Resection, Cytoreductive Surgery and Intraperitoneal Chemotherapy for Stage IV Colorectal Cancer.

BACKGROUND: The outcome of stage IV colorectal cancer (CRC) has improved with modern systemic therapy. However, the concomitant presence of liver metastases (LM) and peritoneal carcinomatosis (PC) remains associated with a dismal prognosis and surgery in this context remains exceptional. METHODS: Stage IV CRC patients with LM and PC undergoing simultaneous cytoreductive surgery, intraperitoneal chemotherapy (IPC) and liver resection/ablation were identified from prospectively collected databases. We assessed response to neoadjuvant chemotherapy (NACT), postoperative complications, progression free survival (PFS), and overall survival (OS). RESULTS: Twenty-one patients with resectable disease were treated between 2007 and 2014. In 16 patients (76%), NACT was administered and tumour response defined their selection. The remaining 5 (24%) were selected according to the pattern of recurrence. Median peritoneal cancer index was 5 (range: 3-10.5). Liver surgery included 34 wedge resections, 5 ablations and one bisectionectomy to treat a total of 45 hepatic lesions with a median of 2 per patient (range: 1-2) and a median size of 1.35 cm (range: 0.8-2). Tumour regression grade 4 (fibrosis but residual cancer cells predominate) was seen in 50% of the resected metastases after NACT. Median hospital stay was 17 days (range: 14-24); severe morbidity (Clavien-Dindo grade 3-4) occurred in 24% and no perioperative mortality (0-90 days) was recorded. The median OS was 44 months (range: 31-57) while the median PFS was 10 months (range: 8-12). CONCLUSIONS: Combined parenchyma-preserving liver resection, cytoreductive surgery and IPC in patients with LM and PC from CRC can be performed safely and results in promising mid-term overall survival.

Postmortem pump-driven reperfusion of the vascular system of porcine lungs: towards a new model for surgical training.

PURPOSE: The objective of this experiment is to establish a continuous postmortem circulation in the vascular system of porcine lungs and to evaluate the pulmonary distribution of the perfusate. This research is performed in the bigger scope of a revascularization project of Thiel embalmed specimens. This technique enables teaching anatomy, practicing surgical procedures and doing research under lifelike circumstances. METHODS: After cannulation of the pulmonary trunk and the left atrium, the vascular system was flushed with paraffinum perliquidum (PP) through a heart-lung machine. A continuous circulation was then established using red PP, during which perfusion parameters were measured. The distribution of contrast-containing PP in the pulmonary circulation was visualized on computed tomography. Finally, the amount of leak from the vascular system was calculated. RESULTS: A reperfusion of the vascular system was initiated for 37 min. The flow rate ranged between 80 and 130 ml/min throughout the experiment with acceptable perfusion pressures (range: 37-78 mm Hg). Computed tomography imaging and 3D reconstruction revealed a diffuse vascular distribution of PP and a decreasing vascularization ratio in cranial direction. A self-limiting leak (i.e. 66.8% of the circulating volume) towards the tracheobronchial tree due to vessel rupture was also measured. CONCLUSIONS: PP enables circulation in an isolated porcine lung model with an acceptable pressure-flow relationship resulting in an excellent recruitment of the vascular system. Despite these promising results, rupture of vessel walls may cause leaks. Further exploration of the perfusion capacities of PP in other organs is necessary. Eventually, this could lead to the development of reperfused Thiel embalmed human bodies, which have several applications.

Training models in laparoscopy: a systematic review comparing their effectiveness in learning surgical skills.

BACKGROUND: Surgery has traditionally been learned on patients in the operating room, which is time-consuming, can have an impact on the patient outcomes, and is of variable effectiveness. As a result, surgical training models have been developed, which are compared in this systematic review. METHODS: We searched Pubmed, CENTRAL, and Science Citation index expanded for randomised clinical trials and randomised cross-over studies comparing laparoscopic training models. Studies comparing one model with no training were also included. The reference list of identified trials was searched for further relevant studies. RESULTS: Fifty-eight trials evaluating several training forms and involving 1591 participants were included (four studies with a low risk of bias). Training (virtual reality (VR) or video trainer (VT)) versus no training improves surgical skills in the majority of trials. Both VR and VT are as effective in most studies. VR training is superior to traditional laparoscopic training in the operating room. Outcome results for VR robotic simulations versus robot training show no clear difference in effectiveness for either model. Only one trial included human cadavers and observed better results versus VR for one out of four scores. Contrasting results are observed when robotic technology is compared with manual laparoscopy. CONCLUSION: VR training and VT training are valid teaching models. Practicing on these models similarly improves surgical skills. A combination of both methods is recommended in a surgical curriculum. VR training is superior to unstructured traditional training in the operating room. The reciprocal effectiveness of the other models to learn surgical skills has not yet been established.

Life-threatening side effects of malabsorptive procedures in obese patients necessitating conversion surgery: a review of 17 cases.

BACKGROUND: Malabsorptive surgery (MAS) can cause huge weight loss but is also known for its serious side effects. We investigated whether conversion surgery is an effective treatment for MAS-induced complications. METHODS: We searched our hospital database for patients who underwent conversion surgery after MAS. Any complication was recorded till time of conversion. The conversion techniques and their effect on the course of the patients were analyzed and compared to the situation after MAS. RESULTS: We identified 17 patients who suffered a wide range of complications after biliopancreatic diversion (BPD) (n = 11), biliopancreatic diversion with duodenal switch (BPD-DS) (n = 4), or distal gastric bypass (D-GBP) (n = 2). After a (mean +/- SD) period of 6.0 +/- 3.6 years the MAS was either converted to a gastric bypass (GBP) in 6 patients or an elongation of the common limb (ECL) in 9 patients. Two conversions were atypical. After a (mean +/- SD) follow-up of 2.4 +/- 2.5 years the majority of blood test results improved. The incidence of most complaints diminished except abdominal discomfort, critical illness polyneuropathy, need for total parenteral nutrition (TPN), wheelchair dependency, and asthenia. One patient died of irreversible liver failure after 3 liver transplantations. Two patients died of cachexia. The preferred conversion technique is still unclear. CONCLUSIONS: MAS can cause invalidating and life-threatening side effects. If there are signs of incipient deterioration in organ function and/or nutritional status, conversion surgery should not be delayed. Although we have the impression that early conversion causes better outcome, many patients experience lifelong postoperative complications.

Role of patient-specific virtual reality rehearsal in carotid artery stenting.

BACKGROUND: Recent advances in simulation science permit patient-specific rehearsal of endovascular stenting procedures. This study aimed to evaluate how effectively real interventions are replicated by patient-specific rehearsal technology, and to assess its value as a preparatory tool for the interventionalist and the operating team. METHODS: All patients deemed candidates for carotid artery stenting procedures with suitable computed tomography images were enrolled. Each team member rehearsed the virtual procedure in the laboratory, simulated operating theatre or angiography suite environment immediately before treating the real patient. Dexterity and qualitative metrics were recorded. Subjective questionnaires used a Likert scale from 1 (poor) to 5 (excellent). RESULTS: Of 18 patients, three were excluded. In 11 of 15 and 13 of 15 patients respectively endovascular tool use and fluoroscopy angles were identical during rehearsal and the real procedure. In a third of patients, the simulator did not adequately predict difficulties in cannulating the stenotic internal or common carotid arteries. The procedure realism, value in evaluating the case, increase in efficiency in tool use, and potential to increase communication, confidence and team performance were all rated highly (4 of 5). CONCLUSION: Patient-specific rehearsal was rated highly for both face and content validity. Access strategy, endovascular material use and angiographic imaging were all replicated effectively, although certain biomechanical vessel properties seemed to be replicated to a lesser degree. Patient-specific rehearsal constitutes a unique tool that may help tailor endovascular material choice, and optimize the preoperative preparation of the interventionalist and team.

Efficient implementation of patient-specific simulated rehearsal for the carotid artery stenting procedure: part-task rehearsal.

OBJECTIVE(S): Patient-specific simulated rehearsal (PsR) is a technological advance within the domain of endovascular virtual reality (VR) simulation. It allows incorporation of patient-specific computed tomography Digital Imaging and Communications in Medicine (CT DICOM) data into the simulation and subsequent rehearsal of real patient cases. This study aimed to evaluate whether a part-task rehearsal (PTr) of a carotid artery stenting procedure (CAS) on a VR simulator is as effective as a full-task (FTr) preoperative run through. METHODS: Medical trainees were trained in the CAS procedure and randomised to a PTr or FTr of a challenging CAS case (Type-II arch). PTr consisted of 30 min of repeated catheterisations of the common carotid artery (CCA). Thereafter, both groups performed the CAS procedure in a fully functional simulated operating suite (SOS) with an interventional team. Technical performances were assessed using simulator-based metrics and expert ratings. Other aspects of performance were assessed using the Non-Technical Skills for Surgeons (NOTSS) scoring. RESULTS: Twenty trainees were evenly randomised to either PTr or FTr. No differences in performance were seen except for the total time the embolic protection device (EPD) was deployed (9.4 min for the PT vs. 8.1 min for the FT, p = 0.02). Total time (26.3 vs. 25.5 min, p = 0.94), fluoroscopy time (15.8 vs. 14.4 min, p = 0.68), number of roadmaps (10.5 vs. 11.0, p = 0.54), amount of contrast (53.5 vs. 58.0 ml, p = 0.33), time to deploy the EPD (0.9 vs. 0.8 min, p = 0.31) and time to catheterise the CCA (9.2 vs. 8.9 min, p = 0.94) were similar. Qualitative performances as measured by expert ratings (score 24 vs. 24, p = 0.49) and NOTSS (p > 0.05 for all categories) were also comparable. CONCLUSIONS: Part- and full-task rehearsals are equally effective with respect to the operative performance of a simulated CAS intervention. This finding makes a patient-specific rehearsal more efficient and may increase the feasibility of implementation of this technology into medical practice.

Patient-specific endovascular simulation influences interventionalists performing carotid artery stenting procedures.

OBJECTIVE: The ability to perform patient-specific simulated rehearsal of complex endovascular interventions is a technological advance with potential benefits to patient outcomes. This study aimed to evaluate whether patient-specific rehearsal of a carotid artery stenting (CAS) procedure has an influence on tool selection and the use of fluoroscopy. METHODS: Following case note and computed tomography (CT) angiographic review of a real patient case, subjects performed the CAS procedure on a virtual reality simulator. Endovascular tool requirements and fluoroscopic angles were evaluated with a pre- and post-case questionnaire. Participants also rated the simulation from 1 (poor) to 5 (excellent). RESULTS: Thirty-three endovascular physicians with varying degrees of CAS experience were recruited: inexperienced (5-20 CAS procedures) n = 11, moderately (21-50 CAS procedures) n = 7 or highly experienced (>50 CAS procedures) n = 15. For all participants, 96 of a possible 363 changes (26%) were observed from pre- to post-case questionnaires. This was most notable for optimal fluoroscopy C-arm position 15/33 (46%), choice of selective catheter 13/33 (39%), choice of sheath or guiding catheter 11/33 (33%) and balloon dilatation strategy 10/33 (30%). Experience with the CAS procedure did not influence the degree of change significantly (p > 0.05), and all groups exhibited a considerable modification in tool and fluoroscopy preference. The model was considered realistic and useful as a tool to practice a real case (median score 4/5). CONCLUSION: Patient-specific simulated rehearsal of a complex endovascular procedure strongly influences tool selection and fluoroscopy preferences for the real case. Further research has to evaluate how this technology may transfer from in vitro to in vivo and if it can reduce the radiation dose and the number of endovascular tools used and improve outcomes for patients in the clinical setting.

Patient-specific simulation for endovascular procedures: qualitative evaluation of the development process.

BACKGROUND: Recent advancements in simulation permit patient-specific rehearsal of carotid artery stenting procedures. This study evaluates the feasibility of transferring patient-specific CT data into the simulator, creating a 3D reconstruction and performing a rehearsal. The face validity of the model was assessed. METHODS/RESULTS: By thematic analysis of qualitative data, an algorithm was generated, focusing on simulation set-up, time of data transfer, software/compatibility issues and problem-solving strategies. The face validity of the simulated case was evaluated by 15 expert interventionalists: realism (median 4/5), training potential (median 4/5) and pre-procedure rehearsal potential for challenging CAS cases (median 4/5) were rated highly. CONCLUSIONS: Setting up a procedure rehearsal is feasible and reproducible for different patients in different hospital settings without major software compatibility issues. The time to create a 3D reconstruction of patient-specific CT data is a major factor in the total time necessary to set up a rehearsal. The face validity is highly rated by experts.

Harlequin syndrome: two new cases and a management proposal.

The Harlequin syndrome is a rare autonomic disorder, characterized by unilateral diminished sweating and flushing of the face in response to heat or exercise. We present two new cases and evaluate the data of 83 patients described in the literature. We provide diagnostic and therapeutic guidelines.

A case of a spontaneous popliteal arteriovenous fistula.

This case report describes a 69-year-old female diagnosed with a spontaneous popliteal arteriovenous fistula of the right leg. Some deliberation is given on the aetiology of this rare condition as well as a description of the diagnostic and therapeutic options for fistula of the popliteal artery in general.

Robotically enhanced minimally invasive direct coronary artery bypass surgery: a winning strategy?

AIM: Minimally invasive direct coronary artery bypass (MIDCAB) through a small anterolateral thoracotomy on the beating heart can be considered as the better approach for treating isolated lesions on the left anterior descending (LAD) artery. This original MIDCAB procedure, however, involves a larger and often painful thoracotomy due to rib spreading. We describe our experience with robotically enhanced harvesting of one or both internal mammary arteries (IMAs), and with anastomosis performed under direct vision on a beating heart through a very small thoracotomy without rib retraction. METHODS: Between February 2001 and January 2006, 146 consecutive patients underwent robotically enhanced MIDCAB surgery. Perioperative and early follow-up data were analyzed. RESULTS: In all, 144 left and 13 right IMAs were harvested. The mean extubation time was 11.3 h, the mean intensive care (ICU) stay was 30.3 h, the mean hospital stay 8 days. There were no in-hospital deaths, postoperative myocardial infarctions or renal failures. Systematic control angiograms performed in the first 64 patients showed a 96.3% patency rate of the investigated anastomoses. CONCLUSION: Robotically assisted takedown of the IMA and direct off-pump anastomosis through a small anterolateral thoracotomy with no rib retraction appears to be safe, with minimal morbidity, little blood loss, and a reasonable ventilation time, ICU and hospital stay. It is recommended as the preferred method of revascularization for a growing number of indications and certainly an acceptable alternative to percutaneous transluminal coronary angioplasty.

[Treatment of iatrogenic femoral pseudoaneurysms by ultrasound-guided percutaneous thrombin injection: effectiveness and complications]. / Behandeling van iatrogene femorale pseudoaneurysmata door middel van echogeleide percutane trombine-injectie: doeltreffendheid en complicaties.

AIM: We retrospectively assessed the effectiveness of ultrasound-guided percutaneous thrombin injection in the treatment of iatrogenic femoral pseudoaneurysms and registered the occurrence of complications in the systemic circulation. METHODS: We performed ultrasound-guided thrombin injection in 26 iatrogenic femoral pseudoaneurysms: 24 were classified as single en 2 as complex. We registered the volume and the pseudoaneurysm neck measurements, as well as the complication rate. RESULTS: Ultrasound-guided percutaneous thrombin injection led to a successful obliteration of pseudoaneurysm in 25 out of 26 cases (96.2%). The thrombin amount varied between 250 and 1000 IU. A thrombosis of the common femoral artery after the thrombin injection occurred only in one patient. CONCLUSION: Ultrasound-guided percutaneous thrombin injection is effective and safe in the treatment of iatrogenic femoral pseudoaneurysms provided the exclusion criteria are respected. Complications are rare.

Surgical options for complete resectable lung cancer invading the phrenic nerve.

We describe a 58-year-old male diagnosed with a tumour of the left lung, which on subsequent thoracotomy proved to be invading the phrenic nerve. The clinical and spirometric outcome of a lobectomy, which resulted in a postoperative ipsilateral hemidiaphragmatic paralysis, versus the alternative surgical option of a pneumonectomy is discussed.