Prognostic significance of low muscle volume in patients undergoing surgery for oesophageal cancer.

BACKGROUND & AIMS: This study aimed to determine the prognostic significance of low muscle volume (LMV) Bioelectrical Impedance Analysis (BIA), defined skeletal muscle index (SMI, Kg/m2 male ≤8.75, female ≤5.75) in patients undergoing potentially curative surgery for Oesophageal Cancer (OC). METHODS: A prospective study of 122 patients diagnosed with OC [median age 65 yr, 104 male, 65 neoadjuvant therapy] who underwent preoperative BIA (Maltron Bioscan 920). Primary outcome measure was Overall Survival (OS). RESULTS: LMV was identified in 11 (9.0%) of patients, which was associated with low lean muscle mass (27.3 vs. 31.1 kg, p = 0.012), low body fat (8.8 vs.19.3 kg, p < 0.001), and greater total body water (72.2 vs. 62.2%, p = 0.001), and more open & close laparotomies (36.4 vs. 8.1%, p = 0.012). Median and 5-year OS was 16 months and 18.2% in LMV patients, compared with 51 months and 52.4% in non-sarcopenic patients (p = 0.002). On multivariable analysis of pre-operative variables, only LMV (HR 2.75; 95% CI 1.33-5.66, p = 0.006) was associated with OS. CONCLUSION: BIA is an important prognostic indicator in OC and focused pre-habilitation consequently has strong potential.

Systematic review and meta-analysis of the effectiveness of radiofrequency ablation in low grade dysplastic Barrett's esophagus.

BACKGROUND: Barrett's esophagus (BE) is a premalignant condition characterized by replacement of the esophageal lining with metastatic columnar epithelium, and its management when complicated by low grade dysplasia (LGD) is controversial. This systematic review and meta-analysis aimed to determine the efficacy of radiofrequency ablation (RFA) in patients with LGD. METHODS: MEDLINE, EMBASE, and Web of Science were searched for studies including patients with BE-associated LGD receiving RFA (January 1990 to May 2017). The outcome measures were complete eradication of intestinal metaplasia (CE-IM) and dysplasia (CE-D), rates of progression to high grade dysplasia (HGD) or cancer, and recurrence. RESULTS: Eight studies including 619 patients with LGD (RFA = 404, surveillance = 215) were analyzed. After a median follow-up of 26 months (range 12 - 44 months), the overall pooled rates of CE-IM and CE-D after RFA were 88.17 % (95 % confidence interval [CI] 88.13 % - 88.20 %; P < 0.001) and 96.69 % (95 %CI 96.67 % - 96.71 %; P < 0.001), respectively. When compared with surveillance, RFA resulted in significantly lower rates of progression to HGD or cancer (odds ratio [OR] 0.07, 95 %CI 0.02 - 0.22). The pooled recurrence rates of IM and dysplasia were 5.6 % (95 %CI 5.57 - 5.63; P < 0.001) and 9.66 % (95 %CI 9.61 - 9.71; P < 0.001), respectively. CONCLUSIONS: RFA safely eradicates IM and dysplasia and reduces the rates of progression from LGD to HGD or cancer in the short term.

Using the mind as a simulator: a randomized controlled trial of mental training.

OBJECTIVES: Laparoscopic simulators have been introduced as safe and effective methods of developing basic skills. Mental training is a novel training method likened to using the mind as a simulator to mentally rehearse the movements of a task or operation. It is widely used by professional athletes and musicians and has been suggested as a technique that could be used by surgical trainees. The purpose of this study was to assess the use of mental training in developing basic laparoscopic skills in novices. METHODS: Sixty-four medical students without laparoscopic experience were randomized into 4 groups. The first 3 groups were trained to cut a circle on a box trainer. Group 1 received no additional training (BT), Group 2 received additional virtual reality training (BT + VRS), and Group 3 received additional mental training (BT + MT). The fourth group was trained on a virtual reality simulator with additional mental training (box-free). The following 4 assessment criterias: time, accuracy, precision and overall performance were measured on both the box-trainer and virtual simulator. RESULTS: The mental training group (BT + MT) demonstrated improved laparoscopic skills over both assessments. The improvement in skills in the VRS group (BT + VRS) was limited to VRS assessment and not observed in the box assessment. The fourth group (box-free) had the worst performance on both methods of assessment. CONCLUSION: The addition of mental training led to improved laparoscopic skills development. It is a flexible technique and has the potential to challenge VRS as a more cost-effective training method associated with lower capital investment. Given the benefits of mental training with further research, it could be considered for inclusion in training curricula.

Learning basic laparoscopic skills: a randomized controlled study comparing box trainer, virtual reality simulator, and mental training.

OBJECTIVES: The objectives of this study were (1) to compare different methods of learning basic laparoscopic skills using box trainer (BT), virtual reality simulator (VRS) and mental training (MT); and (2) to determine the most effective method of learning laparoscopic skills. DESIGN: Randomized controlled trial. SETTING: King's College, London. METHODS: 41 medical students were included in the study. After randomization, they were divided into 5 groups. Group 1 was the control group without training; group 2 was box trained; group 3 was also box trained with an additional practice session; group 4 was VRS trained; and group 5 was solely mentally trained. The task was to cut out a circle marked on a stretchable material. All groups were assessed after 1 week on both BT and VRS. Four main parameters were assessed, namely time, precision, accuracy, and performance. RESULTS: Time: On BT assessment, the box-trained group with additional practice group 3 was the fastest, and the mental-trained group 5 was the slowest. On VRS assessment, the time difference between group 3 and the control group 1 was statistically significant. Precision: On BT assessment, the box-trained groups 2 and 3 scored high, and mental trained were low on precision. On VRS assessment, the VRS-trained group ranked at the top, and the MT group was at the bottom on precision. Accuracy: On BT assessment, the box-trained group 3 was best and the mental-trained group was last. On VRS assessment, the VRS-trained group 4 scored high closely followed by box-trained groups 2 and 3. Performance: On BT assessment, the box-trained group 3 ranked above all the other groups, and the mental-trained group ranked last. On VRS assessment, the VRS group 4 scored best, followed closely by box-trained groups 2 and 3. CONCLUSIONS: The skills learned on box training were reproducible on both VRS and BT. However, not all the skills learned on VRS were transferable to BT. Furthermore, VRS was found to be a reliable and the most convenient method of assessment. MT alone cannot replace conventional training.

Lateral cervical lymph node metastases in papillary thyroid cancer: a systematic review of imaging-guided and prophylactic removal of the lateral compartment.

BACKGROUND: Papillary thyroid cancer (PTC) is a common endocrine cancer and frequently presents with lymph node (LN) metastases. The frequency of LN metastases in the lateral compartment and their surgical removal are poorly defined. There are no prospective randomised controlled trials addressing an eventual outcome difference relating to the extent of the initial surgical approach. The aim of this study was to define the extent of lateral LN involvement and the role of imaging in identification of these metastatic LN. DESIGN AND METHODS: A systematic review of studies of patients with PTC undergoing either prophylactic or therapeutic lymphadenectomy of the lateral cervical compartment. Studies involving imaging modalities in the detection of lateral cervical LNs in PTC were also analysed. RESULTS: Systematic review on the frequency of lateral LN metastases and their detection using various imaging tools identified 19 studies containing data on 5587 patients undergoing prophylactic or imaging-guided removal of the lateral compartment. Imaging-guided surgery retrieved cancerous lateral LNs in 446/3178 or 14% of eligible patients, whilst prophylactic lateral neck dissection yielded histopathological proof of cancer in 1177/204 or 57·5% of patients. The frequency of lateral compartment metastases increased with T stage. The sensitivity of ultrasound and CT was poor as low as 27% when accurately calculated. CONCLUSION: Metastatic cervical LNs were found in more than half of patients when prophylactic lateral LN dissection was performed. Use of conventional imaging for the selection of the surgical approach to the lateral cervical compartment may commonly identify stage N1a instead of N1b and thus lead to false stage assignment as stage III rather than stage IV, concealing the severe prognostic implications of this stage progression in individual patients.

Central cervical lymph node metastases in papillary thyroid cancer: a systematic review of imaging-guided and prophylactic removal of the central compartment.

BACKGROUND: Papillary thyroid cancer (PTC) is a common endocrine cancer and commonly presents with lymph node (LN) metastases. The role of surgical removal of the central cervical LN compartment is poorly defined. There are no prospective randomized controlled trials addressing the relevance to the extent of the initial surgical approach. DESIGN AND METHODS: A systematic review of studies of patients with PTC undergoing either prophylactic or therapeutic lymphadenectomy of the central LNs was carried out. Studies involving imaging modalities in the detection of LNs in PTC were also analysed. RESULTS: Twenty-one studies contained data on 4188 patients undergoing prophylactic or imaging-guided removal of the central compartment. Imaging-guided surgery retrieved cancerous central LNs in 346 or 30% of eligible patients, whilst prophylactic central neck dissection yielded histopathological proof of cancer in 898 or 26·2% of patients. Five imaging studies revealed data on the use of ultrasound (US) and/or computerized tomography (CT). The sensitivity of US and CT was poor, ranging from 50% to 70% when accurately calculated. CONCLUSION: Metastatic central LNs are found in nearly half of all patients with PTC when prophylactic central lymph node dissection (CLND) is performed. With unreliable imaging modalities, prophylactic CLND should be performed on all patients with PTC.

Terminology inaccuracies in the interpretation of imaging results in detection of cervical lymph node metastases in papillary thyroid cancer.

UNLABELLED: Cervical lymph nodes (CLNs) are the most common site of metastases in papillary thyroid cancer (PTC). Ultrasound scan (US) is the most commonly used imaging modality in the evaluation of CLNs in PTC. Computerised tomography (CT) and (18)fluorodeoxyglucose positron emission tomography ((18)FDG PET-CT) are used less commonly. It is widely believed that the above imaging techniques should guide the surgical approach to the patient with PTC. METHODS: We performed a systematic review of imaging studies from the literature assessing the usefulness for the detection of metastatic CLNs in PTC. We evaluated the author's interpretation of their numeric findings specifically with regard to 'sensitivity' and 'negative predictive value' (NPV) by comparing their use against standard definitions of these terms in probabilistic statistics. RESULTS: A total of 16 studies used probabilistic terms to describe the value of US for the detection of LN metastases. Only 6 (37.5%) calculated sensitivity and NPV correctly. For CT, out of the eight studies, only 1 (12.5%) used correct terms to describe analytical results. One study looked at magnetic resonance imaging, while three assessed (18)FDG PET-CT, none of which provided correct calculations for sensitivity and NPV. CONCLUSION: Imaging provides high specificity for the detection of cervical metastases of PTC. However, sensitivity and NPV are low. The majority of studies reporting on a high sensitivity have not used key terms according to standard definitions of probabilistic statistics. Against common opinion, there is no current evidence that failure to find LN metastases on ultrasound or cross-sectional imaging can be used to guide surgical decision making.

Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis.

BACKGROUND: Pancreatic necrosis may complicate severe acute pancreatitis, and is detectable by computed tomography (CT). If it becomes infected mortality increases, but the use of prophylactic antibiotics raises concerns about antibiotic resistance and fungal infection. OBJECTIVES: To determine the efficacy and safety of prophylactic antibiotics in acute pancreatitis complicated by CT proven pancreatic necrosis. SEARCH STRATEGY: Searches were updated in November 2008, in The Cochrane Library (Issue 2, 2008), MEDLINE, EMBASE, and CINAHL. Conference proceedings and references from found articles were also searched. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing antibiotics versus placebo in acute pancreatitis with CT proven necrosis. DATA COLLECTION AND ANALYSIS: Primary outcomes were mortality and pancreatic infection rates. Secondary end-points included non pancreatic infection, all sites infection, operative rates, fungal infections, and antibiotic resistance. Subgroup analyses were performed for antibiotic regimen (beta-lactam, quinolone, and imipenem). MAIN RESULTS: Seven evaluable studies randomised 404 patients. There was no statistically significant effect on reduction of mortality with therapy: 8.4% versus controls 14.4%, and infected pancreatic necrosis rates: 19.7% versus controls 24.4%. Non-pancreatic infection rates and the incidence of overall infections were not significantly reduced with antibiotics: 23.7% versus 36%; 37.5% versus 51.9% respectively. Operative treatment and fungal infections were not significantly different. Insufficient data were provided concerning antibiotic resistance.With beta-lactam antibiotic prophylaxis there was less mortality (9.4% treatment, 15% controls), and less infected pancreatic necrosis (16.8% treatment group, 24.2% controls) but this was not statistically significant. The incidence of non-pancreatic infections was non-significantly different (21% versus 32.5%), as was the incidence of overall infections (34.4% versus 52.8%), and operative treatment rates. No significant differences were seen with quinolone plus imidazole in any of the end points measured. Imipenem on its own showed no difference in the incidence of mortality, but there was a significant reduction in the rate of pancreatic infection (p=0.02; RR 0.34, 95% CI 0.13 to 0.84). AUTHORS' CONCLUSIONS: No benefit of antibiotics in preventing infection of pancreatic necrosis or mortality was found, except for when imipenem (a beta-lactam) was considered on its own, where a significantly decrease in pancreatic infection was found. None of the studies included in this review were adequately powered. Further better designed studies are needed if the use of antibiotic prophylaxis is to be recommended.

Large bowel obstruction in pregnancy: a rare entity, an unusual cause.

BACKGROUND: Large bowel obstruction is a rare and difficult diagnosis in pregnancy. Common causes are caecal and sigmoid volvulus and less common pseudo-obstruction. An infrequent cause of large bowel obstruction from an adhesive band in pregnancy causing diagnostic difficulty is reported. METHODS: Report of an unusual cause of large bowel obstruction in pregnancy. RESULTS: Diagnostic colonoscopy confirmed large bowel obstruction at the level of sigmoid. Laparotomy revealed this to be from a single band adhesion originating from the site of previous appendicectomy. Division of the band resolved the obstruction. CONCLUSIONS: A high index of suspicion is necessary for the diagnosis of large bowel obstruction in pregnancy especially in women with previous history of abdominal or pelvic surgery. Colonoscopy is helpful avoiding radiation to foetus and mother. Prompt surgical intervention reduces risks and maximises chances for a favourable outcome for both mother and child.