Implementation of an Enhanced Recovery after Surgery Protocol in Advanced and Recurrent Rectal Cancer Patients after beyond Total Mesorectal Excision Surgery: A Feasibility Study.

INTRODUCTION: The implementation of an Enhanced Recovery After Surgery (ERAS) protocol in patients with locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) has been deemed unfeasible until now because of the heterogeneity of this disease and low caseloads. Since evidence and experience with ERAS principles in colorectal cancer care are increasing, a modified ERAS protocol for this specific group has been developed. The aim of this study is to evaluate the implementation of a tailored ERAS protocol for patients with LARC or LRRC, requiring beyond total mesorectal excision (bTME) surgery. METHODS: Patients who underwent a bTME for LARC or LRRC between October 2021 and December 2022 were prospectively studied. All patients were treated in accordance with the ERAS LARRC protocol, which consisted of 39 ERAS care elements specifically developed for patients with LARC and LRRC. One of the most important adaptations of this protocol was the anaesthesia procedure, which involved the use of total intravenous anaesthesia with intravenous (iv) lidocaine, iv methadone, and iv ketamine instead of epidural anaesthesia. The outcomes showed compliance with ERAS care elements, complications, length of stay, and functional recovery. A follow-up was performed at 30 and 90 days post-surgery. RESULTS: Seventy-two patients were selected, all of whom underwent bTME for either LARC (54.2%) or LRRC (45.8%). Total compliance with the adjusted ERAS protocol was 73.6%. Major complications were present in 12 patients (16.7%), and the median length of hospital stay was 9 days (IQR 6.0-14.0). Patients who received multimodal anaesthesia (75.0%) stayed in the hospital for a median of 7.0 days (IQR 6.8-15.5). These patients received fewer opioids on the first three postoperative days than patients who received epidural analgesia (p < 0.001). CONCLUSIONS: The implementation of the ERAS LARRC protocol seemed successful according to its compliance rate of >70%. Its complication rate was substantially reduced in comparison with the literature. Multimodal anaesthesia is feasible in beyond TME surgery with promising effects on recovery after surgery.

Biplanar versus conventional two-dimensional ultrasound guidance for radial artery catheterisation.

Background: Ultrasound guidance increases first-pass success rates and decreases the number of cannulation attempts and complications during radial artery catheterisation but it is debatable whether short-, long-, or oblique-axis imaging is superior for obtaining access. Three-dimensional (3D) biplanar ultrasound combines both short- and long-axis views with their respective benefits. This study aimed to determine whether biplanar imaging would improve the accuracy of radial artery catheterisation compared with conventional 2D imaging. Methods: This before-and-after trial included adult patients who required radial artery catheterisation for elective cardiothoracic surgery. The participating anaesthesiologists were experienced in 2D and biplanar ultrasound-guided vascular access. The primary endpoint was successful catheterisation in one skin break without withdrawals. Secondary endpoints were the numbers of punctures and withdrawals, scanning and procedure times, needle visibility, perceived mental effort of the operator, and posterior wall puncture or other mechanical complications. Results: From November 2021 until April 2022, 158 patients were included and analysed (2D=75, biplanar=83), with two failures to catheterise in each group. First-pass success without needle redirections was 58.7% in the 2D group and 60.2% in the biplanar group (difference=1.6%; 95% confidence interval [CI], -14.0%-17.1%; P=0.84), and first-pass success within one skin break was 77.3% in the 2D group vs 81.9% in the biplanar group (difference=4.6%; 95% CI, 8.1%-17.3%; P=0.473). None of the secondary endpoints differed significantly. Conclusions: Biplanar ultrasound guidance did not improve success rates nor other performance measures of radial artery catheterisation. The additional visual information acquired with biplanar imaging did not offer any benefit. Clinical trial registration: N9687 (Dutch Trial Register).

A Multidisciplinary Approach for the Personalised Non-Operative Management of Elderly and Frail Rectal Cancer Patients Unable to Undergo TME Surgery.

Despite it being the optimal curative approach, elderly and frail rectal cancer patients may not be able to undergo a total mesorectal excision. Frequently, no treatment is offered at all and the natural course of the disease is allowed to unfold. These patients are at risk for developing debilitating symptoms that impair quality of life and require palliative treatment. Recent advancements in non-operative treatment modalities have enhanced the toolbox of alternative treatment strategies in patients unable to undergo surgery. Therefore, a proposed strategy is to aim for the maximal non-operative treatment, in an effort to avoid the onset of debilitating symptoms, improve quality of life, and prolong survival. The complexity of treating elderly and frail patients requires a patient-centred approach to personalise treatment. The main challenge is to optimise the balance between local control of disease, patient preferences, and the burden of treatment. A comprehensive geriatric assessment is a crucial element within the multidisciplinary dialogue. Since limited knowledge is available on the optimal non-operative treatment strategy, these patients should be treated by dedicated multidisciplinary rectal cancer experts with special interest in the elderly and frail. The aim of this narrative review was to discuss a multidisciplinary patient-centred treatment approach and provide a practical suggestion of a successfully implemented clinical care pathway.

A prospective cohort study to evaluate continuous wound infusion with local analgesics within an enhanced recovery protocol after colorectal cancer surgery.

AIM: To reduce detrimental opioid-related side effects, minimising the postoperative opioid consumption is needed, especially in older patients. Continuous wound infusion (CWI) with local analgesics appears to be an effective opioid-sparing alternative. However, the added value of CWI to an enhanced recovery protocol after colorectal cancer (CRC) surgery is unclear. The aim of this study was to evaluate the outcomes of CWI after CRC surgery within a strictly adhered to enhanced recovery protocol. METHODS: In this multicentre prospective observational cohort study, patients who underwent CRC surgery between May 2019 and January 2021 were included. Patients were treated with CWI as adjunct to multimodal pain management within an enhanced recovery protocol. Postoperative opioid consumption, pain scores and outcomes regarding functional recovery were evaluated. RESULTS: A cohort of 130 consecutive patients were included, of whom 36.2% were ≥75 years. Postoperative opioids were consumed by 80 (61.5%) patients on postoperative day 0, and by 28 (21.5%), 27 (20.8%), and 18 (13.8%) patients on postoperative days 1, 2, and 3, respectively. Median pain scores were <4 on all days. The median time until first passage of stool was 1.0 (IQR: 1.0-2.0) day. Postoperative delirium occurred in 0.8%. Median length of hospital stay was 3.0 days (IQR: 2.0-5.0). CONCLUSION: In patients treated with CWI, low amounts of postoperative opioid consumption, adequate postoperative pain control, and enhanced recovery were observed. CWI seems a beneficial opioid-sparing alternative and may further improve the outcomes of an enhanced recovery protocol after CRC surgery, which seems especially valuable for older patients.

Acoustic lens improves superficial in-plane ultrasound-guided procedures - The significance of the beam width artefact.

STUDY OBJECTIVE: The three-dimensional shape of the ultrasound beam produces a thicker scan plane than most users assume. Viewed longitudinally, a needle placed lateral to a vessel just outside the central scanning plane can be displayed incorrectly in the ultrasound image as if placed intravascularly. This phenomenon is called the beam width artefact, also known as the elevation or slice thickness artefact. The goal of this study was to demonstrate the potential negative effect of the beam width artefact on the performance of in-plane ultrasound-guided vascular access procedures, and to provide a solution. DESIGN: Randomized, double-blinded study SETTING: Department of anaesthesiology and intensive care of a teaching hospital PARTICIPANTS: 31 experienced (anesthesiologists and intensivists) and 36 inexperienced (anesthetic nurses) ultrasound users INTERVENTIONS: We developed an acoustic lens that narrows the scan plane to reduce the beam width artefact. The lens was tested in a simulated vascular access study. MEASUREMENTS: The primary endpoint was first pass success. Secondary endpoints were the number of punctures and needle withdrawals, procedure time, needle visibility and operator satisfaction. MAIN RESULTS: First pass success was highly enhanced using the acoustic lens, with a success rate of 92.5% versus 68.7% without the lens (difference 23.8, 95% confidence interval 11.0-35.3, p < 0.001). The total number of punctures needed to obtain intravenous access was also reduced using the lens (1.10 versus 1.38, difference 0.27, 95% CI 0.11-0.43, p = 0.002). Procedure time, needle withdrawals, needle visibility and satisfaction were similar. Both inexperienced and experienced users benefited from the acoustic lens. CONCLUSIONS: The beam width artefact has a significant effect on the performance of ultrasound-guided needle-based procedures. The efficacy of in-plane superficial vascular access procedures can be enhanced by narrowing the imaging plane using an acoustic lens.

The learning curve for ultrasound-guided peripheral intravenous cannulation in adults: a multicenter study.

AIMS: To lower the threshold for applying ultrasound (US) guidance during peripheral intravenous cannulation, nurses need to be trained and gain experience in using this technique. The primary outcome was to quantify the number of procedures novices require to perform before competency in US-guided peripheral intravenous cannulation was achieved. MATERIALS AND METHODS: A multicenter prospective observational study, divided into two phases after a theoretical training session: a hands-on training session and a supervised life-case training session. The number of US-guided peripheral intravenous cannulations a participant needed to perform in the life-case setting to become competent was the outcome of interest. Cusum analysis was used to determine the learning curve of each individual participant. RESULTS: Forty-nine practitioners participated and performed 1855 procedures. First attempt cannulation success was 73% during the first procedure, but increased to 98% on the fortieth attempt (p<0.001). The overall first attempt success rate during this study was 93%. The cusum learning curve for each practitioner showed that a mean number of 34 procedures was required to achieve competency. Time needed to perform a procedure successfully decreased when more experience was achieved by the practitioner, from 14±3 minutes on first proce-dure to 3±1 minutes during the fortieth procedure (p<0.001). CONCLUSIONS: Competency in US-guided peripheral intravenous cannulation can be gained after following a fixed educational curriculum, resulting in an increased first attempt cannulation success as the number of performed procedures increased.

Establishing the required components for training in ultrasoundguided peripheral intravenous cannulation: a systematic review of available evidence.

Ultrasound increases a first-attempt success rate for vascular access when considered by knowledgeable and experienced practitioners. Education and training of these practitioners in ultrasound-guided peripheral intravenous cannulation is becoming increasingly common, although no consensus has been reached regarding its curriculum. The current systematic literature review aims to explore different training modules and components in use, and its efficacy and efficiency in ultrasound-guided peripheral intravenous cannulation in hospitalized adults by different healthcare providers. Database search was performed from January 2009 to December 2018 for publications describing the training or education of healthcare professionals in ultrasound-guided peripheral intravenous cannulation in adult patients. Data-analyses was performed on 23 studies, concluding that competency on ultrasound-guided peripheral intravenous cannulation can be achieved after following a brief training in a fixed curriculum, consisting of a didactic training session, a simulated hands-on component, and is completed after a supervised live-case training. Lectures should focus on ultrasound physics, including the vascular anatomy. The hands-on training included identification of veins on a life model without cannulating, followed by cannulation of veins using a nonhuman tissue model. At the end, supervised cannulation of veins on the upper extremity with an ultrasound-guided technique was performed on live patients to show competency.

Repetitive electrostatic pressurised intraperitoneal aerosol chemotherapy (ePIPAC) with oxaliplatin as a palliative monotherapy for isolated unresectable colorectal peritoneal metastases: protocol of a Dutch, multicentre, open-label, single-arm, phase II study (CRC-PIPAC).

INTRODUCTION: Repetitive electrostatic pressurised intraperitoneal aerosol chemotherapy with oxaliplatin (ePIPAC-OX) is offered as a palliative treatment option for patients with isolated unresectable colorectal peritoneal metastases (PM) in several centres worldwide. However, little is known about its feasibility, safety, tolerability, efficacy, costs and pharmacokinetics in this setting. This study aims to explore these parameters in patients with isolated unresectable colorectal PM who receive repetitive ePIPAC-OX as a palliative monotherapy. METHODS AND ANALYSIS: This multicentre, open-label, single-arm, phase II study is performed in two Dutch tertiary referral hospitals for the surgical treatment of colorectal PM. Eligible patients are adults who have histologically or cytologically proven isolated unresectable PM of a colorectal or appendiceal carcinoma, a good performance status, adequate organ functions and no symptoms of gastrointestinal obstruction. Instead of standard palliative treatment, enrolled patients receive laparoscopy-controlled ePIPAC-OX (92 mg/m2 body surface area (BSA)) with intravenous leucovorin (20 mg/m2 BSA) and bolus 5-fluorouracil (400 mg/m2 BSA) every 6 weeks. Four weeks after each procedure, patients undergo clinical, radiological and biochemical evaluation. ePIPAC-OX is repeated until disease progression, after which standard palliative treatment is (re)considered. The primary outcome is the number of patients with major toxicity (grade ≥3 according to the Common Terminology Criteria for Adverse Events v4.0) up to 4 weeks after the last ePIPAC-OX. Secondary outcomes are the environmental safety of ePIPAC-OX, procedure-related characteristics, minor toxicity, postoperative complications, hospital stay, readmissions, quality of life, costs, pharmacokinetics of oxaliplatin, progression-free survival, overall survival, and the radiological, histopathological, cytological, biochemical and macroscopic tumour response. ETHICS AND DISSEMINATION: This study is approved by an ethics committee, the Dutch competent authority and the institutional review boards of both study centres. Results are intended for publication in peer-reviewed medical journals and for presentation to patients, healthcare professionals and other stakeholders. TRIAL REGISTRATION NUMBER: NCT03246321, Pre-results; ISRCTN89947480, Pre-results; NTR6603, Pre-results; EudraCT: 2017-000927-29, Pre-results.

Barriers to ultrasound guidance for central venous access: a survey among Dutch intensivists and anaesthesiologists.

Accumulating evidence shows that ultrasound (US) guidance improves effectiveness and safety of central venous catheter (CVC) placement. Several international guidelines therefore recommend the use of US for placement of CVCs. However, surveys show that the landmark-based technique is still widely used, while the percentage of physicians using US is increasing less than expected. The goal of this study was to investigate current practice for central venous catheterization in anaesthesiology and intensive care in the Netherlands, identify barriers for further implementation of US guidance and to evaluate whether personality traits are associated with the choice of technique. We conducted a web-based national survey, distributed among members of the Dutch societies of anaesthesiology (NVA) and intensive care (NVIC). The survey contained questions regarding physician and hospital characteristics, frequency of US use and reasons for use or non-use, as well as the NEO-FFI-3, a validated, translated questionnaire to characterize personality traits according to the 'Big Five' concept. Response rate was 22% (506/2291), of which 400 had also the personality questionnaire complete. Ultrasound guidance was used always or almost always in 68%; barriers for US use were working in a non-academic non-teaching hospital, providing cardiac anaesthesia and more years of physician experience. Reasons for not using US were perceived lack of benefit, increased procedure time, lack of US equipment and fear of loss of landmark technique skills. 13% of respondents had never experienced a complication during CVC placement, and 67% knew of a complication occurring the past year at their department. Ultrasound was thought not to be able to prevent the complication in half of these cases. Of the personality traits, only neuroticism and extraversion showed a minor positive association with US guidance. A majority of anaesthesiologists and intensivists uses US guidance for CVC placement, but a significant proportion of physicians still prefers the landmark technique. Most arguments from respondents against US guidance can be challenged. Personality traits most likely do not play a major role in the acceptance of US guidance for central venous catheterization. A potential intervention to increase US use could be formalizing local hospital policies mandating compliance with US guidance. Future research can perhaps focus on cognitive biases that currently limit more widespread use of US guidance.

Medical Instrument Detection in 3-Dimensional Ultrasound Data Volumes.

Ultrasound-guided medical interventions are broadly applied in diagnostics and therapy, e.g., regional anesthesia or ablation. A guided intervention using 2-D ultrasound is challenging due to the poor instrument visibility, limited field of view, and the multi-fold coordination of the medical instrument and ultrasound plane. Recent 3-D ultrasound transducers can improve the quality of the image-guided intervention if an automated detection of the needle is used. In this paper, we present a novel method for detecting medical instruments in 3-D ultrasound data that is solely based on image processing techniques and validated on various ex vivo and in vivo data sets. In the proposed procedure, the physician is placing the 3-D transducer at the desired position, and the image processing will automatically detect the best instrument view, so that the physician can entirely focus on the intervention. Our method is based on the classification of instrument voxels using volumetric structure directions and robust approximation of the primary tool axis. A novel normalization method is proposed for the shape and intensity consistency of instruments to improve the detection. Moreover, a novel 3-D Gabor wavelet transformation is introduced and optimally designed for revealing the instrument voxels in the volume, while remaining generic to several medical instruments and transducer types. Experiments on diverse data sets, including in vivo data from patients, show that for a given transducer and an instrument type, high detection accuracies are achieved with position errors smaller than the instrument diameter in the 0.5-1.5-mm range on average.