Patients over 65 years with Acute Complicated Calculous Biliary Disease are Treated Differently-Results and Insights from the ESTES Snapshot Audit.

BACKGROUND: Accrued comorbidities are perceived to increase operative risk. Surgeons may offer operative treatments less often to their older patients with acute complicated calculous biliary disease (ACCBD). We set out to capture ACCBD incidence in older patients across Europe and the currently used treatment algorithms. METHODS: The European Society of Trauma and Emergency Surgery (ESTES) undertook a snapshot audit of patients undergoing emergency hospital admission for ACCBD between October 1 and 31 2018, comparing patients under and ≥ 65 years. Mortality, postoperative complications, time to operative intervention, post-acute disposition, and length of hospital stay (LOS) were compared between groups. Within the ≥ 65 cohort, comorbidity burden, mortality, LOS, and disposition outcomes were further compared between patients undergoing operative and non-operative management. RESULTS: The median age of the 338 admitted patients was 67 years; 185 patients (54.7%) of these were the age of 65 or over. Significantly fewer patients ≥ 65 underwent surgical treatment (37.8% vs. 64.7%, p < 0.001). Surgical complications were more frequent in the ≥ 65 cohort than younger patients, and the mean postoperative LOS was significantly longer. Postoperative mortality was seen in 2.2% of patients ≥ 65 (vs. 0.7%, p = 0.253). However, operated elderly patients did not differ from non-operated in terms of comorbidity burden, mortality, LOS, or post-discharge rehabilitation need. CONCLUSIONS: Few elderly patients receive surgical treatment for ACCBD. Expectedly, postoperative morbidity, LOS, and the requirement for post-discharge rehabilitation are higher in the elderly than younger patients but do not differ from elderly patients managed non-operatively. With multidisciplinary perioperative optimization, elderly patients may be safely offered optimal treatment. TRIAL REGISTRATION: ClinicalTrials.gov (Trial # NCT03610308).

Evidence based management of polyps of the gall bladder: A systematic review of the risk factors of malignancy.

BACKGROUND: There are no evidence-based guidelines to dictate when Gallbladder Polyps (GBPs) of varying sizes should be resected. AIM: To identify factors that accurately predict malignant disease in GBP; to provide an evidence-based algorithm for management. METHODS: A systematic review following PRISMA guidelines was performed using terms "gallbladder polyps" AND "polypoid lesion of gallbladder", from January 1993 and September 2013. Inclusion criteria required histopathological report or follow-up of 2 years. RTI-IB tool was used for quality analysis. Correlation with GBP size and malignant potential was analysed using Euclidean distance; a logistics mixed effects model was used for assessing independent risk factors for malignancy. RESULTS: Fifty-three articles were included in review. Data from 21 studies was pooled for analysis. Optimum size cut-off for resection of GBPs was 10 mm. Probability of malignancy is approximately zero at size <4.15 mm. Patient age >50 years, sessile and single polyps were independent risk factors for malignancy. For polyps sized 4 mm-10 mm, a risk assessment model was formulated. CONCLUSIONS: This review and analysis has provided an evidence-based algorithm for the management of GBPs. Longitudinal studies are needed to better understand the behaviour of polyps <10 mm, that are not at a high risk of malignancy, but may change over time.

Communication skills assessment in the final postgraduate years to established practice: a systematic review.

INTRODUCTION: Communication breakdown is a factor in the majority of all instances of medical error. Despite the importance, a relative paucity of time is invested in communication skills in postgraduate curricula. Our objective is to systematically review the literature to identify the current tools used to assess communication skills in postgraduate trainees in the latter 2 years of training and in established practice. METHODS: Two reviewers independently reviewed the literature identifying communication skill assessment tools, for postgraduate trainees in the latter 2 years of training and in established practice following Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework, and inclusion/exclusion criteria from January 1990 to 15 August 2014. DATABASES: PubMed/CINAHL/ERIC/EMBASE/PsycInfo/Psyc Articles/Cochrane. RESULTS: 222 articles were identified; after review, 34 articles fulfilled criteria for complete evaluation; the majority (26) had a high level of evidence scoring 3 or greater on the Best Evidence Medical Education guide. 22 articles used objective structured clinical examination/standardised patient (SP)-based formats in an assessment or training capacity. Evaluation tools included author-developed questionnaires and validated tools. Nineteen articles demonstrated an educational initiative. CONCLUSIONS: The reviewed literature is heterogeneous for objectives and measurement techniques for communication. Observed interactions, with patients or SPs, is the current favoured method of evaluation using author-developed questionnaires. The role of self-evaluation of skill level is questioned. The need for a validated assessment tool for communication skills is highlighted.

Does EUS-FNA molecular analysis carry additional value when compared to cytology in the diagnosis of pancreatic cystic neoplasm? A systematic review.

BACKGROUND: Endoscopic ultrasonography with fine needle aspiration (EUS-FNA) has become an integral tool in the diagnosis of pancreatic cystic lesions (PCLs) and the analysis of molecular/DNA abnormalities might improve the accuracy of pre-operative diagnosis. A review was conducted of all studies using EUS-FNA aspirates of PCLs to assess the accuracy and added benefit that molecular analysis provides to cytological analysis. METHODS: A systematic review of the literature was conducted using PRISMA guidelines and electronic databases: PubMed/SCOPUS/EMBASE/Cochrane/CINAHL. Surgical pathology was used as the definitive reference standard. The QUADAS-2 tool was used for quality assessment. RESULTS: In total, 162 articles were identified; 12 articles met inclusion/exclusion criteria. Ten studies reported on cytology and 8 studies reported k-ras mutational analysis. 362 patients (of 1115 total) had surgical pathology available. The sensitivity and specificity of cytology was 0.42 and 0.99; the sensitivity and specificity of k-ras was 0.39 and 0.95; and the sensitivity and specificity of the combined test of cytology and k-ras was 0.71 and 0.88, respectively. CONCLUSIONS: k-ras mutational analysis used as an individual screening test has a poor diagnostic accuracy, as does cytology when used alone. The benefit comes with utilization in a combined fashion. More studies are needed to evaluate the correct sequence and utility of these tests for cyst differentiation.

A patient-centred approach toward surgical wait times for colon cancer: a population-based analysis.

BACKGROUND: Administrative wait times reflect the time from the decision to treat until surgery; however, this does not reflect the total time a patient actually waits for treatment. Several factors may prolong the wait for colon cancer surgery. We sought to analyze the time from the date of surgical consultation to the date of surgery and any events within this time frame that may extend wait times. METHODS: We retrospectively reviewed the cases of all adult patients in Ontario aged 18-80 years with diagnosed colon cancer who did not receive neoadjuvant therapy and underwent resection electively between Jan. 1, 2002, and Dec. 31, 2009. Wait times were measured from the date of surgical consultation to the date of surgery. We chose a wait time of 28 days, reflecting local administrative targets, as a comparative benchmark. We performed univariate and multivariate analyses to identify variables contributing to a waits longer than 28 days. Variables were analyzed in continuous linear and logistic regression models. RESULTS: We included 10 223 patients in our study. The median wait time from initial surgical consultation to resection was 31 (range 0-182) days. Age older than 65 years had a negative impact on wait time. Preoperative services, including computed tomography, cardiac consultation, echocardiography, multigated acquisition scan, magnetic resonance imaging, colonoscopy and cardiac catheterization also significantly increased wait times. Wait times were longer in rural hospitals. CONCLUSION: Preoperative services significantly increased wait times between initial surgical consultation and surgery.

CONTEXTE: Au plan administratif, les temps d'attente sont le reflet de l'intervalle entre la prise de décision de traiter et la chirurgie elle-même. Toutefois, cette mesure ne tient pas toujours compte du temps total d'attente d'un patient pour son traitement. Plusieurs facteurs peuvent prolonger l'attente dans le cas d'une chirurgie pour le cancer du côlon. Nous avons voulu mesurer le temps écoulé entre la date de la consultation en chirurgie et la date de la chirurgie, et tout événement à l'intérieur de cet intervalle susceptible de prolonger les délais. MÉTHODES: Nous avons passé en revue de façon rétrospective le cas de tous les patients adultes ontariens âgés de 18 à 80 ans porteurs d'un diagnostic de cancer du côlon qui n'ont pas reçu de traitement néo-adjuvant et qui ont subi une résection non urgente entre le 1er janvier 2002 et le 31 décembre 2009. Les temps d'attente ont été mesurés entre la date de la consultation en chirurgie et la date de la chirurgie elle-même. Nous avons choisi un temps d'attente de 28 jours qui reflète les objectifs administratifs locaux comme valeur comparative. Nous avons effectué des analyses univariées et multivariées pour faire ressortir les facteurs qui contribuent à des périodes d'attente de plus de 28 jours. Les variables ont été analysées selon des modèles de régression linéaire et logistique continue. RÉSULTATS: Nous avons inclus 10 223 patients dans notre étude. Le temps d'attente médian entre la consultation en chirurgie et la résection a été de 31 (entre 0 et 182) jours. L'âge de plus de 65 ans a exercé un impact négatif sur le temps d'attente. Les services préopératoires, notamment la tomodensitométrie, la consultation en cardiologie, l'angiographie isotopique, l'imagerie par résonance magnétique, la colonoscopie et le cathétérisme cardiaque ont également significativement prolongé les temps d'attente. Les temps d'attente ont été plus longs dans les hôpitaux ruraux. CONCLUSION: Les services préopératoires ont considérablement allongé les temps d'attente entre la consultation initiale en chirurgie et la chirurgie elle-même.

Real-World Use of Electronic Patient-Reported Outcome (ePRO) Tools Integrated in the Electronic Medical Record During Radiation Therapy for Head and Neck Cancer: Feasibility Study.

Purpose Use of electronic patient-reported outcome (ePRO) tools in routine oncology practice can be challenging despite evidence showing they can improve survival, improve patient and practitioner satisfaction, and reduce medical resource utilization. Head and neck cancer (HNC) patients receiving radiation therapy (RT) may be a group that would particularly benefit from interventions focused on early symptom management. Methods Patients undergoing definitive RT for HNC were enrolled in a feasibility study and received ePRO surveys integrated within the electronic medical record (EMR) on a weekly basis during RT. After completion of each ePRO survey, a radiation oncology registered nurse documented the findings and subsequent interventions within the EMR. Results Thirty-four patients with HNC who received curative RT at a single center were enrolled. The total number of surveys completed was 194 with a median of 7 surveys per patient (range 1-8). There was a total of 887 individual abnormal findings reported on the ePROs, and the authors found that all 887 had a corresponding documented intervention. Post-treatment practitioner questionnaires highlighted that ePROs were felt to be helpful for the care team in providing care to HNC patients. Conclusion For patients with HNC receiving RT, ePROs can be effectively utilized to address patient symptoms within an integrated health care system. Creating an infrastructure for the use of ePROs integrated within the EMR in routine care requires an approach that accounts for local workflows and buy-in from patients and the entire care team.

Patterns of prevalence and contemporary clinical management strategies in complicated acute biliary calculous disease: an ESTES 'snapshot audit' of practice.

BACKGROUND: Acute complications of biliary calculi are common, morbid, and complex to manage. Variability exists in the techniques utilized to treat these conditions at an individual surgeon and unit level. AIM: To identify, through an international prospective nonrandomized cohort study, the epidemiology and areas of practice variability in management of acute complicated calculous biliary disease (ACCBD) and to correlate them against reported outcomes. METHODS: A preplanned analysis of the European Society of Trauma and Emergency Surgery (ESTES) 2018 Complicated Biliary Calculous Disease audit was performed. Patients undergoing emergency hospital admission with ACCBD between 1 October 2018 and 31 October 2018 were included. All eligible patients with acute complicated biliary calculous disease were recorded contemporaneously using a standardized predetermined protocol and a secure online database and followed-up through to 60 days from their admission. ENDPOINTS: A two-stage data collection strategy collecting patient demographics, details of operative, endoscopic and radiologic intervention, and outcome metrics. Outcome measures included mortality, surgical morbidity, ICU stay, timing of operative intervention, and length of hospital stay. RESULTS: Three hundred thirty-eight patients were included, with a mean age of 65 years and 54% were female. Diagnosis at admission were: cholecystitis (45.6%), biliary pancreatitis (21%), choledocholithiasis with and without cholangitis (13.9% and 18%). Index admission cholecystectomy was performed in just 50% of cases, and 28% had an ERCP performed. Morbidity and mortality were low. CONCLUSION: This first ESTES snapshot audit, a purely descriptive collaborative study, gives rich 'real world' insights into local variability in surgical practice as compared to international guidelines, and how this may impact upon outcomes. These granular data will serve to improve overall patient care as well as being hypothesis generating and inform areas needing future prospective study.

Primary cutaneous phalangeal neuroendocrine/squamous cell carcinoma with mixed axillary metastasis.

Cutaneous neuroendocrine tumours are rare and aggressive tumours associated with advanced age and immunosuppression. They are typically characterised by a high rate of local recurrence and nodal disease. The presence of a mixed squamous cell component is rare. These tumours are uncommonly found on the hand. We present a case and histological images of a 78-year-old woman with a primary CK20 negative TTF-1 positive cutaneous neuroendocrine tumour with squamous dedifferentiation arising from the fifth digit with axillary metastasis showing a mixed phenotype. Initial biopsy of the lesion was positive for chromogranin, synaptophysin and TTF-1, but negative for CK20, Melan-A and S100. After CT of the thorax abdomen and pelvis and octreotide single positron emission CT demonstrated a 15 mm axillary metastasis and no evidence of distal disease, our patient underwent an amputation of the affected digit and an axillary lymph node dissection. She is currently awaiting adjuvant chemoradiotherapy. Only two cases are reported in the literature to have mixed squamous/neuroendocrine features. We present the first case which is CK20 negative and TTF-1 positive.

Body composition is associated with operative and oncologic outcomes in the management of retroperitoneal and trunk soft tissue sarcoma.

BACKGROUND: Sarcopenia, myosteatosis and obesity in cancer may confer negative clinical outcomes, but their prevalence and impact among patients with retroperitoneal and trunk soft tissue sarcoma have not been systematically studied. The aim of this study was to determine body composition among patients with retroperitoneal and trunk sarcoma, and assess impact on operative and oncologic outcomes. METHODS: Consecutive patients undergoing treatment with curative intent from 2009 to 2019 were studied. Subcutaneous fat area and visceral fat areas, intramuscular adipose, lean body mass and fat mass were determined at diagnosis by CT at L3. Univariable and multivariable linear, logistic and Cox proportional hazards regression were performed. RESULTS: 95 patients (43.2% retroperitoneal, 48.4% trunk, 46.3% multivisceral resection) were studied. Visceral obesity was evident in 47.4%. Postoperative morbidity occurred in 25.9%, with preoperative radiotherapy (OR10.53 [95% CI 1.08-102.39], P = 0.042) and fat mass (OR1.41 [1.12-1.79], P = 0.004) independently predictive on multivariable analysis, while intramuscular adipose independently predicted inpatient LOS (P < 0.001), wound infection (P = 0.024, OR1.20 [1.02-1.40]) and major postoperative morbidity (P = 0.027, OR1.15 [1.02-1.31]). Increasing fat mass, subcutaneous fat area and intramuscular adipose were associated with greater tumor size (all P < 0.01), while intramuscular adipose predicted disease progression during neoadjuvant therapy (P = 0.024), and independently predicted disease specific survival (DSS) (P = 0.005, HR1.11 [1.03-1.20]) and overall survival (OS) on multivariable analysis (P < 0.001, HR1.19 [1.08-1.31]). CONCLUSION: Visceral obesity is common in retroperitoneal and trunk sarcoma, and measures of adiposity are associated with adverse operative, but not oncologic outcomes. Myosteatosis is independently associated with postoperative morbidity and adverse oncologic outcomes. Body composition may represent a marker of risk among patients with retroperitoneal and trunk sarcoma.

Evaluation of an emergency safe supply drugs and managed alcohol program in COVID-19 isolation hotel shelters for people experiencing homelessness.

BACKGROUND: During a COVID-19 outbreak in the congregate shelter system in Halifax, Nova Scotia, Canada, a healthcare team provided an emergency "safe supply" of medications and alcohol to facilitate isolation in COVID-19 hotel shelters for residents who use drugs and/or alcohol. We aimed to evaluate (a) substances and dosages provided, and (b) outcomes of the program. METHODS: We reviewed medical records of all COVID-19 isolation hotel shelter residents during May 2021. The primary outcome was successful completion of 14 days isolation, as directed by public health orders. Adverse events included (a) overdose; (b) intoxication; and (c) diversion, selling, or sharing of medications or alcohol. RESULTS: Seventy-seven isolation hotel residents were assessed (mean age 42 ± 14 years; 24% women). Sixty-two (81%) residents were provided medications, alcohol, or cigarettes. Seventeen residents (22%) received opioid agonist treatment (methadone, buprenorphine, or slow-release oral morphine) and 27 (35%) received hydromorphone. Thirty-one (40%) residents received prescriptions stimulants. Six (8%) residents received benzodiazepines and forty-two (55%) received alcohol. Over 14 days, mean daily dosages increased of hydromorphone (45 ± 32 - 57 ± 42 mg), methylphenidate (51 ± 28 - 77 ± 37 mg), and alcohol (12.3 ± 7.6 - 13.0 ± 6.9 standard drinks). Six residents (8%) left isolation prematurely, but four returned. During 1059 person-days, there were zero overdoses. Documented concerns regarding intoxication occurred six times (0.005 events/person-day) and medication diversion/sharing three times (0.003 events/person-day). CONCLUSIONS: COVID-19 isolation hotel residents participating in an emergency safe supply and managed alcohol program experienced high rates of successful completion of 14 days isolation and low rates of adverse events.

A rare case of perforated gastric duplication cyst associated with gastric diverticulum.

A 50-year-old man presented to the emergency department with a 1-day history of severe epigastric pain, vomiting and fever. He had a background of alcohol excess and smoking. The patient was tachycardic and febrile with an elevated white blood cell count and C reactive protein. CT demonstrated extensive upper abdominal free fluid, without free air, with a large cystic lesion arising from the greater curvature of the stomach, and a second smaller cystic lesion arising from the posterior aspect of the gastric fundus. The patient was managed with nasogastric drainage, parenteral nutrition, intravenous antibiotics and proton pump inhibitors, and CT-guided abdominal drainage, with resolution of sepsis, and further outpatient care was transferred to our unit. Follow-up endoscopy demonstrated a diverticulum arising from the posterior aspect of the gastric fundus, with normal mucosa throughout the remaining stomach, while CT showed an additional cystic lesion arising from the greater curvature, with thickening of the adjacent gastric wall consistent with a gastric duplication cyst (GDC). Laparoscopy confirmed a small diverticulum at the fundus, and a large GDC anteriorly with associated omental adhesions consistent with prior perforation-two wedge resections were performed. Histology demonstrated no evidence of malignancy or ectopic mucosa. The patient recovered uneventfully and remained free from recurrent symptoms at 6 weeks postoperatively. GDC is a rare entity, which may be associated with ectopic mucosa, malignant transformation and upper gastrointestinal perforation. No previous report describes the coexistence of a GDC and gastric diverticulum. Herein we describe the investigation and management of this condition, and review the associated peer-reviewed literature.

Sarcopenia and obesity among patients with soft tissue sarcoma - Association with clinicopathologic characteristics, complications and oncologic outcome: A systematic review and meta-analysis.

BACKGROUND AND AIMS: Sarcopenia and obesity may be associated with negative outcomes in many cancers, but their prevalence and impact in modern regimens for soft-tissue sarcoma (STS) have not been systematically studied. This study summarises and critically evaluates the current evidence-based literature on body mass index (BMI) and body composition among patients with STS, with respect to clinical and pathologic characteristics, treatment-associated morbidity and oncologic outcome. METHODS: A systematic literature search of the PubMed, Embase and Cochrane databases was performed. Meta-analysis of the relationship between BMI, body composition and pathologic characteristics, operative morbidity and oncologic outcome was undertaken using RevMan v.5.4 using fixed or random effects methods as appropriate. RESULTS: 14 studies including 3598 patients met inclusion criteria. Ten studies reported on BMI, two on CT and two on PET-CT assessment of body composition. BMI ranged from 14.6 to 63.7 kg/m2, with obesity in 18%-39% of patients. Although some studies demonstrated larger tumours among patients with obesity, this was not significant on meta-analysis (P = 0.31, I2 = 99%). There was no significant difference in tumour grade or histologic type according to BMI. Postoperatively, obesity was associated with increased risk of overall morbidity (odds ratio (OR) 2.03 [95% CI 1.41-2.92], P = 0.0001, I2 = 22%), and wound morbidity (OR 1.32 [95% CI 1.02-1.71], P = 0.03, I2 = 0%). Similar effects were observed in studies of visceral adiposity. No differences in functional outcomes were observed. There was a trend towards reduced local recurrence among patients with obesity (HR 0.64 [95% CI 0.38-1.08], P = 0.10, I2 = 0%), but no difference in distant metastasis (HR 1.00 [95% CI 0.76-1.30], P = 0.98, I2 = 0%) or overall survival (HR 0.98 [95% CI 0.43-2.22], P = 0.95, I2 = 64%). Various measures of sarcopenia were associated with poorer survival outcomes. CONCLUSION: While obesity is associated with increased postoperative morbidity, it had no significant association with long-term oncologic outcomes. Sarcopenia may be associated with a poorer long-term prognosis. A greater understanding of the impact of nutritional status on disease characteristics and treatment outcomes is essential to facilitate improvements in clinical care for patients with STS.

Bile duct clearance and cholecystectomy for choledocholithiasis: Definitive single-stage laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiopancreatography versus staged procedures.

BACKGROUND: Clinical equipoise exists regarding optimal sequencing in the definitive management of choledocholithiasis. Our current study compares sequential biliary ductal clearance and cholecystectomy at an interval to simultaneous laparoendoscopic management on index admission in a pragmatic retrospective manner. METHODS: Records were reviewed for all patients admitted between January 2015 and December 2018 to a Swedish and an Irish university hospital. Both hospitals differ in their practice patterns for definitive management of choledocholithiasis. At the Swedish hospital, patients with choledocholithiasis underwent laparoscopic cholecystectomy with intraoperative rendezvous endoscopic retrograde cholangiopancreatography (ERCP) at index admission (one stage). In contrast, interval day-case laparoscopic cholecystectomy followed index admission ERCP (two stages) at the Irish hospital. Clinical characteristics, postprocedural complications, and inpatient duration were compared between cohorts. RESULTS: Three hundred fifty-seven patients underwent treatment for choledocholithiasis during the study period, of whom 222 (62.2%) underwent a one-stage procedure in Sweden, while 135 (37.8%) underwent treatment in two stages in Ireland. Patients in both cohorts were closely matched in terms of age, sex, and preoperative serum total bilirubin. Patients in the one-stage group exhibited a greater inflammatory reaction on index admission (peak C-reactive protein, 136 ± 137 vs. 95 ± 102 mg/L; p = 0.024), had higher incidence of comorbidities (age-adjusted Charlson Comorbidity Index, ≥3; 37.8% vs. 20.0%; p = 0.003), and overall were less fit for surgery (American Society of Anesthesiologists, ≥3; 11.7% vs. 3.7%; p < 0.001). Despite this, a significantly shorter mean time to definitive treatment, that is, cholecystectomy (3.1 ± 2.5 vs. 40.3 ± 127 days, p = 0.017), without excess morbidity, was seen in the one-stage compared with the two-stage cohort. Patients in the one-stage cohort experienced shorter mean postprocedure length of stay (3.0 ± 4.7 vs. 5.0 ± 4.6 days, p < 0.001) and total length of hospital stay (6.5 ± 4.6 vs. 9.0 ± 7.3 days, p = 0.002). The only significant difference in postoperative complications between the cohorts was urinary retention, with a higher incidence in the one-stage cohort (19% vs. 1%, p = 0.004). CONCLUSION: Where appropriate expertise and logistics exist within developing models of acute care surgery worldwide, consideration should be given to index-admission laparoscopic cholecystectomy with intraoperative ERCP for the treatment of choledocholithiasis. Our data suggest that this strategy significantly shortens the time to definitive treatment and decreases total hospital stay without any excess in adverse outcomes. LEVEL OF EVIDENCE: Therapeutic/Care Management Level IV.

Splenectomy for isolated splenic metastasis from primary lung adenocarcinoma.

A 73-year-old woman was referred to a tertiary centre with isolated splenic metastasis from previous pT1aNo stage 1a lung adenocarcinoma. The patient underwent a right lower lobe lobectomy and mediastinal lymph node dissection 2 years ago for invasive adenocarcinoma with no adjuvant therapy. An incidental finding of new splenic cyst was noted on surveillance imaging, which was fluorodeoxyglucose positive on positron emission tomography, and confirmed on cytology to be metastatic lung adenocarcinoma. After multi-disciplinary team's review, the patient underwent splenectomy, with partial excision of diaphragm due to local infiltration. Her postoperative course was eventful, and was complicated by a simple fluid collection in the surgical bed (amylase negative), a left sided pneumonia and atelectasis and left sided pleural effusion, requiring antibiotics and radiological drainage of the abdominal and pleural collection. The patient recovered well and is currently doing well 9 months postoperatively with no evidence of recurrence or metastatic disease.

Decreased aortic growth and middle aortic syndrome in patients with neuroblastoma after radiation therapy.

BACKGROUND: Long-term CT follow-up studies are required in pediatric patients who have received intraoperative radiation therapy (IORT) and external beam radiation therapy (EBRT) to assess vascular toxicities and to determine the exact complication rate. OBJECTIVE: To analyze with CT the effects of radiation therapy (RT) on the growth of the aorta in neuroblastoma patients. MATERIALS AND METHODS: Abdominal CT scans of 31 patients with intraabdominal neuroblastoma (stage II-IV), treated with RT (20 IORT+/-EBRT, 11 EBRT alone), were analyzed retrospectively. The diameter of the abdominal aorta was measured before and after RT. These data were compared to normal and predicted normal aortic diameters of children, according to the model of Fitzgerald, Donaldson and Poznanski (aortic diameter in centimeters = 0.844 + 0.0599 x age in years), and to the diameters of a control group of children who had not undergone RT. Statistical analyses for the primary aims were performed using the chi-squared test, t-test, Mann-Whitney test, nonparametric Wilcoxon matched-pairs test and analysis of variance for repeated measures. Clinical files and imaging studies were evaluated for signs of late vascular complications of neuroblastoma patients who had received RT. RESULTS: The mean diameter before and after RT and the growth of the aorta were significantly lower than expected in patients with neuroblastoma (P<0.05 for each) and when compared to the growth in a control group with normal and nonirradiated aortas. Among the patients who had received RT, there was no difference due to the type of RT. Seven patients from the IORT+/-EBRT group developed vascular complications, which included hypertension (five), middle aortic syndrome (two), death due to mesenteric ischemia (one) and critical aortic stenosis, which required aortic bypass surgery (two). CONCLUSION: Patients with neuroblastoma who had received RT showed impaired growth of the abdominal aorta. Significant long-term vascular complications occurred in seven patients who received IORT+/-EBRT. Thus, CT evaluation of patients with neuroblastoma who receive RT should include not only reports of changes in tumor extension, but also documentation of perfusion, and the size and growth of the aorta and its branches over time.

Robot Assisted Surgical Ward Rounds: Virtually Always There.

BACKGROUND:  While an explosion in technological sophistication has revolutionized surgery within the operating theatre, delivery of surgical ward-based care has seen little innovation.  Use of telepresence allowing off-site clinicians communicate with patients has been largely restricted to outpatient settings or use of complex, expensive, static devices.  We designed a prospective study to ascertain feasibility and face validity of a remotely controlled mobile audiovisual drone (LUCY) to access inpatients.  This device is, uniquely, lightweight, freely mobile and emulates 'human' interaction by swiveling and adjusting height to patients' eye-level.   METHODS: Robot-assisted ward rounds(RASWR) were conducted over 3 months. A remotely located consultant surgeon communicated with patients/bedside teams via encrypted audiovisual telepresence robot (DoubleRoboticstm, California USA).  Likert-scale satisfaction questionnaires, incorporating free-text sections for mixed-methods data collection, were disseminated to patient and staff volunteers following RASWRs.  The same cohort completed a linked questionnaire following conventional (gold-standard) rounds, acting as control group. Data were paired, and non-parametric analysis performed.  RESULTS: RASWRs are feasible (>90% completed without technical difficulty). The RASWR(n=52 observations) demonstrated face validity with strong correlations (r>0.7; Spearman, p-value <0.05) between robotic and conventional ward rounds among patients and staff on core themes, including dignity/confidentiality/communication/satisfaction with management plan. Patients (96.08%, n=25) agreed RASWR were a satisfactory alternative when consultant physical presence was not possible. There was acceptance of nursing/NCHD cohort (100% (n=11) willing to regularly partake in RASWR).  CONCLUSION: RASWRs receive high levels of patient and staff acceptance, and offer a valid alternative to conventional ward rounds when a consultant cannot be physically present.

Dose calculation using megavoltage cone-beam CT.

PURPOSE: To demonstrate the feasibility of performing dose calculation on megavoltage cone-beam CT (MVCBCT) of head-and-neck patients in order to track the dosimetric errors produced by anatomic changes. METHODS AND MATERIALS: A simple geometric model was developed using a head-size water cylinder to correct an observed cupping artifact occurring with MVCBCT. The uniformity-corrected MVCBCT was calibrated for physical density. Beam arrangements and weights from the initial treatment plans defined using the conventional CT were applied to the MVCBCT image, and the dose distribution was recalculated. The dosimetric inaccuracies caused by the cupping artifact were evaluated on the water phantom images. An ideal test patient with no observable anatomic changes and a patient imaged with both CT and MVCBCT before and after considerable weight loss were used to clinically validate MVCBCT for dose calculation and to determine the dosimetric impact of large anatomic changes. RESULTS: The nonuniformity of a head-size water phantom ( approximately 30%) causes a dosimetric error of less than 5%. The uniformity correction method developed greatly reduces the cupping artifact, resulting in dosimetric inaccuracies of less than 1%. For the clinical cases, the agreement between the dose distributions calculated using MVCBCT and CT was better than 3% and 3 mm where all tissue was encompassed within the MVCBCT. Dose-volume histograms from the dose calculations on CT and MVCBCT were in excellent agreement. CONCLUSION: MVCBCT can be used to estimate the dosimetric impact of changing anatomy on several structures in the head-and-neck region.

Long-term outcome and toxicities of intraoperative radiotherapy for high-risk neuroblastoma.

PURPOSE: To review a historical cohort of consecutively accrued patients with high-risk neuroblastoma treated with intraoperative radiotherapy (IORT) to determine the therapeutic effect and late complications of this treatment. METHODS AND MATERIALS: Between 1986 and 2002, 31 patients with newly diagnosed high-risk neuroblastoma were treated with IORT as part of multimodality therapy. Their medical records were reviewed to determine the outcome and complications. Kaplan-Meier probability estimates of local control, progression-free survival, and overall survival at 36 months after diagnosis were recorded. RESULTS: Intraoperative radiotherapy to the primary site and associated lymph nodes achieved excellent local control at a median follow-up of 44 months. The 3-year estimate of the local recurrence rate was 15%, less than that of most previously published series. Only 1 of 22 patients who had undergone gross total resection developed recurrence at the primary tumor site. The 3-year estimate of local control, progression-free survival, and overall survival was 85%, 47%, and 60%, respectively. Side effects attributable to either the disease process or multimodality treatment were observed in 7 patients who developed either hypertension or vascular stenosis. These late complications resulted in the death of 2 patients. CONCLUSIONS: Intraoperative radiotherapy at the time of primary resection offers effective local control in patients with high-risk neuroblastoma. Compared with historical controls, IORT achieved comparable control and survival rates while avoiding many side effects associated with external beam radiotherapy in young children. Although complications were observed, additional analysis is needed to determine the relative contributions of the disease process and specific components of the multimodality treatment to these adverse events.

Patient dose considerations for routine megavoltage cone-beam CT imaging.

Megavoltage cone-beam CT (MVCBCT), the recent addition to the family of in-room CT imaging systems for image-guided radiation therapy (IGRT), uses a conventional treatment unit equipped with a flat panel detector to obtain a three-dimensional representation of the patient in treatment position. MVCBCT has been used for more than two years in our clinic for anatomy verification and to improve patient alignment prior to dose delivery. The objective of this research is to evaluate the image acquisition dose delivered to patients for MVCBCT and to develop a simple method to reduce the additional dose resulting from routine MVCBCT imaging. Conventional CT scans of phantoms and patients were imported into a commercial treatment planning system (TPS: Phillips, Pinnacle) and an arc treatment mimicking the MVCBCT acquisition process was generated to compute the delivered acquisition dose. To validate the dose obtained from the TPS, a simple water-equivalent cylindrical phantom with spaces for MOSFETs and an ion chamber was used to measure the MVCBCT image acquisition dose. Absolute dose distributions were obtained by simulating MVCBCTs of 9 and 5 monitor units (MU) on pelvis and head and neck patients, respectively. A compensation factor was introduced to generate composite plans of treatment and MVCBCT imaging dose. The article provides a simple equation to compute the compensation factor. The developed imaging compensation method was tested on routinely used clinical plans for prostate and head and neck patients. The quantitative comparison between the calculated dose by the TPS and measurement points on the cylindrical phantom were all within 3%. The dose percentage difference for the ion chamber placed in the center of the phantom was only 0.2%. For a typical MVCBCT, the dose delivered to patients forms a small anterior-posterior gradient ranging from 0.6 to 1.2 cGy per MVCBCT MU. MVCBCT acquisitions in the pelvis and head and neck areas deliver slightly more dose than current portal imaging but render soft tissue information for positioning. Overall, the additional dose from daily 9 MU MVCBCTs of prostate patients is small compared to the treatment dose (<4%). Dose-volume histograms of compensated plans for pelvis and head and neck patients imaged daily with MVCBCT showed no additional dose to the target and small increases at low doses. The results indicate that the dose delivered for MVCBCT imaging can be precisely calculated in the TPS and therefore included in the treatment plan. This allows simple plan compensations, such as slightly reducing the treatment dose, to minimize the total dose received by critical structures from daily positioning with MVCBCT. The proposed compensation factor reduces the number of MU per treatment beam per fraction. Both the number of fractions and the beam arrangement are kept unchanged. Reducing the imaging volume in the cranio-caudal direction can further reduce the dose delivered for MVCBCT. This is a useful feature to eliminate the imaging dose to the eyes or to focus on a specific region of interest for alignment.