Decision analysis of minimally invasive management options for cholecysto-choledocholithiasis.

BACKGROUND: The management of cholecysto-choledocholithiasis is controversial with the risks and benefits of one versus two-stage approaches debated. This study aims to perform decision analysis of minimally invasive laparo-endoscopic approaches. METHODS: An advanced decision tree was constructed to compare pre, intra and post-operative ERCP and laparoscopic common bile duct exploration in terms of primary ductal clearance and significant complications for patients intended to undergo laparoscopic cholecystectomy. Transition probabilities were calculated from randomised controlled trials following a comprehensive literature search. Model uncertainties were extensively tested through deterministic and probabilistic Monte Carlo sensitivity analysis. Utility outcomes were 1 and 0.5 for successful primary clearance without and with complications, respectively, and 0 for failure of primary clearance of the duct. RESULTS: Twenty-one studies (n = 2697) were included in the analysis. At base case analysis, a laparo-endoscopic rendezvous approach had the highest utility output (0.90; no complication probability: 0.87/complication probability 0.06). Laparoscopic common bile duct exploration was ranked second with a utility output 0.87 (no complication probability: 0.82/complication probability 0.10). Pre-operative ERCP utility score was 0.84 (no complication probability: 0.78/ complication probability 0.11) and post-operative ERCP utility score was 0.78 (no complication probability: 0.71/complication probability 0.13). Monte Carlo analysis showed that laparo-endoscopic rendezvous and laparoscopic common bile duct exploration had an equal mean utility output of 0.57 (standard deviation 0.36; variance 0.13; 95% confidence interval 0.00-0.99 versus standard deviation 0.34; variance 0.12; 95% confidence interval 0.01-0.98). Laparo-endoscopic rendezvous had a superior treatment selection frequency of 39.93% followed by laparoscopic bile duct exploration (36.11%), pre-operative ERCP (20.67%) and post-operative ERCP (2.99%). CONCLUSION: One-stage approach to the management of cholecysto-choledocholithiasis is superior to two-stage, in terms of primary clearance of the duct and risk of operative morbidity. Laparo-endoscopic rendezvous approach could offer marginal additional benefit but more high-quality randomised controlled trials are needed.

The Introduction of Magtrace® Lymphatic Tracer for Axillary Sentinel Node Biopsy for Breast Cancer in a Rural Scottish District General Hospital: Initial Experience, Perspectives, Outcomes and Learning Curves.

BACKGROUND: Magtrace is a supraparamagnetic iron lymphatic tracer that has had increasing use in sentinel node biopsy (SNB) for breast cancer and has theoretical logistical benefits in centres where nanocolloid use may be associated with such issues. We describe our initial experience with the introduction of Magtrace into our routine practice by dual localisation with nanocolloid, comparing performance, and concordance. MATERIALS AND METHODS: This was prospective study of the first patients undergoing axillary SNB using Magtrace in a single centre. These patients had dual localisation with nanocolloid and Magtrace. Subjective global assessments of Magtrace and nanocolloid performance as well as objective signal strength and anatomical concordance were compared across multiple timepoints in the operative journey. RESULTS: A total of 30 consecutive patients underwent SNB within the timeframe of this study. While there were no failed SNB, 8 issues were reported including 4 issues of perceived imperfect localisation on global assessment. No patient had a failed or abandoned SNB, and only 1 case had a potential challenge in subsequent management after histopathological examination of the retrieved nodes. The majority of these issues occurred in the first half of the study period. There was overall weak to moderate positive correlation between Magtrace and nanocolloid signals of the retrieved sentinel nodes (Spearman's ρ = 0.392, P = .043). CONCLUSION: This study suggests that introducing Magtrace was feasible and safe in the context of a rural breast cancer service. A possible strategy to ameliorate the learning curve associated with these procedures is the routine dual localisation in the initial phases of performing Magtrace localisation.

A predictive Bayesian network that risk stratifies patients undergoing Barrett's surveillance for personalized risk of developing malignancy.

BACKGROUND: Barrett's esophagus is strongly associated with esophageal adenocarcinoma. Considering costs and risks associated with invasive surveillance endoscopies better methods of risk stratification are required to assist decision-making and move toward more personalised tailoring of Barrett's surveillance. METHODS: A Bayesian network was created by synthesizing data from published studies analysing risk factors for developing adenocarcinoma in Barrett's oesophagus through a two-stage weighting process. RESULTS: Data was synthesized from 114 studies (n = 394,827) to create the Bayesian network, which was validated against a prospectively maintained institutional database (n = 571). Version 1 contained 10 variables (dysplasia, gender, age, Barrett's segment length, statin use, proton pump inhibitor use, BMI, smoking, aspirin and NSAID use) and achieved AUC of 0.61. Version 2 contained 4 variables with the strongest evidence of association with the development of adenocarcinoma in Barrett's (dysplasia, gender, age, Barrett's segment length) and achieved an AUC 0.90. CONCLUSION: This Bayesian network is unique in the way it utilizes published data to translate the existing empirical evidence surrounding the risk of developing adenocarcinoma in Barrett's esophagus to make personalized risk predictions. Further work is required but this tool marks a vital step towards delivering a more personalized approach to Barrett's surveillance.