Introduction of new techniques and technologies in surgery: Where is transanal total mesorectal excision today?

The introduction of new surgical techniques and technologies has traditionally been unregulated. In many settings surgeons frequently adopt novel procedures without following a structured program of implementation or supervision. The appearance of innovative technology played a pivotal role in the advancement of new surgical techniques during the industrial revolution. Innovation has been an essential component of surgical development, which led to contemporary surgical techniques such as minimally invasive surgery. Different initiatives have been developed to guide the safe introduction of new surgical techniques and other procedures. Those include comprehensive concepts such as the Idea, Development, Exploration, Assessment, Long-term study framework, which could be particularly relevant when reflecting on the novel transanal total mesorectal excision (taTME), introduced a decade ago. This relatively novel and complex procedure promised to overcome some of the major limitations of traditional surgical approaches for rectal cancer. According to the Idea, Development, Exploration, Assessment, Long-term study framework, taTME is in the phase of exploration, where there is an existing and increasing number of reports being published as the experience grows. The current management of rectal cancer is in a state of radical evolution, with multiple options that were not previously available. TaTME is only one technique amongst many which could be part of a rectal cancer surgeon’s armamentarium; however, it requires further rigorous study and evaluation.

Challenges and future of chemical assisted heavy oil recovery processes

The primary method for heavy oil and bitumen production across the world is still in-situ steam-based technology. There are some drawbacks associated with steam-driven heavy oil recovery methods such as cyclic steam stimulation (CSS), steam flooding, and steam-assisted gravity drainage (SAGD). These cons include the high greenhouse gas footprint, low heavy oil/bitumen recovery, and difficulty in stop operation in emergency conditions. There exists a need for an improved method for recovering residual oils after applying steam injection. One of the potential technologies for doing this is chemical assisted heavy oil recovery, especially alkaline and surfactant additives. But the challenging question is how to develop a chemical-based oil recovery method considering long-term steam-rock interactions. Several associated issues of chemical additives, including adsorption behavior of surfactant at reservoir conditions and thermal stability of surfactant at steam chamber temperature, make this question more complex. This paper addresses all these concerns and provides solid knowledge regarding this technology. We delve into newly formulated chemicals for coupling with thermal oil recovery techniques that are still limited to lab-scale research, with the need for further studies. This critical review also provides the opportunities and challenges associated with chemical assisted heavy oil/bitumen production in a post-steam injection scenario. Finally, different aspects of such a method are covered in this review, along with practical information on field trials and best practices across the world.

Safety and Feasibility of a Lower-Cost Stapler in Bariatric Surgery

BACKGROUND

Laparoscopic staplers are integral to bariatric surgery. Their pricing significantly impacts the overall cost of procedures. An independent device company has designed a stapler handle and single-use reloads for cross-compatibility and equivalency with existing manufacturers, at a lower cost.

OBJECTIVES

We aim to demonstrate non-inferior function and cross-compatibility of a newly introduced stapler handle and reloads compared to our institution's current stapling system in a large animal survival study.

SETTING

University-affiliated animal research facility, USA.

METHODS

Matched small bowel anastomoses were created in four pigs, one with each stapler (a total of two per animal). After 14 days, investigators blinded to stapler type evaluated the anastomoses grossly and microscopically. Each anastomosis was scored on multiple measures of healing. Individual parameters were added for a global "healing score."

RESULTS

Clinical stapler function and gross quality of anastomoses were similar between stapler groups. Individual scores for anastomotic ulceration, reepithelialization, granulation tissue, mural healing, eosinophilic infiltration, serosal inflammation, and microscopic adherences were also statistically similar. The mean "healing scores" were equal. While this study was underpowered for subtle differences, safe and reliable performance in large animals still supports the feasibility of introducing new devices into human use.

CONCLUSIONS

The new stapler system delivers a similar technical performance and is cross-compatible with currently marketed stapling devices. An equivalent quality device at a lower price point should enable case cost reduction, helping to maintain hospital case margin and procedure value in the face of potentially declining reimbursement. This device may provide a safe and functional alternative to currently used laparoscopic surgical staplers.

Exploring life with a long-term condition using asynchronous online communication

OBJECTIVE

We describe the development and evaluation of a novel programme that uses an online patient portal system to provide medical students with early and authentic experience of patient interaction.

METHODS

Focus group discussions were held with students, tutors and patients who had taken part in the first year of the programme.

RESULTS

The programme provided an opportunity for early patient interaction in a safe environment. Students were able to practice communication skills learnt elsewhere in the course as well as identifying some of the different skills required for asynchronous online interactions. The approach gave opportunities to develop understanding of aspects of life with a long-term condition.

CONCLUSION

Using an online patient portal system to interact with a patient enabled students to develop and apply their communication skills in a safe environment and gain a holistic view of a patient's experience.

PRACTICE IMPLICATIONS

Medical students need to be equipped with the skills needed to communicate electronically with patients. Current medical curricula currently focus on more traditional models of the consultation. Further research is needed to establish best practice in this rapidly growing area.

Evaluation of therapeutic relationship skills training for mental health professionals: the Therapeutic Relationship Enabling Programme (TREP)

This article was migrated. The article was marked as recommended. Background: A 3-day workshop in Taiwan, developed in accordance with Carl Rogers' person-centred theory, used an experiential-learning pedagogy and a helping learning technology mPath. This study aimed to evaluate the effectiveness of a short-term course for mental health professional students assessing to the acquisition of therapeutic relationship competencies. Objective:To evaluate the training effects and investigate any changes in the level of therapeutic relationship competence of the participants before, at the end and two weeks after the intervention. Methods:A sample of 59 mental health professional students from 7 medical schools studying in nursing, occupational therapy, medicine, clinical psychology and other specialities with the completion of psychiatry-relevant courses. 26 of 59 mental health professional students volunteered to form the experimental group, and the controls were recruited using the snowball sampling technique. All of them completed the Barrett-Lennard Relationship Inventory OS-40 three times. Mean values and statistical significance tests were computed to compare the results. Results:Within 3 days, the mental health professional students in the experimental group (N=26) completed the Therapeutic Relationship Enabling Programme (TREP) and showed a statistically significant level of change (Mean Difference= +9.5, p= 0.002), which was in contrast to the outcome of the control group (N=33, Mean Difference= +0.18, p= 0.683), in the therapeutic relationship competences. The effecting growth curve of therapeutic relationship competence in the experimental group continually inclined two weeks after the intervention (Mean Difference= +19.423, p= 0.000) while the control group reflected a decline in therapeutic relationship competence (Mean Difference= -0.515, p= 0.812). Conclusions: A person-centred-theory-based training workshop with the use of a specially designed technology enhanced Taiwanese mental health professional students' learning on therapeutic relationship competences. A further investigation into learning person-centred therapeutic relationship qualities in the workshop as an innovative pedagogy and learning approach for medical education would be recommended.

Laparoscopic liver resection for hepatocellular carcinoma in Fontan-associated chronic liver disease. The first case report

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Hepatocellular carcinoma after Fontan procedure is associated with high mortality.

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Liver resection after Fontan procedure has high-risk liver/cardiac decompensation.

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Laparoscopic liver resection is feasible with low intra-abdominal pressures.

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Adequate anaesthetic management is essential in Fontan procedure patients.

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Laparoscopic liver resection is a new therapeutic option after Fontan procedure.

Introduction

A well-recognized long-term complication after Fontan procedure (FP), a complex cardiac surgery performed in patients with univentricular hearts, is the development of chronic liver disease and hepatocellular carcinoma (HCC). Due to the risk of cardiac and liver decompensation, liver resection of HCC is challenging and the laparoscopic approach has never been reported.

Presentation of the case

We present the first case of laparoscopic liver resection (LLR) of HCC in a 33-years-old girl with cardiac-related cirrhosis after FP. Intraoperatively, the pneumoperitoneum was established at 8–10 mmHg and adequate fluid infusion was given to maintain the cardiac preload. After an ultrasound-guided thermoablation along the free-tumor margin of the hepatic lesion, a full laparoscopic non-anatomical resection of the tumor in segment V was performed, without Pringle manouver and blood transfusion requirement. The cardiac function remained stable during the surgery and thereafter, and the post-operative course was uneventful.

Discussion

HCC in chronic liver disease after FP is associated with high-risk mortality. Due to the complex hemodynamic changes after FP, open surgical resections often aren’t feasible and loco-regional percutaneous treatment or combined liver-heart transplantation are the only therapeutic options. This case suggests that LLR in FP patients has low-risk of liver and cardiac decompensation, minimizing the pneumoperitoneum insufflation to ensure low intra-abdominal/intra-thoracic pressures and providing accurate anaesthetic management to maintain proper cardiac preload and output.

Conclusion

LLR for HCC after FP is safe and feasible, and might be considered an alternative treatment of HCC for which the best treatment has not been defined yet.

[Current status and prospect of traumatic orthopedics treatment]

The development of medicine technology is supported by the progress of materials, electronics, machinery, physics and other related fields.The article mainly reviews the research achievements of traumatic orthopedics from four aspects: big data, new theory, new technology and new implants. The prospects of intelligent minimally invasive, new materials, three-dimensional printing technology, surgical assistant robot of fracture reduction, digital orthopedics and other aspects are presented.Aiming at improving the treatments of traumatic orthopedics in China, this paper tracks the frontier of the orthopedics and absorbed advanced concepts and technologies of treatments on traumatic orthopedics in the world.

Emergent coordination and situated learning in a Hybrid OR: The mixed blessing of using radiation

Mobilising knowledge and coordinating actions in order to make use of new innovations and technologies is a major challenge in the health care sector. Drawing upon a longitudinal, qualitative study of a Hybrid Operating Room in Sweden, we illustrate how the staff from a variety of medical specialties need to coordinate their tasks and competencies, and learn how to use the technology in a safe way. This study shows that learning across highly-professionalized communities is a recursive process of emergent coordination and situated learning, which includes the acknowledgement of others' expertise, task interdependence, and the pragmatic accommodation of latitude and control. Moreover, there was continuous negotiations between the different communities about what should constitute approved practice based on the task being performed. This obstructed the development of a dominant community with the authority to independently exclude other communities. We thus conclude that emergent coordination of tasks and expertise is an important aspect of learning how to use technologies that break with conventions of established and previously separated practices.

Progress in Knee Arthroscopy Skills of Residents and Medical Students: A Prospective Assessment of Simulator Exercises and Analysis of Learning Curves

OBJECTIVE

Knee arthroscopies are very common orthopedic procedures. For a number of reasons, including increased public awareness for medical errors, patient safety, strict regulations governing duty-hours for residents, surgeons' liability, and an increasing emphasis on the efficient use of operating room time, interest in simulator training is on the rise. It was the purpose of this study to analyze learning curves of medical students and orthopedic resident surgeons using a virtual knee arthroscopy simulator.

DESIGN

Learning curves of medical students and orthopedic residents were measured perspective using an arthroscopic training simulator for 2 different exercises. Time, camera and probe movement as well as camera and probe roughness were the parameters to be compared. Mean and standard deviation of the initial and the final score for the consecutively performed exercises as well as their slope were reported.

SETTING

The study was performed at the Medical University of Innsbruck, Department of Orthopaedic Surgery. Level of clinical care: institutional.

PARTICIPANTS

A Students Group (n = 10) consisting of medical students at the Medical University of Innsbruck with no prior knowledge of arthroscopy but interest in orthopedic surgery was selected. The group was compared to a Residents Group (n = 9) which was comprised of orthopedic resident surgeons who had learned arthroscopy in operation courses. All participants involved in the study did several repetitions of the described exercises.

RESULTS

Both groups improved their skills after several repetitions. Residents were on average faster, moved the camera less, and touched the cortical tissue less than the students. For certain parameters students showed a steeper improvement curve than did residents, because the students started from a different experience level.

CONCLUSIONS

In conclusion, our results demonstrate the usefulness of virtual knee arthroscopy simulators as an important tool for improving surgical and arthroscopic skills in orthopedic resident surgeons, and medical students.

Best Practices for Training, Educating and Introducing New Techniques and Technology into Practice

Adoption of new practices is challenging to the surgeon innovator given lack of standardized processes for implementation. Credentialed surgeons who want to apply new practices need to ensure adequate training depending on the procedure and underlying skills. A competent and motivated team needs to be identified and appropriate privileging sought for the procedure from the local institution. Planning for meticulous monitoring of outcomes ensures continuous safety and quality surveillance. Patients need complete transparency when being informed about a novel practice with information on comparison to standard of care treatments.

What new technology means for the energy demand in China? A sustainable development perspective

This paper explores the direct impact of new technology on the energy intensity in China. The autoregressive distributed lag (ARDL) bounds test approach to cointegration is utilised over the extended period of 1985-2013. The variables found cointegrated and confirm the long-run association among all the underlying vectors. Furthermore, the results of long- and short-run analysis reveal that new technology spurs energy intensity in China. A 1% increase in technological innovation boosts energy intensity by 0.4% and 0.03% in the long and short run, respectively. The findings suggest that the establishment of smart grids and solar energy parks followed by the reforms in energy sector is yet to achieve plausible efficiency in China. The existing investment and innovation policy reforms are insufficient to assist the energy sector to cope up with the country's exceptional economic growth trend. Unlike other studies, this paper accommodates structural break in the series. During sensitivity analysis, the model is found stable. Hence, the findings possess important policy implications for China and open up new discussion in the field.

Hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal malignancies using new hybrid CO2 system: preliminary experience in referral center

The most frequent peritoneal surface malignancies originate principally by gastric cancer, colorectal cancer and ovarian cancer. Apart from the origin, peritoneal carcinosis (PC) is considered a negative prognostic factor. The hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) in the treatment of peritoneal malignancies is considered an attractive method to deliver chemotherapy with enhanced effect directly at the tumor site. The use of such loco-regional approach has proved to improve prognosis of peritoneal carcinomatosis from different origins. Recently, new devices are suitable for loco-regional intraperitoneal chemotherapy as Peritoneal Recirculation System (PRS-1.0 Combat) with CO₂ technology. This is a retrospective study with the aim to assess the perioperative outcomes using PRS. Seventeen patients were enrolled affected by colorectal or ovarian cancer. Complete cytoreduction (RT = 0) was achieved for all cases. Median operative time was 420 min (range: 335-665) and median drugs dose used for HIPEC was 137 mg/m2 (115-756). Median EBL was 200 ml (range 50-1000). Median post-operative hospital stay was 9 days (range: 4-24). Treatment-related early complications were recorded in 8 (47.0%) cases and were G1-G2 Major complications occurred in two (11.7%) cases. Considering our aim to test the PRS in different cases and in different pathologies, the results confirmed that the technique is feasible with good perioperative outcomes.

Evaluating New Technology

There are multiple complex issues to consider when evaluating any new technology. First evaluate the efficacy of the device. Then considering your patient population decide whether this technology brings an added benefit to your patients. If it meets these 2 criteria, then proceed to the financial analysis of acquiring this technology. The complete financial analysis has several important components that include but are not limited to cost, value, alternatives, return on investment, and associated marketing expense.

Cost of New Technologies in Prostate Cancer Treatment: Systematic Review of Costs and Cost Effectiveness of Robotic-assisted Laparoscopic Prostatectomy, Intensity-modulated Radiotherapy, and Proton Beam Therapy

CONTEXT

Some of the high costs of robot-assisted radical prostatectomy (RARP), intensity-modulated radiotherapy (IMRT), and proton beam therapy may be offset by better outcomes or less resource use during the treatment episode.

OBJECTIVE

To systematically review the literature to identify the key economic trade-offs implicit in a particular treatment choice for prostate cancer.

EVIDENCE ACQUISITION

We systematically reviewed the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement and protocol. We searched Medline, Embase, and Web of Science for articles published between January 2001 and July 2016, which compared the treatment costs of RARP, IMRT, or proton beam therapy to the standard treatment. We identified 37, nine, and three studies, respectively.

EVIDENCE SYNTHESIS

RARP is costlier than radical retropubic prostatectomy for hospitals and payers. However, RARP has the potential for a moderate cost advantage for payers and society over a longer time horizon when optimal cancer and quality-of-life outcomes are achieved. IMRT is more expensive from a payer's perspective compared with three-dimensional conformal radiotherapy, but also more cost effective when defined by an incremental cost effectiveness ratio <$50 000 per quality-adjusted life year. Proton beam therapy is costlier than IMRT and its cost effectiveness remains unclear given the limited comparative data on outcomes. Using the Grades of Recommendation, Assessment, Development and Evaluation approach, the quality of evidence was low for RARP and IMRT, and very low for proton beam therapy.

CONCLUSIONS

Treatment with new versus traditional technologies is costlier. However, given the low quality of evidence and the inconsistencies across studies, the precise difference in costs remains unclear. Attempts to estimate whether this increased cost is worth the expense are hampered by the uncertainty surrounding improvements in outcomes, such as cancer control and side effects of treatment. If the new technologies can consistently achieve better outcomes, then they may be cost effective.

PATIENT SUMMARY

We review the cost and cost effectiveness of robot-assisted radical prostatectomy, intensity-modulated radiotherapy, and proton beam therapy in prostate cancer treatment. These technologies are costlier than their traditional counterparts. It remains unclear whether their use is associated with improved cure and reduced morbidity, and whether the increased cost is worth the expense.

Suitability of functional evaluation embedded in serious game rehabilitation exercises to assess motor development across lifespan

The aim of this study was to determine if the results of activities performed using specially developed serious games for physical rehabilitation could be used as an indicator of the natural maturation and decline of motor control in healthy participants. Eighty-one participants (19 children (5-15 years old), 40 adults (18-65 years old) and 22 aged subjects (60-88 years old) participated in this study. Motions performed were recorded using the Kinect sensor. Three different exercises embedded in the games were used to assess upper limb, trunk and lower limb control. The trial duration and accuracy, measures of gross motor function and fine motor control, respectively, were computed for each participant. ANOVA tests shows statistically significant differences between the three groups for duration (53±15, 27±10 and 119±30s for children, adults and elderly subjects respectively) and accuracy (87±5, 89±10 and 70±8% for children, adults and elderly subjects respectively). The slopes of the curves that approximated the evolution of the performance over various ages are coherent with previous studies about motor control development and physiological decline. The proposed solution, i.e. serious games rehabilitation exercises coupled to motion analysis, seems to be an interesting tool to assess global motor function. Further studies are needed to study the influence of pathologies on the studied parameters.

New tools in cytometry

Cytometry aims to analyze cells, of any type, using dedicated instruments. The quantitative aspect makes flow cytometry (FCM) a good complementary tool for morphology. Most of the identification tools are based on immunostaining of cell structure details and more and more tools are available in terms of specificities and labels. FCM is under exponential development thanks to technical, immunological and data analysis progresses. Actual generations are now routinely using 6 to 10 simultaneous immuno-labeling on 20 to 100,000 cells, at high speed and short sample preparation and can easily detect rare events at frequency below 10^-4 cells. Data interpretation is complex and requires expertise. Mathematical tools are available to support analysis and classification of cells based. Cells from tissues can also be analyzed by FCM after mechanical and or enzymatic separation, but in situ cells can also be analyzed with the help of cytometry. Very new instruments bring spectral analysis, image in flow and mass spectrometry. Medical applications are very broad, notably in hemopathies, immunology, solid tumors, but also microbiology, toxicology, drug discovery, food and environmental industry. But, the limit of FCM is its dependence on operator from sample preparation, instrument settings up to data analysis and a strong effort is now under progress for standardization and constitution of international data bank for references and education.

A new approach to simplify surgical colpotomy in laparoscopic hysterectomy

New surgical techniques and technology have simplified laparoscopic hysterectomy and have enhanced the safety of this procedure. However, the surgical colpotomy step has not been addressed. This study evaluates the surgical colpotomy step in laparoscopic hysterectomy with respect to difficulty and duration. Furthermore, it proposes an alternative route that may simplify this step in laparoscopic hysterectomy. A structured interview, a prospective cohort study, and a problem analysis were performed regarding experienced difficulty and duration of surgical colpotomy in laparoscopic hysterectomy. Sixteen experts in minimally invasive gynecologic surgery from 12 hospitals participated in the structured interview using a 5-point Likert scale. The colpotomy in LH received the highest scores for complexity (2.8 ± 1.2), compared to AH and VH. Colpotomy in LH was estimated as more difficult than in AH (2.8 vs 1.4, p < .001). In the cohort study, 107 patients undergoing LH were included. Sixteen percent of the total procedure time was spent on colpotomy (SD 7.8 %). BMI was positively correlated with colpotomy time, even after correcting for longer operation time. No relation was found between colpotomy time and blood loss or uterine weight. The surgical colpotomy step in laparoscopic hysterectomy should be simplified as this study demonstrates that it is time consuming and is considered to be more difficult than in other hysterectomy procedures. A vaginal approach to the colpotomy is proposed to achieve this simplification.

Regulatory science of new technology: tendency of medical professionals' interests on silicone breast implants

New technology related to artificial organs is most attractive for worldwide researchers. We believe they must contribute for the future patients against untreatable diseases. Regulatory science is a new science to establish 'social acceptance' of new technology into the clinical market as soon as possible. In the history of silicone breast implants, we could recognize risks many times; however, we missed such chances to prevent a subsequent crisis. We analyzed the trend of published literature related to silicone breast implants to review the medical professionals' interests on such risks. This trend showed, despite issues of a social acceptance of silicone breast implants in a few countries, other countries' medical professionals had no interest. Our hypothesis is 'medical professionals face the government and do not have contributed to re-establish the social acceptance of new technologies for patients'. Any technology does not have the complete evidence of safety, efficacy and quality, despite regulatory authorities' review and approval with clinical evidences. medical professionals need to conduct subsequently the epidemiological study, to take a meta-analysis periodically and to create/update the guidance for their patients under their professional ethics after the marketing of new technologies. We need to take seriously the 'lesson learned' from the history of silicone breast implants for all kind of new technologies existed in the present.

What is changing in radiotherapy for the treatment of locally advanced nonsmall cell lung cancer patients? A review

Radiotherapy treatment continues to have a relevant impact in the treatment of nonsmall cell cancer (NSCLC). Use of concurrent chemotherapy and radiotherapy is considered the gold standard in the treatment of locally advanced NSCLC but clinical outcomes are not satisfactory. Introduction of new radiotherapy technology and chemotherapy regimens are under investigation in this setting with the goal to improve unsatisfactory results. We report how radiotherapy is changing in the treatment of locally advanced NSCLC.

How to improve colon cancer screening rates

Colorectal carcinoma is a common cause of death throughout the world and may be prevented by routine control, which can detect precancerous neoplasms and early cancers before they undergo malignant transformation or metastasis. Three strategies may improve colon cancer screening rates: convince the population about the importance of undergoing a screening test; achieve higher efficacy in standard screening tests and make them more available to the community and develop new more sensitive and efficacious screening methods and make them available as routine tests. In this light, the present study seeks to review these three means through which to increase colon cancer screening rates.

Safety and efficacy of a side-to-side duodeno-ileal anastomosis for weight loss and type-2 diabetes: duodenal bipartition, a novel metabolic surgery procedure

Background

Partial bypass of the GI tract may promote weight loss by decreased absorption of nutrients and changes in incretins. The aim of the study was to evaluate the safety and efficacy of performing a side-to-side duodeno-ileal anastomosis.

Methods

Seven 40–50 kg female Yorkshire pigs were allocated to a duodeno-ileal anastomosis (DIA), and were compared to a control group (SHAM). Swine’s weights were followed for 56 days. Gastroscopies were also performed at 28 days. Blood samples were also taken at regular intervals (CBC and Basic biochemistry profiles). At autopsy, gross changes and histological changes of the liver, duodenum and ileum samples were performed.

Results

While the SHAM group gained 33.2 % more weight at 56 days, the DIA group had shown a weight loss of −6.8 %, for a difference of 40.0 % between the 2 groups (p < 0.05). One pig developed an incisional hernia. Gastroscopies demonstrated normal healing without ulceration or inflammation at 28 days. Histological examination of the anastomosis at 56 days showed normal and smooth healing, with absence of liver toxicity.

Conclusion

In this porcine model with short follow-up, a side-to-side duodeno-ileal anastomosis provided excellent weight loss without apparent nutritional or grossly aberrant histological changes.

New technologies and techniques to improve adenoma detection in colonoscopy

Adenoma detection rate (ADR) is a key component of colonoscopy quality assessment, with a direct link between itself and future mortality from colorectal cancer. There are a number of potential factors, both modifiable and non-modifiable that can impact upon ADR. As methods, understanding and technologies advance, so should our ability to improve ADRs, and thus, reduce colorectal cancer mortality. This article will review new technologies and techniques that improve ADR, both in terms of the endoscopes themselves and adjuncts to current systems. In particular it focuses on effective techniques and behaviours, developments in image enhancement, advancement in endoscope design and developments in accessories that may improve ADR. It also highlights the key role that continued medical education plays in improving the quality of colonoscopy and thus ADR. The review aims to present a balanced summary of the evidence currently available and does not propose to serve as a guideline.

The introduction of basic critical care echocardiography reduces the use of diagnostic echocardiography in the intensive care unit

BACKGROUND

Basic critical care echocardiography (CCE) is routinely used by intensive care unit (ICU) providers to rapidly address key hemodynamic questions for the critically ill. By comparison, diagnostic echocardiography (DE) uses a comprehensive examination with more traditional workflow and sophisticated techniques. Despite these differences, both are frequently used to answer similar questions in ICU. This overlap raises questions of duplicate testing and redundancy of hospital resources. We therefore evaluated the effect of the introduction of basic CCE over the use of DE in Victoria Hospital, a tertiary care ICU in London Ontario, Canada.

METHODS

The monthly mean ratios of basic CCE and DE studies to patient care days (PCD) were plotted and general linear models were used to test for trends over time. Student t test was used to compare the mean DE/PCD before and after the introduction of basic CCE. The ratio of management actions for basic CCE studies was described. Outcome measures were compared using Pearson χ(2) test of association or the Wilcoxon rank sum test.

RESULTS

Over the 2-year study period, 1264 basic CCE studies were performed. Over this time, the ratio of CCE/PCD increased significantly (P<.001), whereas the ratio of DE/PCD decreased significantly (P=.004). When comparing the pre- and post-CCE periods, the mean DE/PCD decreased significantly from 5.27% to 4.51% (P=.01). There was no adverse change in ICU outcomes before and after the introduction of basic CCE. Mortality rates (pre- and post-CCE) were 23.69% and 24.61% (P=.48); median length of stay was 4.18 and 3.53 days (P<.001); and ventilated patient day rate was 64.96% and 64.93% (P>.9). There was a significant increase in vasoactive/inotropic drugs from a 20.47% vasoactive/inotropic drug/patient day rate to 21.99% (P<.001). Of all basic CCE studies, 61% led to a specific management action, including ordering a DE in 10.7% of cases.

CONCLUSION

In a hospital with a significant increase in basic CCE use, an associated significant decrease in DE use was observed with no increase in adverse outcomes. The significant increase in basic CCE use resulted in a change of management in most cases including the request for DE in a minority of cases.

Phase II clinical experience and long-term follow-up using the next-generation single-incision platform FMX314

BACKGROUND

Single-incision minimally invasive surgery has previously been associated with incisions 2.0-3.0 cm in length. We present a novel single-incision surgical platform compatible for insertion through a standard 15-mm trocar we previously described in six patients with short-term follow-up data. The objective of this phase II study was to evaluate the safety and feasibility of the platform in a larger collective and to evaluate 1-year follow-up data of the phase I trial.

METHODS

The technology features a multiple-use introducer, accommodating the articulating instruments, and is inserted through a 15-mm laparoscopic trocar. Cholecystectomy is performed through an umbilical incision. A prospective feasibility study was performed at a single center. Inclusion criteria were age of 18-75 years and biliary colic, exclusion criteria were acute cholecystitis, dilation of the biliary tree, severe coagulopathy, BMI > 40 kg/m(2), or choledocholithiasis. Endpoints included complications, length of stay, pain medication, cosmetic results, and the presence of hernia.

RESULTS

Twenty-seven patients (23 females; phase I: 6 patients, phase II: 21 patients) with an average age of 41.7 years and BMI 26.6 kg/m(2) were recruited for the study. Umbilical incision length did not exceed 15 mm. There were no intraoperative complications. Average OR time decreased from 91 min for the first six cases to 56 min for the last six cases. Average length of stay was 7.8 h. Pain control was achieved with diclofenac for no more than 7 days. All patients had no adverse events at 5-month follow-up, and all phase I patients had no adverse events nor evidence of umbilical hernia at 1 year.

CONCLUSION

This study demonstrates that single-incision cholecystectomy with the platform is feasible, safe, and reproducible in a larger patient population. Long-term follow-up showed no hernias or other adverse events. Further studies will be needed to evaluate longer-term hernia rates.

Comparison between Corvis and other tonometers in healthy eyes

PURPOSE

To determine the agreement of intraocular pressure (IOP) values in healthy eyes among Goldmann applanation tonometer, dynamic contour tonometer, ocular response analyzer and Corvis. Additionally, to study the relationship between their differences with central corneal thickness (CCT) and corneal curvature (CK).

METHODS

Seventy-six eyes of 76 healthy subjects were examined. Every subject underwent a complete ophthalmic evaluation, a Pentacam scan and three consecutive IOP measurements with each instrument (DCT, GAT, ORA and CST). IOP measurements provided by each device were compared with each other and the differences between them were correlated with morphological parameters obtained by Pentacam (CCT and CK). Statistical analysis was performed using SPSS software, version 18.0.

RESULTS

The mean age of enrolled subjects was 36.8 ± 10.6 years old. The mean IOP measurements that were obtained with GAT, DCT, ORA and CST was 15.62 ± 2.33 mmHg, 17.44 ± 2.51 mmHg, 15.99 ± 3.58 mmHg and 17.24 ± 3.44 mmHg respectively. The mean CCT was 543.63 ± 36.15 μm, the mean CK was 43.35 ± 1.23 D. GAT and ORA provided IOP values not showing a statistical difference; CST and DCT IOP measurements did not show a statistical difference whereas CST provided statistically higher IOP values both than GAT and both ORA.

CONCLUSIONS

According to our data, CST produces IOP values that are notably higher than GAT measures; therefore they cannot be used interchangeably. If CST should be used as the next gold standard, higher IOP values will come to be considered normal.