Development of a reliable surgical quality assurance tool for gastrectomy in oncological trials

BACKGROUND

Despite its recognized importance, there is currently no reliable tool for surgical quality assurance (SQA) of gastrectomy in surgical oncology. The aim of this study was to develop an SQA tool for gastrectomy and to apply this tool within the ADDICT Trial in order to assess the extent and completeness of lymphadenectomy.

METHODS

The operative steps for D1+ and D2 gastrectomy have been previously described in the literature and ADDICT trial manual. Two researchers also performed fieldwork in the UK and Japan to document key operative steps through photographs and semi-structured interviews with expert surgeons. This provided the steps that were used as the framework for the SQA tool. Sixty-two photographic cases from the ADDICT Trial were rated by three independent surgeons. Generalizability (G) theory determined inter-rater reliability. D-studies examined the effect of varying the number of assessors and photographic series they rated. Chi-square assessed intra-rater reliability, comparing how the individual assessor's responses corresponded to their global rating for extent of lymphadenectomy.

RESULTS

The tool comprised 20 items, including 19 anatomical landmarks and a global rating score. Overall reliability had G-coefficient of 0.557. Internal consistency was measured with a Cronbach's alpha score of 0.869 and Chi-square confirmed intra-rater reliability for each assessor as < 0.05.

CONCLUSIONS

A photographic surgical quality assurance tool is presented for gastrectomy. Using this tool, the assessor can reliably determine not only the quality but also the extent of the lymphadenectomy performed based on remaining anatomy rather than the excised specimen.

Severe Dumping Symptoms Are Uncommon Following Transthoracic Esophagectomy But Significantly Decrease Health-Related Quality of Life in Long-Term, Disease-Free Survivors

BACKGROUND

High-quality documentation of dumping symptoms after esophagectomy is currently limited. The aim of the study was to describe the incidence of symptoms associated with dumping syndrome and their relationship with health-related quality of life after esophagectomy.

METHODS

The study cohort was identified from prospective IRB-approved databases from two high-volume esophagectomy centers. Patients that were alive and without evidence of recurrence in April 2018 completed the validated Dumping Symptom Rating Scale and health-related quality of life questionnaires. Compound dumping symptom score was created by combining the individual scores for severity and frequency for each symptom.

RESULTS

In total, 171 patients who underwent esophagectomy 1995-2017 responded to the questionnaires, corresponding to a response rate of 77.0%. Median age was 66 years and median time from operation to survey was 5.5 years. Absent or mild problems in all nine dumping symptoms were reported by 94 (59.5%) patients; 19 (12.0%) patients reported moderate or severe problems in at least three symptoms, the most common being postprandial "need to lie down," "diarrhea," and "stomach cramps." Increasing compound dumping symptom score was associated with significantly decreased function scores in all aspects of health-related quality of life except physical functioning (P < 0.005).

CONCLUSIONS

Esophagectomy has the potential to change long-term eating patterns; however, the majority of patients in the study did not have severe postoperative dumping symptoms. On the other hand, moderate-to-severe dumping symptoms, which were reported by 12% of patients in this study, were strongly associated with decreased health-related quality of life.

Patient-reported outcomes after oesophagectomy in the multicentre LASER study

BACKGROUND

Data on the long-term symptom burden in patients surviving oesophageal cancer surgery are scarce. The aim of this study was to identify the most prevalent symptoms and their interactions with health-related quality of life.

METHODS

This was a cross-sectional cohort study of patients who underwent oesophageal cancer surgery in 20 European centres between 2010 and 2016. Patients had to be disease-free for at least 1 year. They were asked to complete a 28-symptom questionnaire at a single time point, at least 1 year after surgery. Principal component analysis was used to assess for clustering and association of symptoms. Risk factors associated with the development of severe symptoms were identified by multivariable logistic regression models.

RESULTS

Of 1081 invited patients, 876 (81.0 per cent) responded. Symptoms in the preceding 6 months associated with previous surgery were experienced by 586 patients (66.9 per cent). The most common severe symptoms included reduced energy or activity tolerance (30.7 per cent), feeling of early fullness after eating (30.0 per cent), tiredness (28.7 per cent), and heartburn/acid or bile regurgitation (19.6 per cent). Clustering analysis showed that symptoms clustered into six domains: lethargy, musculoskeletal pain, dumping, lower gastrointestinal symptoms, regurgitation/reflux, and swallowing/conduit problems; the latter two were the most closely associated. Surgical approach, neoadjuvant therapy, patient age, and sex were factors associated with severe symptoms.

CONCLUSION

A long-term symptom burden is common after oesophageal cancer surgery.

Evaluation of the Ventral Hernia Working Group classification for long-term outcome using English Hospital Episode Statistics: a population study

Purpose

The Ventral Hernia Working Group (VHWG) classification of ventral/incisional hernia (IH) was developed by expert consensus in 2010. Subsequently, Kanters et al. have demonstrated the validity of a modified version of the system for predicting short-term outcomes. This study aims to evaluate the modified system for predicting hernia recurrence.

Methods

Patients undergoing IH surgery (defined by OPCS codes) in the England Hospital Episode Statistics (HES) database, from 1997 to 2012, were identified. Baseline demographics at index hernia operation and episodes of further hernia surgery (FHS) were recorded. Risk factors for FHS were identified using cox regression and evaluated against the modified-VHWG grade using receiver-operating characteristics (ROC).

Results

The final analysis included 214,082 index IH operations. Of these, 52.6% were female and mean age was 56.59 (SD15.9). An admission for FHS was found in 8.3% cases (17,714 patients).

Multi-variate cox regression revealed contaminated hernia (p < 0.0001), pre-existing IBD (p < 0.0001) and hernia comorbidity (p = 0.05) to be significantly related to long-term FHS. Classifying patients using these factors, according to the modified-VHWG classification, revealed that compared to Grade 1, the hazard ratio (HR) of FHS increased in Grade 2 (HR 1.19; p < 0.0001) and further increased in Grade 3 (HR 1.79; p < 0.0001). ROC analysis revealed the area under the curve to be 0.73 (95% CI 0.73–0.74).

Conclusion

This analysis demonstrates the broad validity of the modified-VHWG classification in discriminating risk for FHS. Inclusion of pre-existing IBD as a factor defining Grade 2 patients would be recommended. This analysis is limited by the absence of certain factors within the HES database, such as BMI.

Variation in esophageal anastomosis technique-the role of collaborative learning

Centralization of care has improved outcomes in esophagogastric (EG) cancer surgery. However, specialist surgical centers often work within clinical silos, with little transfer of knowledge and experience. Although variation exists in multiple dimensions of perioperative care, the differences in operative technique are rarely studied. An esophageal anastomosis workshop was held to identify areas of common and differing practice within the operative technique. Surgeons showed videos of their anastomosis technique by open and minimally invasive surgery. Each video was followed by a discussion. Surgeons from 10 different EG cancer centers attended. Eight key technical differences and learning points were identified and discussed: the optimum diameter of the gastric conduit; avoiding ischemia in the gastric conduit; minimizing esophageal trauma; the use of an esophageal mucosal collar; omental wrapping; intraoperative leak testing; ideal diameter of the circular stapler and the growing use of linear stapled anastomoses. The workshop received positive feedback from participants and on 2 years follow-up, 40% stated that they believed that the learning of tips and techniques during the workshop has contributed to lowering their anastomotic leak rate. Many differences exist in surgical technique. The reasons for, and crucially the significance of, these differences must be discussed and examined. Workshops provide a forum for peer-to-peer collaborative learning to reflect on one's own practice and improve surgical technique. These changes can, in turn, generate incremental improvements in patient care and postoperative outcomes.

The development and validation of risk-stratification models for short-term outcomes following contaminated complex abdominal wall reconstruction

BACKGROUND

Short-term outcomes for patients undergoing contaminated complex abdominal wall reconstruction (CCAWR), including risk stratification, have not been studied in sufficiently high numbers. This study aims to develop and validate risk-stratification models for Clavien-Dindo (CD) grade ≥ 3 complications in patients undergoing CCAWR.

METHODS

A consecutive cohort of patients who underwent CCAWR in two European national intestinal failure centers, from January 2004 to December 2015, was identified. Data were collected retrospectively for short-term outcomes and used to develop risk models using logistic regression. A further cohort, from January 2016 to December 2017, was used to validate the models.

RESULTS

The development cohort consisted of 272 procedures performed in 254 patients. The validation cohort consisted of 114 patients. The cohorts were comparable in baseline demographics (mean age 58.0 vs 58.1; sex 58.8% male vs 54.4%, respectively). A multi-variate model including the presence of intestinal failure (p < 0.01) and operative time (p < 0.01) demonstrated good discrimination and calibration on validation. Models for wound and intra-abdominal complications were also developed, including pre-operative immunosuppression (p = 0.05), intestinal failure (p = 0.02), increasing operative time (p = 0.04), increasing number of anastomoses (p = 0.01) and the number of previous abdominal operations (p = 0.02). While these models showed reasonable ability to discriminate patients on internal assessment, they were not found to be accurate on external validation.

CONCLUSION

Acceptable short-term outcomes after CCAWR are demonstrated. A robust model for the prediction of CD ≥ grade 3 complications has been developed and validated. This model is available online at www.smbari.co.uk/smjconv2.

Incisional hernia and enterocutaneous fistula in patients with chronic intestinal failure: prevalence and risk factors in a cohort of patients referred to a tertiary centre

AIM

This study aims to determine the prevalence of incisional hernia (IH) and enterocutaneous fistula (ECF) in patients with intestinal failure (IF) referred to a tertiary centre and to identify factors associated with their development.

METHOD

A retrospective case note review was undertaken of a prospectively maintained database of all patients on home parenteral nutrition between 2011 and 2016 at a UK tertiary referral centre for IF. Risk factors were identified using binary logistic regression.

RESULTS

The database search identified 447 patients, of whom 349 (78.1%) had surgery prior to developing IF. Eighty-one (23.2%) patients had an IH and 123 (35.2%) had an ECF at the time of referral. Of these, 51 (14.6%) had both IH and ECF. IH was associated with a high body mass index (P = 0.05), a history of a major surgical complication resulting in IF (P = 0.01), previous emergency surgery (P = 0.04), increasing number of operations (P = 0.02) and surgical site infection (SSI; P = 0.01). ECF was associated with complications relating to earlier surgery. (P ≤ .001), previous treatment with an open abdomen (P = 0.03), SSI (P = 0.001), intra-abdominal collection (P ≤ 0.001) and anastomotic leak (P = 0.02).

CONCLUSION

In this series, patients with IF had a prevalence of IH which was more than double that expected following elective laparotomy (about 10%) and one in three had an ECF. Risk factors for IH and ECF are discussed.

Cardiorespiratory Comorbidity and Postoperative Complications following Esophagectomy: a European Multicenter Cohort Study

BACKGROUND

The impact of cardiorespiratory comorbidity on operative outcomes after esophagectomy remains controversial. This study investigated the effect of cardiorespiratory comorbidity on postoperative complications for patients treated for esophageal or gastroesophageal junction cancer.

PATIENTS AND METHODS

A European multicenter cohort study from five high-volume esophageal cancer centers including patients treated between 2010 and 2017 was conducted. The effect of cardiorespiratory comorbidity and respiratory function upon postoperative outcomes was assessed.

RESULTS

In total 1590 patients from five centers were included; 274 (17.2%) had respiratory comorbidity, and 468 (29.4%) had cardiac comorbidity. Respiratory comorbidity was associated with increased risk of overall postoperative complications, anastomotic leak, pulmonary complications, pneumonia, increased Clavien-Dindo score, and critical care and hospital length of stay. After neoadjuvant chemoradiotherapy, respiratory comorbidity was associated with increased risk of anastomotic leak [odds ratio (OR) 1.83, 95% confidence interval (CI) 1.11-3.04], pneumonia (OR 1.65, 95% CI 1.10-2.47), and any pulmonary complication (OR 1.52, 95% CI 1.04-2.22), an effect which was not observed following neoadjuvant chemotherapy or surgery alone. Cardiac comorbidity was associated with increased risk of cardiovascular and pulmonary complications, respiratory failure, and Clavien-Dindo score ≥ IIIa. Among all patients, forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) ratio > 70% was associated with reduced risk of overall postoperative complications, cardiovascular complications, atrial fibrillation, pulmonary complications, and pneumonia.

CONCLUSIONS

The results of this study suggest that cardiorespiratory comorbidity and impaired pulmonary function are associated with increased risk of postoperative complications after esophagectomy performed in high-volume European centers. Given the observed interaction with neoadjuvant approach, these data indicate a potentially modifiable index of perioperative risk.

Incidence and risk factors for esophageal cancer following achalasia treatment: national population-based case-control study

The objective of this study is to identify the incidence of and risk factors associated with the development of esophageal cancer in treated achalasia patients in a national cohort. Patients with esophageal achalasia diagnosed and receiving a treatment between 2002 and 2012 were identified in England. Patient and treatment factors were compared between individuals who developed esophageal cancer and those that did not using univariate and multivariate analyses. A total of 7487 patients receiving an interventional treatment for esophageal achalasia were included and 101 patients (1.3%) developed esophageal cancer. The incidence of esophageal cancer was 205 cases per 100,000 patient years at risk. Patients who developed esophageal cancer were older and more commonly primarily treated with pneumatic dilation (82.2% vs. 60.3%; P < 0.001). In the esophageal cancer group, there was an increase in the number of patients requiring reinterventions (47.5% vs. 38.0%; P = 0.041) and the average total number of reinterventions per patient (1.2 vs. 0.8; P = 0.026). Multivariate analysis suggested associations between increased reintervention following both surgical myotomy (HR = 5.1; 95%CI 1.12-23.16) and pneumatic dilation (HR = 1.48; 95%CI 0.95-2.29), and esophageal cancer risk. Increasing patient age and reintervention following primary achalasia treatment are important potential risk factors for the development of esophageal cancer. Treated achalasia patients with symptom recurrence should be carefully evaluated for potential development of esophageal cancer prior to considering reintervention, and increased vigilance may help diagnose esophageal cancer in these individuals at an early stage.

Effects of intraoperative pyloric stretch procedure on outcomes after esophagectomy

Various methods have been described to aid pyloric drainage in patients undergoing esophagectomy with gastric reconstruction. These techniques are intended to prevent delayed gastric empting following esophagectomy that can be associated with early morbidity and long-term functional complaints. The current study aims to review the safety and efficacy of a pyloric stretch procedure performed at the time of esophagectomy. To achieve this, a retrospective review of 100 consecutive patients undergoing esophagectomy during the period 2011-2016 was performed. Until May 2013, no patients received intraoperative pyloric intervention. After May 2013, all patients (N = 50) underwent intraoperative pyloric stretch procedure that involved bidirectional mechanical dilatation of the pylorus. Postoperative outcomes including result of routine oral contrast swallow and early morbidity were evaluated. Intraoperative pyloric stretching was performed safely and without local complications in all patients. Delayed gastric emptying was observed significantly less frequently in patients who received intraoperative pyloric stretching (48% vs. 22%, P = 0.006). No significant differences were observed in postoperative outcomes. When considering all patients as a single cohort, the presence of delayed gastric emptying was associated with significantly higher rates of postoperative pneumonia (71% vs. 45%, P = 0.010), cardiac complications (57% vs. 25%, P = 0.001) as well as longer hospital say (12 vs. 15 days, P < 0.001) and delay to free oral fluid intake (7 vs. 9 days, < 0.001). Binary logistic regression identified age and postoperative delayed gastric emptying as independent risk factors for postoperative pneumonia. In conclusion, this study has demonstrated the safety and efficacy an intraoperative pyloric stretch procedure for the prevention of delayed gastric emptying following esophagectomy.

The influence of hospital volume upon clinical management and outcomes of esophageal achalasia: an English national population-based cohort study

Management of achalasia is potentially complex. Previous studies have identified equivalence between pneumatic dilatation and surgical cardiomyotomy in terms of clinical outcomes. However, previous research has not investigated whether a management strategies and outcomes are different in high-volume achalasia centers. This national population-based cohort study aimed to identify the treatment modalities utilized in centers, which regularly manage achalasia and those which manage it infrequently. This study also assessed rates of re-intervention and complications to establish if a volume-outcome relationship exists for the management of achalasia in England. In this study, the Hospitals Episode Statistics database was used to identify all patients treated for achalasia in England from 2002 to 2012. Primary treatment was defined as surgical cardiomyotomy, sequential pneumatic dilatation, or botulinum toxin therapy. Primary outcome measure was reintervention. Centers were divided into regular achalasia centers (≥5.7 cases per annum) and infrequent achalasia centers (<5.7 cases per annum), and were analyzed according to tertiary cancer center status. In total, there were 7,487 patients treated for achalasia. Out of 1,947 cases (26%) were treated in regular achalasia centers, with 5,540 (74%) treated in infrequent centers. In binary logistic regression modeling regular centers treated a similar proportion of patients with primary surgical cardiomyotomy (OR: 1.11 (95% CI 0.98-1.27)) and had similar rates of re-intervention to infrequent achalasia centers (HR: 1.03 (0.94-1.12)). RA-CUSUM analysis demonstrated no relationship between total hospital volume and reintervention rates. Tertiary cancer centers treated more achalasia patients with primary surgical cardiomyotomy (OR: 1.51 (95% CI 1.31-1.73)) but there was no significant difference in reintervention rates (OR: 1.05 (95% CI 0.95-1.16)). In conclusion, this analysis failed to demonstrate a volume-outcome relationship in the management of achalasia in England. This study highlights that achalasia is treated infrequently by the majority of centers.

Profile of exhaled-breath volatile organic compounds to diagnose pancreatic cancer

Background

Pancreatic cancer has a very poor prognosis as most patients are diagnosed at an advanced stage when curative treatments are not possible. Breath volatile organic compounds (VOCs) have shown potential as novel biomarkers to detect cancer. The aim of the study was to quantify differences in exhaled breath VOCs of patients with pancreatic cancers compared with cohorts without cancer.

Methods

Patients were recruited to an initial development cohort and a second validation cohort. The cancer group included patients with localized and metastatic cancers, whereas the control group included patients with benign pancreatic disease or normal pancreas. The reference test for comparison was radiological imaging using abdominal CT, ultrasound imaging or endoscopic ultrasonography, confirmed by histopathological examination as appropriate. Breath was collected from the development cohort with steel bags, and from the validation cohort using the ReCIVA™ system. Analysis was performed using gas chromatography–mass spectrometry.

Results

A total of 68 patients were recruited to the development cohort (25 with cancer, 43 no cancer) and 64 to the validation cohort (32 with cancer, 32 no cancer). Of 66 VOCs identified, 12 were significantly different between groups in the development cohort on univariable analysis. Receiver operating characteristic (ROC) curve analysis using significant volatile compounds and the validation cohort produced an area under the curve of 0·736 (sensitivity 81 per cent, specificity 58 per cent) for differentiating cancer from no cancer, and 0·744 (sensitivity 70 per cent, specificity 74 per cent) for differentiating adenocarcinoma from no cancer.

Conclusion

Breath VOCs may distinguish patients with pancreatic cancer from those without cancer.

Effect of perioperative blood transfusion on the long-term survival of patients undergoing esophagectomy for esophageal cancer: a systematic review and meta-analysis

Perioperative blood transfusion has been linked to poorer long-term survival in patients undergoing esophagectomy, presumably due to its potential immunomodulatory effects. This review aims to summarize existing evidence relating to the influence of blood transfusion on long-term survival following esophagectomy for esophageal cancer. A systematic literature search (up to February 2017) was conducted for studies reporting the effects of perioperative blood transfusion on survival following esophagectomy for esophageal cancer. Meta-analysis was used to summate survival outcomes. Twenty observational studies met the criteria for inclusion. Eighteen of these studies compared the outcomes of patients who received allogenic blood transfusion to patients who did not receive this intervention. Meta-analysis of outcomes revealed that allogenic blood transfusion significantly reduced long-term survival (HR = 1.49; 95% CI 1.26 to 1.76; P < 0.001). There appeared to be a dose-related response with patients who received ≥3 units of blood having lower long-term survival compared to patient who received between 0 and 2 units (HR = 1.59; 95% CI 1.31 to 1.93; P < 0.001). Two studies comparing patients who received allogenic versus autologous blood transfusion showed superior survival in the latter group. Factors associated with the requirement for perioperative blood transfusion included: intraoperative blood loss; preoperative hemoglobin; operative approach; operative time, and; presences of advanced disease. These findings indicate that perioperative blood transfusion is associated with significantly worse long-term survival in patients undergoing esophagectomy for esophageal cancer. Autologous donation of blood, meticulous intraoperative hemostasis, and avoidance of unnecessary transfusions may prevent additional deaths attributed to this intervention.

Population-based cohort study of surgical myotomy and pneumatic dilatation as primary interventions for oesophageal achalasia

Background

The aim of this national population-based cohort study was to compare rates of reintervention after surgical myotomy versus sequential pneumatic dilatation for the primary management of oesophageal achalasia.

Methods

Patients with oesophageal achalasia diagnosed between 2002 and 2012, and without an intervention in the preceding 5 years were identified from the Hospital Episode Statistics database. Patients were divided into two groups based on the primary treatment, and propensity score matching was used to compensate for differences in baseline characteristics.

Results

Some 14 705 patients were diagnosed with oesophageal achalasia, of whom 7487 (50·9 per cent) received interventional treatment: 1742 (23·3 per cent) surgical myotomy, 4534 (60·6 per cent) pneumatic dilatation and 1211 (16·2 per cent) endoscopic botulinum toxin injection. As age increased, the proportion of patients receiving myotomy decreased and the proportion undergoing dilatation increased. Patients who underwent surgical myotomy were younger (mean age 44·8 years versus 58·5 years among those who had pneumatic dilatation; P &lt; 0·001), a greater proportion had a Charlson co-morbidity index score of 0 (90·1 versus 87·7 per cent; P = 0·003) and they were more commonly men (55·6 versus 51·8 per cent; P = 0·020). Following propensity score matching, the safety of the two initial treatment approaches was equivalent, with no difference in incidence of oesophageal perforation (1·3 and 1·4 per cent after myotomy and dilatation respectively; P = 0·750). However, dilatation was associated with increased need for reintervention (59·6 versus 13·8 per cent; P &lt; 0·001) and frequency of reinterventions (mean 0·34 versus 0·06 per year; P &lt; 0·001).

Conclusion

Surgical myotomy was associated with a lower rate of reintervention and could be offered as primary treatment in patients with oesophageal achalasia who are fit for surgery. For those unfit for surgery, pneumatic dilatation may provide symptomatic relief with approximately 60 per cent of patients requiring reintervention.

Multimodality treatment for esophageal adenocarcinoma: multi-center propensity-score matched study

Background

The primary aim of this study was to compare survival from neoadjuvant chemoradiotherapy plus surgery (NCRS) versus neoadjuvant chemotherapy plus surgery (NCS) for the treatment of esophageal or junctional adenocarcinoma. The secondary aims were to compare pathological effects, short-term mortality and morbidity, and to evaluate the effect of lymph node harvest upon survival in both treatment groups.

Methods

Data were collected from 10 European centers from 2001 to 2012. Six hundred and eight patients with stage II or III oesophageal or oesophago-gastric junctional adenocarcinoma were included; 301 in the NCRS group and 307 in the NCS group. Propensity score matching and Cox regression analyses were used to compensate for differences in baseline characteristics.

Results

NCRS resulted in significant pathological benefits with more ypT0 (26.7% versus 5%; P < 0.001), more ypN0 (63.3% versus 32.1%; P < 0.001), and reduced R1/2 resection margins (7.7% versus 21.8%; P < 0.001). Analysis of short-term outcomes showed no statistically significant differences in 30-day or 90-day mortality, but increased incidence of anastomotic leak (23.1% versus 6.8%; P < 0.001) in NCRS patients.

There were no statistically significant differences between the groups in 3-year overall survival (57.9% versus 53.4%; Hazard Ratio (HR)= 0.89, 95%C.I. 0.67-1.17, P = 0.391) nor disease-free survival (52.9% versus 48.9%; HR = 0.90, 95%C.I. 0.69-1.18, P = 0.443). The pattern of recurrence was also similar (P = 0.660). There was a higher lymph node harvest in the NCS group (27 versus 14; P < 0.001), which was significantly associated with a lower recurrence rate and improved disease free survival within the NCS group.

Conclusion

The survival differences between NCRS and NCS maybe modest, if present at all, for the treatment of locally advanced esophageal or junctional adenocarcinoma. Future large-scale randomized trials must control and monitor indicators of the quality of surgery, as the extent of lymphadenectomy appears to influence prognosis in patients treated with NCS, from this large multi-center European study.

Influence of national centralization of oesophagogastric cancer on management and clinical outcome from emergency upper gastrointestinal conditions

Background

In England in 2001 oesophagogastric cancer surgery was centralized. The aim of this study was to evaluate whether centralization of oesophagogastric cancer to high-volume centres has had an effect on mortality from different emergency upper gastrointestinal conditions.

Methods

The Hospital Episode Statistics database was used to identify patients admitted to hospitals in England (1997–2012). The influence of oesophagogastric high-volume cancer centre status (20 or more resections per year) on 30- and 90-day mortality from oesophageal perforation, paraoesophageal hernia and perforated peptic ulcer was analysed.

Results

Over the study interval, 3707, 12 441 and 56 822 patients with oesophageal perforation, paraoesophageal hernia and perforated peptic ulcer respectively were included. There was a passive centralization to high-volume cancer centres for oesophageal perforation (26·9 per cent increase), paraoesophageal hernia (19·5 per cent increase) and perforated peptic ulcer (23·0 per cent increase). Management of oesophageal perforation in high-volume centres was associated with a reduction in 30-day (HR 0·58, 95 per cent c.i. 0·45 to 0·74) and 90-day (HR 0·62, 0·49 to 0·77) mortality. High-volume cancer centre status did not affect mortality from paraoesophageal hernia or perforated peptic ulcer. Annual emergency admission volume thresholds at which mortality improved were observed for oesophageal perforation (5 patients) and paraoesophageal hernia (11). Following centralization, the proportion of patients managed in high-volume cancer centres that reached this volume threshold was 88·0 per cent for oesophageal perforation, but only 30·3 per cent for paraoesophageal hernia.

Conclusion

Centralization of low incidence conditions such as oesophageal perforation to high-volume cancer centres provides a greater level of expertise and ultimately reduces mortality.

Evaluation of 18F-fluorothymidine positron emission tomography ([18F]FLT-PET/CT) methodology in assessing early response to chemotherapy in patients with gastro-oesophageal cancer

BACKGROUND

3'-Deoxy-3'-[18F]fluorothymidine ([18F]FLT) PET has limited utility in abdominal imaging due to high physiological hepatic uptake of a tracer. We evaluated [18F]FLT-PET/CT combined with a temporal-intensity information-based voxel-clustering approach termed kinetic spatial filtering (KSF) to improve tumour visualisation in patients with locally advanced and metastatic gastro-oesophageal cancer and as a marker of early response to chemotherapy. Dynamic [18F]FLT-PET/CT data were collected before and 3 weeks post first cycle of chemotherapy. Changes in tumour [18F]FLT-PET/CT variables were determined. Response was determined on contrast-enhanced CT after three cycles of therapy using RECIST 1.1.

RESULTS

Ten patients were included. Following application of the KSF, visual distinction of all oesophageal and/or gastric tumours was observed in [18F]FLT-PET images. Among the nine patients available for response evaluation (RECIST 1.1), three patients had responded (partial response) and six patients were non-responders (stable disease). There was a significant association between Ki-67 and all baseline [18F]FLT-PET parameters. Area under the curve (AUC) from 0 to 1 min was associated with treatment response.

CONCLUSIONS

The results of this study indicate that application of the KSF allowed accurate visualisation of both primary and metastatic lesions following imaging with the proliferation marker, [18F]FLT-PET/CT. However, [18F]FLT-PET uptake parameters did not correlate with response. Instead, we observe significant changes in tracer delivery following chemotherapy suggesting that further [18F]FLT-PET/CT studies in this tumour type should be undertaken with caution.

The psychological impact of symptoms related to esophagogastric cancer resection presenting in primary care: A national linked database study

BACKGROUND

The objective was to evaluate incidence, risk factors and impact of postoperative symptoms following esophagogastric cancer resection in primary care.

METHODS

Patients undergoing esophagogastrectomy for cancer from 1998 to 2010 with linked records in Clinical Practice Research Datalink, Hospital Episodes Statistics and Office of National Statistics databases were studied. The recording of codes for reflux, dysphagia, dyspepsia, nausea, vomiting, dumping, diarrhea, steatorrhea, appetite loss, weight loss, pain and fatigue were identified up to 12 months postoperatively. Psychiatric morbidity was also examined and its risk evaluated by logistic regression analysis.

RESULTS

Overall, 58.6% (1029/1755) of patients were alive 2 years after surgery. Of these, 41.1% had recorded postoperative symptoms. Reflux, dysphagia, dyspepsia and pain were more frequent following esophagectomy compared with gastrectomy (p < 0.05). Complications (OR = 1.40 95%CI 1.00-1.95) and surgical procedure predicted postoperative symptoms (p < 0.05). When compared with partial gastrectomy, esophagectomy (OR = 2.03 95%CI 1.26-3.27), total gastrectomy (OR = 2.44 95%CI 1.57-3.79) and esophagogastrectomy (OR = 2.66 95%CI 1.85-2.86) were associated with postoperative symptoms (p < 0.05). The majority of patients with postoperative psychiatric morbidity had depression or anxiety (98%). Predictors of postoperative depression/anxiety included younger age (OR = 0.97 95%CI 0.96-0.99), complications (OR = 2.40 95%CI 1.51-3.83), psychiatric history (OR = 6.73 95%CI 4.25-10.64) and postoperative symptoms (OR = 1.78 95%CI 1.17-2.71).

CONCLUSIONS

Over 40% of patients had symptoms related to esophagogastric cancer resection recorded in primary care, and were associated with an increase in postoperative depression and anxiety.

Surgical timing after chemoradiotherapy for rectal cancer, analysis of technique (STARRCAT): results of a feasibility multi-centre randomized controlled trial

BACKGROUND

The optimal time of rectal resection after long-course chemoradiotherapy (CRT) remains unclear. A feasibility study was undertaken for a multi-centre randomized controlled trial evaluating the impact of the interval after chemoradiotherapy on the technical complexity of surgery.

METHODS

Patients with rectal cancer were randomized to either a 6- or 12-week interval between CRT and surgery between June 2012 and May 2014 (ISRCTN registration number: 88843062). For blinded technical complexity assessment, the Observational Clinical Human Reliability Analysis technique was used to quantify technical errors enacted within video recordings of operations. Other measured outcomes included resection completeness, specimen quality, radiological down-staging, tumour cell density down-staging and surgeon-reported technical complexity.

RESULTS

Thirty-one patients were enrolled: 15 were randomized to 6 and 16-12 weeks across 7 centres. Fewer eligible patients were identified than had been predicted. Of 23 patients who underwent resection, mean 12.3 errors were observed per case at 6 weeks vs. 10.7 at 12 weeks (p = 0.401). Other measured outcomes were similar between groups.

CONCLUSIONS

The feasibility of measurement of operative performance of rectal cancer surgery as an endpoint was confirmed in this exploratory study. Recruitment of sufficient numbers of patients represented a challenge, and a proportion of patients did not proceed to resection surgery. These results suggest that interval after CRT may not substantially impact upon surgical technical performance.

Application of objective clinical human reliability analysis (OCHRA) in assessment of technical performance in laparoscopic rectal cancer surgery

BACKGROUND

Laparoscopic rectal resection is technically challenging, with outcomes dependent upon technical performance. No robust objective assessment tool exists for laparoscopic rectal resection surgery. This study aimed to investigate the application of the objective clinical human reliability analysis (OCHRA) technique for assessing technical performance of laparoscopic rectal surgery and explore the validity and reliability of this technique.

METHODS

Laparoscopic rectal cancer resection operations were described in the format of a hierarchical task analysis. Potential technical errors were defined. The OCHRA technique was used to identify technical errors enacted in videos of twenty consecutive laparoscopic rectal cancer resection operations from a single site. The procedural task, spatial location, and circumstances of all identified errors were logged. Clinical validity was assessed through correlation with clinical outcomes; reliability was assessed by test-retest.

RESULTS

A total of 335 execution errors identified, with a median 15 per operation. More errors were observed during pelvic tasks compared with abdominal tasks (p < 0.001). Within the pelvis, more errors were observed during dissection on the right side than the left (p = 0.03). Test-retest confirmed reliability (r = 0.97, p < 0.001). A significant correlation was observed between error frequency and mesorectal specimen quality (r s = 0.52, p = 0.02) and with blood loss (r s = 0.609, p = 0.004).

CONCLUSIONS

OCHRA offers a valid and reliable method for evaluating technical performance of laparoscopic rectal surgery.

Validation of an oncoplastic breast simulator for assessment of technical skills in wide local excision

Background

Simulation enables safe practice and facilitates objective assessment of technical skills. However, simulation training in breast surgery is rare and assessment remains subjective. The primary aim was to evaluate the construct validity of technical skills assessments in wide local excision (WLE).

Methods

Surgeons of different grades performed a WLE of a 25-mm palpable tumour on an in-house synthetic breast simulator. Procedures were videotaped (blinded), reviewed retrospectively, and independently rated against a procedure-specific global rating scale by two consultant breast surgeons. Specimen radiographs were obtained and the macroscopic distance from the ‘tumour’ edge to the resection margin was recorded in four cardinal directions. Expert consensus was used to construct an Oncoplastic Deviation Score (ODS), assigning points for excessively wide (more than 10 mm) and, conversely, close (less than 5 mm) macroscopic margins.

Results

Thirty-four surgeons (12 consultant surgeons, 12 specialty trainees and 10 core trainees) participated in the study. Video-based rating scores varied hierarchically with operator expertise (P &lt; 0·050). Inter-rater reliability was excellent (α ≥ 0·80, P &lt; 0·050 for all scales), and inter-rater agreement was moderate (κ = 0·132–0·361, P &lt; 0·050 for all scales). Statistically significant differences were observed on pairwise comparisons between each grade of surgeon in scores for ‘exposure’, ‘skin flap development’, ‘glandular remodelling’, ‘skin closure’ and ‘final product review’ (P &lt; 0·050). Consultants received significantly fewer ODS points than specialty trainees (P = 0·012) and core trainees (P = 0·028). Compared with experts (median 9·0 mm), wider margins were observed amongst specialty trainees (median 12·0 mm) and narrower margins amongst core trainees (median 7·1 mm) (P = 0·001).

Conclusion

Video ratings of performance and a proposed ODS differentiate surgeons based on technical skills in WLE and may be useful for objective assessment of breast surgery trainees.

National proficiency-gain curves for minimally invasive gastrointestinal cancer surgery

BACKGROUND

Minimal access surgery for gastrointestinal cancer has short-term benefits but is associated with a proficiency-gain curve. The aim of this study was to define national proficiency-gain curves for minimal access colorectal and oesophagogastric surgery, and to determine the impact on clinical outcomes.

METHODS

All adult patients undergoing minimal access oesophageal, colonic and rectal surgery between 2002 and 2012 were identified from the Hospital Episode Statistics database. Proficiency-gain curves were created using risk-adjusted cumulative sum analysis. Change points were identified, and bootstrapping was performed with 1000 iterations to identify a confidence level. The primary outcome was 30-day mortality; secondary outcomes were 90-day mortality, reintervention, conversion and length of hospital stay.

RESULTS

Some 1696, 15 008 and 16 701 minimal access oesophageal, rectal and colonic cancer resections were performed during the study period. The change point in the proficiency-gain curve for 30-day mortality for oesophageal, rectal and colonic surgery was 19 (confidence level 98·4 per cent), 20 (99·2 per cent) and three (99·5 per cent) procedures; the mortality rate fell from 4·0 to 2·0 per cent (relative risk reduction (RRR) 0·50, P = 0·033), from 2·1 to 1·2 per cent (RRR 0·43, P < 0·001) and from 2·4 to 1·8 per cent (RRR 0·25, P = 0·058) respectively. The change point in the proficiency-gain curve for reintervention in oesophageal, rectal and colonic resection was 19 (98·1 per cent), 32 (99·5 per cent) and 26 (99·2 per cent) procedures respectively. There were also significant proficiency-gain curves for 90-day mortality, conversion and length of stay.

CONCLUSION

The introduction of minimal access gastrointestinal cancer surgery has been associated with a proficiency-gain curve for mortality and major morbidity at a national level. Unnecessary patient harm should be avoided by appropriate training and monitoring of new surgical techniques.

Anastomotic reinforcement with omentoplasty following gastrointestinal anastomosis: A systematic review and meta-analysis

Anastomotic leak is a potentially devastating complication following gastrointestinal anastomosis. Some surgeons believe that reinforcing the anastomosis with omentum reduces the incidence and severity of anastomotic leak. A comprehensive electronic search of EMBASE, Medline, Web of Science and Cochrane databases was performed. Pooled odds ratios (POR) were calculated for discrete variables. There were six studies investigating esophageal anastomosis and 3 studies investigating colorectal anastomosis identified by the literature search. A total of 2296 patients were included, 1073 with omentoplasty and 1223 without. In esophageal surgery omentoplasty significantly reduced the rate of anastomotic leak (2.9% vs 10.5% (POR = 0.28; 95% CI = 0.17 to 0.47; P < 0.0001), but there was no significant effect upon in-hospital mortality (2.3% vs. 2.5%; POR = 0.911 [95% CI 0.439-1.887]; P = 0.802) or anastomotic stricture between the two groups (6.6% vs 9.1%; POR = 0.842 [95% CI 0.331 to 2.145]; P = 0.720). In colorectal surgery there was no significant difference in anastomotic leak rate (5.0% vs 8.4%; POR: 0.50; 95% CI 0.21 to 1.17) or in-hospital mortality (4.2% vs 4.1%; POR: 0.90; 95% CI 0.34 to 2.41). The results of this analysis show that omentoplasty significantly reduced the rate of anastomotic leak following esophageal anastomosis but these results were not observed in colorectal anastomosis. Omentoplasty could be used as an adjunct technique to reduce the incidence of anastomotic leak in oesophageal anastomosis.

Clinical validity of consultant technical skills assessment in the English National Training Programme for Laparoscopic Colorectal Surgery

Background

The English National Training Programme for Laparoscopic Colorectal Surgery introduced a validated objective competency assessment tool to accredit surgeons before independent practice. The aim of this study was to determine whether this technical skills assessment predicted clinical outcomes.

Methods

Established consultants, training in laparoscopic colorectal surgery, were asked to submit two operative videos for evaluation by two blinded assessors using the competency assessment tool. A mark of 2·7 or above was considered a pass. Clinical and oncological outcomes were compared above and below this mark, including regression analysis.

Results

Eighty-five consultant surgeons submitted 171 videos. Of these, 44 (25·7 per cent) were in the fail group (score less than 2·7). This low scoring group had more postoperative morbidity (25 versus 8·7 per cent; P = 0·005), including surgical complications (18 versus 6·3 per cent; P = 0·020) and fewer lymph nodes harvested (median 13 versus 18; P = 0·004). A score of less than 2·7 was an independent predictor of surgical complication, lymph node yield and distal resection margin clearance. Consultants with higher scores had performed similar numbers of laparoscopic colorectal operations (median 37 versus 40; P = 0·373) but more structured training operations (18 versus 9; P &lt; 0·001).

Conclusion

An objective technical skills assessment provided a discriminatory tool with which to accredit laparoscopic colorectal surgeons.

Discrimination of lymph node metastases using desorption electrospray ionisation-mass spectrometry imaging

Desorption electrospray ionisation mass spectrometry imaging (DESI-MSI) has been used for the identification of cancer within lymph nodes with accurate spatial distribution in comparison to gold standard matched immuno-histopathological images. The metabolic profile of the cancerous lymph nodes was similar to that of the primary tumour site.

The impact of pyloric drainage on clinical outcome following esophagectomy: a systematic review

Delayed emptying of the gastric conduit following esophagectomy can be associated with an increased incidence of complications including aspiration pneumonia and anastomotic leak. The aim of this systematic review is to evaluate the current modalities of pyloric drainage following esophagectomy and their impact on anastomotic integrity and postoperative morbidity. Medline, Web of Science, Cochrane library, trial registries, and conference proceedings were searched. Five pyloric management strategies following esophagectomy were evaluated: no intervention, botulinum toxin (botox) injection, finger fracture, pyloroplasty, and pyloromyotomy. Outcomes evaluated were hospital mortality, anastomotic leak, pulmonary complications, delayed gastric emptying, and the late complication of bile reflux. Twenty-five publications comprising 3172 patients were analyzed. Pooled analysis of six comparative studies published after 2000 revealed pyloric drainage to be associated with a nonsignificant trend toward a reduced incidence of anastomotic leak, pulmonary complications, and delayed gastric emptying. Overall, the current level of evidence regarding the merits of individual pyloric drainage strategies remains very poor. There is significant heterogeneity in the definitions of clinical outcomes, in particular delayed gastric emptying, which has prevented meaningful assessment and formulation of consensus regarding the management of the pylorus during esophagectomy. Pyloric drainage procedures showed a non-significant trend toward fewer anastomotic leaks, pulmonary complications, and reduced gastric stasis when employed following esophagectomy. However, the ideal technique remains unproven suggesting that further collaborative investigations are needed to determine the intervention that will maximize the potential benefits, if any, of pyloric intervention.

Metabolomic profiling of oesophago-gastric cancer: a systematic review

AIMS

This review aims to identify metabolomic biomarkers of oesophago-gastric (OG) cancer in human biological samples, and to discuss the dominant metabolic pathways associated with the observed changes.

METHODS

A systematic review of the literature, up to and including 9th November 2012, was conducted for experimental studies investigating the metabolomic profile of human biological samples from patients with OG cancer compared to a control group. Inclusion criteria for analytical platforms were mass spectrometry or nuclear magnetic resonance spectroscopy. The QUADAS-2 tool was used to assess the quality of the included studies.

RESULTS

Twenty studies met the inclusion criteria and samples utilised for metabolomic analysis included tissue (n = 11), serum (n = 8), urine (n = 1) and gastric content (n = 1). Several metabolites of glycolysis, the tricarboxylic acid cycle, anaerobic respiration and protein/lipid metabolism were found to be significantly different between cancer and control samples. Lactate and fumurate were the most commonly recognised biomarkers of OG cancer related to cellular respiration. Valine, glutamine and glutamate were the most commonly identified amino acid biomarkers. Products of lipid metabolism including saturated and un-saturated free fatty acids, ketones and aldehydes and triacylglycerides were also identified as biomarkers of OG cancer. Unclear risk of bias for patient selection was reported for the majority of studies due to the lack of clarity regarding patient recruitment.

CONCLUSION

The application of metabolomics for biomarker detection in OG cancer presents new opportunities for the purposes of screening and therapeutic monitoring. Future studies should provide clear details of patient selection and develop metabolite assays suitable for progress beyond phase 1 pre-clinical exploratory studies.

Safety of training and assessment in operating theatres--a systematic review and meta-analysis

OBJECTIVE

Procedural outcomes can be used to assess the performance of specialists and trainees. This article establishes a systematic evidence base for the safety of training in the operating theatre. It also explores the possibility of using early, intermediate and late procedural outcomes of cardiac surgical operations to evaluate the performance of the clinicians and the healthcare system.

METHODS

Medline, EMBASE and PsycINFO databases were searched. Comparative studies evaluating quality indicators of cardiac surgical procedures (coronary artery bypass grafting (CABG) and valve surgery) were included. guidelines from the preferred reporting items for systematic reviews and meta-analyses (PRISMA) were used.

RESULTS

Fourteen studies met the inclusion criteria. For CABG, meta-analysis of outcomes did not show any significant differences between the technical and non-technical skills of trainees versus specialists apart from bypass time (less for specialists) and intensive care unit (ICU) length of stay (less for trainees). Studies reporting outcomes on valve surgery also did not report any statistically significant differences amongst the outcomes.

CONCLUSION

This systematic review did not discern any significant differences between the procedural outcomes of trainees and specialists, which indicates that trainees are safe to operate under senior supervision. In addition, this article recommends that various procedural outcomes can be used to evaluate the performance of clinicians and healthcare systems. Prospective studies need to be performed, taking into account the specific contribution of trainees and specialists during the procedure. This will give a clearer indication of safety and performance of trainees and specialists in the operating theatre.

'Trainee' evaluation of the English National Training Programme for laparoscopic colorectal surgery

AIM

The aim of this study was to review trainees' opinions of the training they had received through the National Training Programme (NTP).

METHOD

An online questionnaire was distributed to NTP trainees who had completed five or more training episodes within the programme. Demographic data were collected. Opinion was given using a five-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = undecided, 4 = agree, 5 = strongly agree). Percentages, mean values and SD were presented. ANOVA and Mann-Whitney U-tests were used to examine the impact of different factors on ratings and the difference between ratings, respectively.

RESULTS

Fifty-four registered trainees fulfilled the inclusion criteria, and 37 (69% response rate) completed the questionnaire. Teaching sessions were organized using an inreach (11%), in-house (11%), outreach (27%) or combination (51%) system of training. Trainees felt that their trainers seldom cancelled sessions (93%), that it was easy to organize (92%) and consent (100%) the patient, and that their hospital was supportive of training (97%). Trainees stated that overall their trainers were excellent at training (Likert scale = 4.71 ± 0.46) and that they received regular feedback (87%). The only variable to have a significant impact on the level of NTP approval was whether the trainee was able to choose his or her trainer (supportive of NTP, chose trainer P = 0.050; critical of NTP, chose trainer P = 0.020).

CONCLUSION

The large majority of trainees was highly satisfied with the training received in this innovative programme, irrespective of region or training structure used, thus demonstrating acceptability of the programme in its current form.

Lymph node metastases and prognosis in oesophageal carcinoma--a systematic review

Oesophageal cancer is the 7th most common cause of cancer-related death in the developed world and the incidence of oesophageal adenocarcinoma is now the fastest growing of any gastrointestinal cancer. Lymph node involvement is the single most important prognostic factor in oesophageal cancer. Imaging to determine the extent of lymph node involvement and plan treatment often requires a combination of modalities to avoid under-staging. The 7th edition of the staging system released by the International Union Against Cancer (IUCC) has stratified lymph node involvement according to the number of lymph nodes involved and redefined its groupings for location of metastatic lymph node involvement. This review discusses the prognostic and treatment implications of these modifications and explores micrometastatic lymph node involvement, capsular infiltration and lymph node ratio as possible additions to the staging system.

The National Training Programme for Laparoscopic Colorectal Surgery in England: a new training paradigm

AIM

The National Training Programme in laparoscopic colorectal surgery was set up in 2008 to introduce laparoscopic colorectal surgery nationwide in a safe and structured way.

METHOD

Over 150 consultant surgeons were enrolled; they received regular and supervised hands on training, and the operative outcome and the structured sign-off process were monitored continuously.

RESULTS

Over 1000 training cases have been recorded with clinical outcomes comparable to established experts; 1/3 elective colorectal resections in England are performed laparoscopically.

CONCLUSION

This successful and novel training model may be a training paradigm for other surgical and interventional specialities.

Hand-assisted laparoscopic surgery is associated with enhanced depth perception in novices

BACKGROUND

The visual information obtained in hand-assisted laparoscopic surgery (HALS) and total laparoscopy is based on two-dimensional depth cues. This study was designed to test the hypothesis that intracorporeal hand improves depth perception in HALS.

METHODS

Ten subjects were divided into two groups using HALS or total laparoscopy. The first task was passing a 10-cm thread through four small metallic loops five times; the second was tying 30 square three-throw intracorporeal laparoscopic knots. End points were (1) number of past pointing as an index of movement accuracy and reflection of depth perception, (2) execution time, and (3) knot quality score.

RESULTS

The HALS group was significantly faster than total laparoscopy with a median (interquartile range (IQR)) of 117 s (75.5) vs. 179 s (235.5; P = 0.001) for the thread passing task and 97 s (43.3) vs. 130 s (68.3; P < 0.0005) for knot tying. The number of past-pointing events was significantly lower with HALS compared with total laparoscopy with a median (IQR) of 12 (8) vs. 23 (24; P = 0.001) for the thread passing task and 7 (5) vs. 13 (10; P < 0.0005) for knot tying. There was a significant main effect of whether the targeted object was in contact with the other instrument in knot tying task when past-pointing occurred (P = 0.031). No difference in a knot quality score was found between the HALS and total laparoscopy.

CONCLUSIONS

The accuracy of instrument movement was significantly better in the HALS group compared with total laparoscopy. The study confirmed the hypothesis that intracorporeal hand improves depth perception in HALS. Also, the touch of the assisting instrument with the target object enhances spatial orientation in the laparoscopic operative field. However, further study is needed to test the hypothesis in experts.

Economic analysis of esophageal stenting for management of malignant dysphagia

Over half of patients diagnosed with esophageal cancer are unsuitable for curative resection. A significant proportion of these patients will subsequently require palliative stenting to alleviate dysphagia. There is growing consensus in the literature that the deployment of a Self-Expanding Metal Stent is the optimum stenting strategy; however, it remains unclear whether covered or uncovered metal stents are more cost-effective. In order to determine which type of prosthesis is more cost-effective, we compared the different stenting strategies in terms of 1-year stent-related mortality, health-related quality of life, and cost. A decision analytical model was constructed to compare the 1-year stent-related mortality, health-related quality of life, and cost between covered and uncovered stents. Probabilistic sensitivity analysis was performed to quantify the uncertainty associated with our results. Value of Information analysis was performed to assess the value of further research. In order to fully characterize the uncertainty associated with this decision, plastic stents were included in our analysis. Stent-related mortality was slightly lower following covered stent deployment compared with uncovered stent deployment (1.00% vs. 1.26%). Covered stents were more effective by 0.0013 Quality-Adjusted Life Years (Standard Deviation [SD] 0.0013 Quality-Adjusted Life Years). They were also less expensive by $729.58 (SD $390.63). Probabilistic sensitivity analysis suggested that these results were not sensitive to model parameter uncertainty. Plastic stents deployment was $2832.64 (SD $1182.72) more expensive than uncovered metal stent deployment. Value of Information analysis suggests that the maximum value of further research in the UK is $61,124.30. The results of this study represent strong evidence for the cost-effectiveness of covered compared with uncovered self-expanding metal stents for the palliation of patients with malignant dysphagia. The findings support previously published literature asserting the dominance of self-expanding metal stents over plastic stents. Value of Information analysis suggests that further research may not be cost-effective. These findings have significant implication for both current clinical practice and future clinical research.

Influence of compression pressure from the hand access device on hand microcirculation during hand-assisted laparoscopic surgery

BACKGROUND

Hand access devices in hand-assisted laparoscopic surgery depend on compression pressure to prevent air leakage. Surgeons frequently experience hand ache during surgery. This study aimed to test whether the pressure with such a device affects the microvascular function of the hand.

METHODS

Eight healthy volunteers participated in this experimental study. The hand access device, applied to the forearm, was inflated to 0, 8, 12, and 16 mmHg in a random order, and the microvascular activity of the skin of the hand dorsum was quantified using laser Doppler and iontophoresis of increasing doses of acetylcholine (endothelial-dependent vasodilator) and sodium nitroprusside (endothelial-independent vasodilator). The end point was skin erythrocyte flux ratio as a measure of microvascular skin activity.

RESULTS

No significant differences in microvascular responses to iontophoresis of acetylcholine and sodium nitroprusside were found at the four doses used when the hand access device was inflated at different pressures. The peak values for the hand allocated to acetylcholine were 3.48 +/- 1.33, 3.42 +/- 2.33, 3.38 +/- 2.55, and 2.84 +/- 3.10 arbitrary units, and the peak values for the hand allocated to sodium nitroprusside were 2.79 +/- 1.60, 2.00 +/- 1.60, 2.30 +/- 1.50, and 2.40 +/- 1.62 arbitrary units at cuff pressures of 0, 8, 12, and 16 mmHg, respectively.

CONCLUSION

The pressure in the hand access device up to 16 mmHg does not affect the hand cutaneous microcirculation.

Proficiency-gain curve for an advanced laparoscopic procedure defined by observation clinical human reliability assessment (OCHRA)

BACKGROUND

There is no established method for defining when a surgeon reaches the proficiency plateau in performing a specific operation. The published literature refers to "learning curves" based on retrospective evaluation of operative time, conversion rates, morbidity etc., which lack objectivity and do not address individual human factors. A more useful study of the gain in proficiency by the individual surgeon for a particular operation may be obtained using observational clinical-human reliability assessment (OCHRA).

METHODS

Following an 8-month fellowship in advanced laparoscopic surgery, the surgeon M.T. performed, independently at his own hospital, a prospective series of 20 palliative bypass operations for advanced gastric or pancreatic cancer. Unedited videotapes of gastro-jejunostomy (GJ) or cholecysto-jejunostomy (CJ) were analyzed independently in the training institution by the OCHRA technique.

RESULTS

For this surgeon proficiency in executing laparoscopic palliative bypass was reached after the 14th anastomosis when efficient execution (reduction in operative time) was accompanied by significant reduction in technical errors and improved economy of movement (reduction of the economy of movement index from 7-5 to 3-2). The majority of errors were enacted in component tasks associated with intracorporeal suturing. The declining incidence of these errors with experience was an integral component of the proficiency-gain curve. The important performance-shaping factors identified were: concentration lapses (n=1,321), misjudgments (n=209), poor camera work (n=193), fatigue (n=128), and impaired coordination (n=108).

CONCLUSIONS

This study has confirmed that OCHRA can describe quantitatively the proficiency-gain curve for a laparoscopic operation and indicate the plateau stage when the individual surgeon attains maximal performance in the execution of a specific procedure.

Characterization of materials eliciting foreign body reaction in stapled human gastrointestinal anastomoses

BACKGROUND

Staples are made of titanium, which elicits minimal tissue reaction. The authors have encountered foreign body reaction associated with stapled human gastrointestinal anastomoses, although the literature has no reports of this. The aim of this study was to identify the refractile foreign materials causing this reaction.

METHODS

Histological sections were taken from 14 gastrointestinal specimens from patients with a history of a stapled anastomosis within the specimen excised. These were reviewed by light and polarization microscopy. Scanning electron microscopy and energy dispersive X-ray analysis were carried out on these sections, staples and stapler cartridges used for gastrointestinal surgery.

RESULTS

Foreign bodies rich in fluorine were found in three patients, and those rich in carbon in 12. Other elements identified included oxygen, calcium, sodium, potassium, magnesium, aluminium and silicon. One specimen was found to contain titanium with no surrounding foreign body reaction. Stapler cartridges contained carbon, oxygen, fluorine, calcium, sodium, potassium, magnesium, aluminium, silicon and traces of titanium. Staples were composed of pure titanium with some fibrous material on the surface containing elements found in stapler cartridges.

CONCLUSION

The presence of foreign body reaction was confirmed in stapled human gastrointestinal anastomoses. The source of refractile materials eliciting this reaction was the stapler cartridges.

Ideal manipulation angle and instrument length in hand-assisted laparoscopic surgery

BACKGROUND

This study aimed to investigate the impact of manipulation angles and instrument length on task performance and muscle workload in hand-assisted laparoscopic surgery.

METHODS

The standard task was to close a 5-cm enterotomy of porcine small bowel inside a hand-assisted laparoscopic trainer. Surgeons were instructed to place the sutures 3 to 5 mm apart and from the enterotomy edge. Ten surgeons participated in each experiment. In the first experiment, each surgeon performed one task for each of the following manipulation angles: 45 degrees , 60 degrees , 75 degrees , and 90 degrees . In the second experiment, each surgeon performed two sessions of three tasks using either standard-length (330 mm) or short (250 mm) needle holders in the external hand. Outcome measures were execution time (s), placement error score (mm deviation from exact placement), leaking pressure (mmHg), and muscle workload by upper extremities as measured by integrated electromyography (mV s).

RESULTS

In the first experiments, the mean execution time was significantly longer with 90 degrees angles than with 45 degrees and 60 degrees manipulation angles (1,074.9 vs 715.9 s and 657.9 s with p < 0.05 and p < 0.01, respectively). The 90 degrees manipulation angle had the greatest muscle workload by the deltoid and trapezius of the extracorporeal and intracorporeal limbs and the extracorporeal dominant arm extensor and flexor groups. In the second experiment, the short instruments had a shorter mean execution time than the standard-length instrument (572.05 vs 618.75 s; p < 0.01). There was less muscle workload with the short than with the standard-length instrument by the extracorporeal dominant forearm extensor and flexor muscle groups and the deltoid of extracorporeal dominant and intracorporeal limbs. There were no significant differences in leaking pressure or placement error score between the different manipulation angles and instrument lengths.

CONCLUSION

The best ergonomic setup in hand-assisted laparoscopic surgery entails a manipulation angle of 45 degrees to 60 degrees and use of an instrument with a shorter shaft than standard laparoscopic length.

Patient safety alerts: a balance between evidence and action

A perspective on the article by Freer and Lyon (see page 327)

Mechanical properties of the human abdominal wall measured in vivo during insufflation for laparoscopic surgery

BACKGROUND

Carbon dioxide insufflation of the peritoneal cavity for laparoscopic surgery offers a unique opportunity to measure some mechanical properties of the human abdominal wall that hitherto have been difficult to obtain.

METHODS

The movement and change of the abdominal wall during insufflation to a pressure of 12 mmHg was studied in 18 patients undergoing laparoscopic surgery using a remote motion analysis system that does not compromise the sterility of the operative filed. These data together with the known abdominal wall thickness of each patient (measured by preoperative ultrasound scanning) enabled estimates of mechanical stiffness.

RESULTS

The findings showed that the abdominal wall changes from a cylinder to a dome during inflation, and that its area is increased by 15%. A volume, averaging 1.27 x 10(-3)m(3), results from expansion, reshaping of the abdominal wall, and displacement of the diaphragm. The abdominal wall is stiffer in the transverse plane than in the sagittal plane (Young's modulus, 42.5 +/- 9.0 kPa vs 22.5 +/- 2.6 kPa; p = 0.03; paired t-test).

CONCLUSIONS

Measurements of mechanical properties of the abdominal wall in patients undergoing laparoscopic surgery were obtained using a remote motion analysis system.

Competence Assessment of Laparoscopic Operative and Cognitive Skills: Objective Structured Clinical Examination (OSCE) or Observational Clinical Human Reliability Assessment (OCHRA)

BACKGROUND

There is no agreed system that is acknowledged as the ideal assessment of laparoscopic operative and cognitive skills. A new approach that combines Objective Structured Clinical Examination (OSCE) and Observational Clinical Human Reliability Assessment (OCHRA) was developed and used to assess trainees' operative and cognitive skills during laparoscopic training courses.

METHODS

Performance of 60 trainees participating in 3-day essential laparoscopic skills training (cognitive and psychomotor) courses were assessed and scored using both OSCE and OCHRA.

RESULTS

The study showed significant inverse correlations between the number of technical errors identified by OCHRA and the scores obtained by OSCE for individual tasks performed either by electro-surgical hook or laparoscopic scissors (r = -0.864 and r = -0.808, respectively). Significant differences between trainees were observed in relation to both overall OSCE scores and OCHRA parameters: execution time, total errors, and consequential errors (P < 0.001).

CONCLUSIONS

OCHRA provides a discriminative feedback assessment of laparoscopic operative skills. OCHRA and OSCE are best regarded as complementary assessment tools for operative and cognitive skills. The present study has documented significant variance between surgical trainees in the acquisition of both cognitive and operative skills.

Consensus guidelines for validation of virtual reality surgical simulators

The Work Group for Evaluation and Implementation of Simulators and Skills Training Programmes is a newly formed sub-group of the European Association of Endoscopic Surgeons (EAES). This work group undertook a review of validation evidence for surgical simulators and the resulting consensus is presented in this article. Using clinical guidelines criteria, the evidence for validation for six different simulators was rated and subsequently translated to a level of recommendation for each system. The simulators could be divided into two basic types; systems for laparoscopic general surgery and flexible gastrointestinal endoscopy. Selection of simulators for inclusion in this consensus was based on their availability and relatively widespread usage as of July 2004. Whilst level 2 recommendations were achieved for a few systems, it was clear that there was an overall lack of published validation studies with rigorous experimental methodology. Since the consensus meeting, there have been a number of new articles, system upgrades and new devices available. The work group intends to update these consensus guidelines on a regular basis, with the resulting article available on the EAES website (http://www.eaes-eur.org ).

Analysis of errors enacted by surgical trainees during skills training courses

BACKGROUND

Despite the emphasis on medical error as a major cause of hospital morbidity and mortality, there has been little published work on errors committed by trainees. This issue is particularly relevant to the training of surgeons and was addressed by our study.

METHODS

Sixty simulated laparoscopic cholecystectomies performed on restructured pig tissue models by 60 surgical trainees provided the study material. The unedited videotapes were analyzed by observational HRA of the component steps of the procedures. Ten generic forms of observable error types were used to categorize patterns of failure. Error probabilities with specific instruments were also calculated.

RESULTS

A total of 1067 errors were identified by observational HRA: 331 consequential and 736 without consequence (ie, total error rate of 18 [SD +/- 10]) per procedure. The study documented a wide variation in the number of errors between the 60 trainee surgeons. The important underlying factors for the trainee errors were (1) omission of important steps, (2) execution of steps in the wrong sequence, and (3) use of excessive force. These 3 errors accounted for 92% of consequential errors.

CONCLUSIONS

This study has shown that trainees vary considerably in their propensity to commit errors. This variability indicates that the surgical training in component skills for laparoscopic surgery should be flexible and individualized. Three mechanisms account for the majority of errors and indicate that skills training in surgery has to be structured, menu driven, and tailored to individual needs.

Identification and categorization of technical errors by Observational Clinical Human Reliability Assessment (OCHRA) during laparoscopic cholecystectomy

HYPOTHESIS

Surgical operative performance benefits from analysis of the mechanisms underlying technical errors committed during surgery.

DESIGN

Prospective study using the Observational Clinical Human Reliability Assessment (OCHRA) system and complete unedited videotapes of the operations.

SETTING

Three National Health Service hospitals within the United Kingdom.

PATIENTS

Two hundred consecutive patients with symptomatic gallstone disease.

INTERVENTIONS

Elective laparoscopic cholecystectomy for symptomatic gallstone disease by surgeons, who were blind to the nature and objectives of the study, using their usual operative technique.

MAIN OUTCOME MEASURES

Surgical consequential and inconsequential operative errors.

RESULTS

The analysis of 38 062 steps of the 200 laparoscopic cholecystectomies performed by 26 surgeons identified 2242 errors. The mean +/- SD total, inconsequential, and consequential errors per surgical procedure were 11.0 +/- 8.0, 8.0 +/- 6.0, and 4.0 +/- 3.0, respectively. Dissection of the Calot triangle (second task zone of the operation) incurred more total errors (6.5 +/- 5.4) compared with the first (2.9 +/- 2.8, P<.001) and third (5.1 +/- 3.9, P<.05) task zones. This translated to a higher error probability (6.9% vs 3.5% for the first and 5.5% for third task zones). The combined sharp and blunt dissection method had fewer errors than the blunt/teasing dissection technique (9.45 +/- 7.6 vs 13.9 +/- 7.3, P<.001) although different surgeons were involved. The most serious consequences were encountered during dissection with the electrosurgical hook knife.

CONCLUSION

This study has confirmed that the Observational Clinical Human Reliability Assessment system provides a comprehensive objective assessment of the quality of surgical operative performance by documenting the errors, the stage of the operation in which errors are enacted most frequently, and where these errors have serious consequences (hazard zones).