Bite by byte: can fitness wearables help bariatric patients lose more weight after surgery?

BACKGROUND

Multidisciplinary approaches to weight loss have been shown to improve outcomes in bariatric patients. Few studies have been performed assessing the utility and compliance of fitness tracking devices after bariatric surgery. We aim to determine whether use of an activity tracking device assists bariatric patients in improving postoperative weight loss behaviors.

METHODS

A fitness wearable was offered to patients undergoing bariatric surgery from 2019 to 2022. A telephone survey was conducted to elucidate the impact of the device on the patient's postoperative weight loss efforts 6 to 12 months after surgery. Weight loss outcomes of sleeve gastrectomy (SG) patients receiving the fitness wearable (FW) were compared to those of a group of SG patients who did not receive one (non-FW).

RESULTS

Thirty-seven patients were given a fitness wearable, 20 of whom responded to our telephone survey. Five patients reported not using the device and were excluded. 88.2% reported that using the device had a positive impact on their overall lifestyle. Patients felt that using the fitness wearable to keeping track of their progress helped them both to achieve short-term fitness goals and sustain them in the long run. From the patients that utilized the device, 44.4% of those that discontinued felt like it helped them build a routine that they maintained even after they were no longer using it. Demographic data between FW and non-FW groups (age, sex, CCI, initial BMI, and surgery BMI) did not differ significantly. The FW group trended towards greater %EWL at 1 year post-operation (65.2% versus 52.4%, p = 0.066) and had significantly greater %TWL at 1 year post-operation (30.3% versus 22.3%, p = 0.02).

CONCLUSION

The use of an activity tracking device enhances a patient's post-bariatric surgery experience, serving to keep patients informed and motivated, and leading to improved activity that may translate to better weight loss outcomes.

Anti-mucin 4 fluorescent antibody brightly targets colon cancer in patient-derived orthotopic xenograft mouse models: A proof-of-concept study for future clinical applications

BACKGROUND

There is a high rate of positive surgical margins with resection of liver metastases in colorectal cancer (CRC). The present study reports using a fluorescent anti-mucin 4 (MUC4) antibodies to label primary CRC and liver metastases to better visualize tumor margins in mouse models.

METHODS

Western blotting for MUC4 protein expression of normal colon and CRC tumor lysates was performed. Orthotopic primary and liver metastatic CRC mouse models received anti-MUC4 antibody conjugated to IR800 (MUC4-IR800). Mice were sacrificed and imaged after 48 hours.

RESULTS

Western blotting demonstrated increased MUC4 expression in a human CRC cell line and patient-derived primary and liver-metastatic CRCs. The LS174T orthotopic primary CRC model tumor to background ratio (TBR) was 2.04 (±0.35). The patient-derived orthotopic xenograft (PDOX) primary CRC model TBR was 2.17 (±0.35). The PDOX liver metastasis model TBR was 1.56 (±0.53).

CONCLUSION

MUC4-IR800 provided bright labeling of primary and liver tumors in CRC orthotopic mouse models, demonstrating their future clinical potential for margin visualization in fluorescence guided surgery.

Proof of concept of improved fluorescence-guided surgery of colon cancer liver metastasis using color-coded imaging of a tumor-labeling fluorescent antibody and indocyanine green restricted to the adjacent liver segment

BACKGROUND

Indocyanine green has been used for fluorescence-guided surgery of liver metastasis and labeling of liver segments. However, indocyanine green is nonspecific, and indocyanine green labeling does not always clearly outline tumor margins. In addition, it is difficult to distinguish between a tumor and its adjacent liver segment colored with indocyanine green alone. In the present study, we performed fluorescence-guided surgery in an orthotopic colon-cancer liver metastasis mouse model by labeling the metastatic liver tumor with an anti-carcinoembryonic antigen fluorescent antibody and with indocyanine green restricted to the adjacent liver segment.

METHODS

A liver metastasis model was established with human LS174T colon cancer tumor fragments. To label the tumor, mice received SGM-101, an anti-carcinoembryonic antigen antibody conjugated to a near-infrared fluorophore (700 nm), currently in clinical trials, 3 days before surgery. Indocyanine green (800 nm) was injected after ligation of the tumor-bearing Glissonean pedicle with fluorescence labeling restricted to the liver segment adjacent to the tumor. Bright-light surgery and fluorescence-guided surgery were performed to resect the liver metastasis. To assess recurrence, mice underwent necropsy 3 weeks after surgery and the tumor was weighed.

RESULTS

Fluorescence-guided anatomic left lateral lobectomy and fluorescence-guided partial liver resection were both performed with color-coded double labeled imaging. Tumor weight 3 weeks after surgery was significantly lower with fluorescence-guided surgery compared to bright-light surgery (38 ± 57 mg vs 836 ± 668 mg, P = .011) for partial liver resection.

CONCLUSION

The present study provides a proof-of-concept that color-coded and double labeling of the tumor and adjacent liver segment has the potential to improve liver metastasectomy.

Robotic left-stapled total intracorporeal bowel anastomosis versus stapled partial extracorporeal anastomosis: operative technical description and outcomes

Background

Although there is extensive literature on robotic total intracorporeal anastomosis (TICA) for right colon resection, left total ICA using the da Vinci Xi robotic platform has only been described in short case series previously. In this study, we report on the largest cohort of robotic left total ICA, provide a description of our institution’s techniques, and compare outcomes to robotic left partial extracorporeal anastomosis (PECA).

Methods

Patients who underwent robotic left colectomy for any underlying pathology from July 1, 2016 through April 30, 2020 were identified by procedure code. A technical description is provided for two unique techniques performed at our institution. Outcomes included operative time, length of stay, supply cost, post-operative ileus, post-operative morbidity and mortality and need for complete mobilization of the splenic flexure.

Results

From a review of our institution’s data, 83 robotic TICA cases were identified and 76 robotic PECA cases were identified. Common procedures included low anterior resection, sigmoidectomy, left hemicolectomy, and rectopexy with resection. TICA was associated with significantly shorter intraoperative time compared to PECA.

Conclusions

Our series shows that TICA is a safe and feasible technique that does not increase the risk of adverse outcomes. Using either the anvil-forward or anvil-backward technique, we were able to reliably reproduce this method in a total of 83 patients undergoing left colon resection for either benign or malignant diseases.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-022-09048-6.

Fluorescent Anti-MUC5AC Brightly Targets Pancreatic Cancer in a Patient-derived Orthotopic Xenograft

BACKGROUND

Overexpression of mucin-5AC (MUC5AC) makes it a targetable biomarker in pancreatic cancer. The present study evaluated tumor targeting with a MUC5AC antibody conjugated to a near-infrared dye in a patient-derived orthotopic xenograft (PDOX) mouse model.

MATERIALS AND METHODS

MUC5AC monoclonal antibody was conjugated to the near-infrared dye IRDye800CW to synthesize MUC5AC-IR800. PDOX models were established by implanting a high-MUC5AC-expressing patient-derived pancreatic tumor on the pancreas of nude mice. After 4 weeks of PDOX tumor growth, mice were imaged after receiving MUC5AC-IR800 (75 μg) intravenously.

RESULTS

In the PDOX models, MUC5AC-IR800 selectively and brightly targeted the pancreatic tumor (tumor to background ratio: 2.46±0.465).

CONCLUSION

MUC5AC-IR800 provides distinct visualization of pancreatic tumors. MUC5AC-IR800 may be used clinically in the future to improve pancreatic cancer resection. This novel fluorescent probe is also promising for targeting of pre-malignant pancreatic lesions with subsequent resection under fluorescence guidance.

Sutureless Surgical Orthotopic Implantation Technique of Primary and Metastatic Cancer in the Liver of Mouse Models

BACKGROUND/AIM

Surgical orthotopic implantation (SOI) is used to establish patient-derived orthotopic xenograft (PDOX) and other orthotopic mouse models. Orthotopic liver models can be challenging, as the liver parenchyma is prone to bleeding. The present report describes a sutureless method to implant tumors in the liver that reduces bleeding and procedural time.

MATERIALS AND METHODS

Human HCC cell-line (Huh-7-GFP) and CM2, a patient-derived colon-cancer liver metastasis, were used for sutureless SOI of tumor fragments in the liver of nude mice. A small cavity was formed on the liver surface. A solitary tumor fragment was implanted in the cavity without suturing to create hemostasis.

RESULTS

Six weeks after sutureless SOI, the tumor volume of Huh-7-GFP (n=5) was 584.41±147.64 mm³ and the tumor volume of CM2 (n=5) was 1336.54±1038.20 mm³ The engraftment rate was 100%.

CONCLUSION

This novel method for establishing orthotopic liver-implantation mouse models is suitable for studies of liver cancer and liver metastases due to its simple procedure and potential high engraftment rate.

Ligation Method to Specifically Label a Liver Segment With Indocyanine Green in an Orthotopic Nude-Mouse Liver-Metastasis Model

BACKGROUND/AIM

The visualization of hepatic segments with indocyanine green (ICG) fluorescence can aid in anatomic liver resection. The present study aimed to develop a method to specifically label an hepatic segment in a nude mouse model with liver metastasis.

MATERIALS AND METHODS

An orthotopic mouse model was established by surgical orthotopic implantation (SOI) of a patient-derived colon-cancer liver metastasis in the left lobe of the liver. Three weeks after SOI, the left Glissonean pedicle was ligated and 10 μg ICG was administrated intravenously. Images were obtained with the Pearl Trilogy Imaging System.

RESULTS

All mice expressed an 800 nm signal from ICG on the right lobe of the liver. The left lobe of the liver, in which the tumor was located, showed no fluorescence and had ischemia due to successful ligation of the Glissonean pedicle.

CONCLUSION

The ligation of the Glissonean pedicle enables specific liver-segment labeling with ICG, which has potential clinical application for liver metastasectomy.

Indocyanine Green Labels an Orthotopic Nude-Mouse Model of Very-Early Colon-Cancer Liver Metastases

BACKGROUND/AIM

Near-infrared (NIR) fluorescence imaging using indocyanine green (ICG) is used to visualize colon-cancer liver metastases (CCLM) during surgery. The present study aimed to use ICG to visualize small CCLM in an orthotopic mouse model.

MATERIALS AND METHODS

A 3-mm fragment of HT29 human colon cancer was implanted to the liver of 5 athymic nude mice (nu/nu). The Pearl Trilogy Small Animal Fluorescence Imaging system was used 24 h after intravenous (IV) injection of 0.025 mg (0.25 mg/ml) ICG.

RESULTS

In four of the five mice, tumor fluorescence was detected. Small tumors (approximately 3 mm) were distinctly visualized with a minimal fluorescence liver signal, with a mean tumor to liver signal ratio of 1.81 (SD±0.167).

CONCLUSION

Small CCLM can be clearly identified by ICG fluorescence in an orthotopic nude-mouse model. This model is translatable to the clinic for the detection of occult early CCLM.

A review of tumor-specific fluorescence-guided surgery for colorectal cancer

The present study reviews the use of tumor-specific antibodies conjugated to fluorescent dyes in preclinical and clinical studies to enhance visualization of primary tumors and metastases for fluorescence-guided surgery (FGS) in colorectal cancer (CRC). A search strategy was developed using the peer-reviewed National Center for Biotechnology Information (NCBI) database on PubMed. Studies using tumor-specific fluorescence imaging and FGS techniques on murine models of colorectal cell lines or patient-derived orthotopic xenograft (PDOX) colorectal cancer are reviewed. A total of 24 articles were identified that met the inclusion criteria, 21 preclinical and 3 clinical trials. The most widely used target antigen in preclinical and clinical trials was carcinoembryonic antigen (CEA). Mouse studies and clinical studies have demonstrated that the use of FGS in CRC can aid in decreased residual tumor and decreased rates of recurrence. As the mainstay of colorectal cancer treatment is surgery, the addition of intraoperative fluorescence imaging can help locate tumor margins, visualize occult micro-metastases, drive surgical decision making and improve patient outcomes.

Humanized Fluorescent Tumor-associated Glycoprotein-72 Antibody Selectively Labels Colon-cancer Liver Metastases in Orthotopic Mouse Models

BACKGROUND/AIM

Fluorescence imaging has been shown to improve intra-operative detection of liver metastasis. The present study aimed to determine whether humanized anti-TAG-72 antibody (huCC49) conjugated to a near-infrared dye provides selective labeling of colorectal-cancer liver metastasis in orthotopic mouse models.

MATERIALS AND METHODS

Humanized anti-TAG-72 (huCC49) was conjugated to IRDye800CW (huCC49-IR800). Orthotopic liver-metastasis nude-mouse models (n=5) were established with the human colon-cancer LS174T cell-line. Three weeks later, mice were administered huCC49-IR800 and intra-vital imaging was performed 48 h later. The mean tumor-to-liver ratio (TLR) was calculated.

RESULTS

Intra-vital imaging demonstrated clear tumor margins with minimal liver fluorescence 48 h after administration of 50 μg huCC49-IR800 with mean TLR=7.53 (SD±2.76).

CONCLUSION

Anti-TAG-72 monoclonal antibody conjugated to IRDye800 provides distinct and bright labeling of colorectal tumors in orthotopic nude-mouse models of liver metastasis. TAG-72 may be a useful target for intra-operative imaging of colorectal cancer liver metastasis in the clinic.

Fluorophore-conjugated Helicobacter pylori recombinant membrane protein (HopQ) labels primary colon cancer and metastases in orthotopic mouse models by binding CEA-related cell adhesion molecules

HopQ is an outer-membrane protein of Helicobacter pylori that binds to human carcinoembryonic antigen-related cell-adhesion molecules (CEACAMs) with high specificity. We aimed to investigate fluorescence targeting of CEACAM-expressing colorectal tumors in patient-derived orthotopic xenograft (PDOX) models with fluorescently labeled recombinant HopQ (rHopQ). Western blotting, flow cytometry and ELISA were performed to determine the efficiency of rHopQ binding to CEACAMs. rHopQ was conjugated to IR800DyeCW (rHopQ-IR800). Nude mice received orthotopic implantation of colon cancer tumors. Three weeks later, mice were administered 25 μg or 50 μg HopQ-IR800 and imaged 24 or 48 h later. Intravital images were analyzed for tumor-to-background ratio (TBR). Flow cytometry and ELISA demonstrated binding of HopQ to CEACAM1, 3 and 5. Dose-response intravital imaging in PDOX models demonstrated optimal results 48 h after administration of 50 μg rHopQ-IR800 (TBR = 3.576) in our protocol. Orthotopic models demonstrated clear tumor margins of primary tumors and small regional metastases with a mean TBR = 3.678 (SD ± 1.027). rHopQ showed specific binding to various CEACAMs in PDOX models. rHopQ may be useful for CEACAM-positive tumor and metastasis detection for pre-surgical diagnosis, intra-operative imaging and fluorescence-guided surgery.

Local excision versus radical resection in patients with rectal neuroendocrine tumours: a propensity score match analysis

BACKGROUND

The rectum is a common site for neuroendocrine tumours of the gastrointestinal tract. Diagnosis of these tumours has been increasing in recent years, highlighting the need to better define treatment options for patients with rectal neuroendocrine tumours (rNETs).

METHODS

We performed a retrospective analysis using the National Cancer Database (2004-2014) to compare overall survival (OS) between local excision (LE) and radical resection (RR). To minimize bias, we performed three propensity score-matched comparisons stratified by tumour size: <10 mm, 10-20 mm, >20 mm. We compared OS by Kaplan-Meier analysis. We also examined margin status and postoperative outcomes for each comparison.

RESULTS

A total of 12 996 patients underwent surgical treatment for rNET. There was no significant difference in probability of 10-year OS between LE and RR for patients with tumours <10 mm (88.6% versus 83.8%, P = 0.631, respectively) and tumours 10-20 mm (69.5% versus 69.3%, P = 0.226, respectively). In patients with tumours >20 mm, probability of 10-year OS was significantly longer in the LE group (76.5% versus 37.0%, P < 0.001). For all tumour sizes <10 mm and >20 mm, RR had significantly higher rates of 30-day readmission and negative margins. In subset analysis, there was no difference in OS for patients with positive margins after LE versus negative margins after RR for all tumour size groups.

CONCLUSIONS

Our findings suggest that LE is a reasonable treatment option in patients with rNETs, especially for patients with high perioperative risk. Limitations to this study include its retrospective nature and inability to analyse surgeon decision-making.

Near-infrared photoimmunotherapy is effective treatment for colorectal cancer in orthotopic nude-mouse models

BACKGROUND

Photoimmunotherapy (PIT) employs the use of a near-infrared (NIR) laser to activate an antibody conjugated to a NIR-activatable dye to induce cancer cell death. PIT has shown to be effective in a number of studies, however, there are no data on its use in colorectal cancer in an orthotopic model.

METHODS

Humanized anti-CEA antibody (M5A) was conjugated to NIR-activatable IRDye700DX (M5A-700). PIT was validated in vitro with a colon cancer cell-line, using a laser intensity of either 4 J/cm2, 8 J/cm2, or 16 J/cm2. Orthotopic colon cancer mouse models were established by surgical implantation of LS174T tumor fragments onto the cecum. M5A-700 was administered and PIT was performed 24 hours later using a 690 nm laser. Repeat PIT was performed after 7 days in one group. Control mice received laser treatment only.

RESULTS

In vitro PIT demonstrated tumor cell death in a laser intensity dose-dependent fashion. In orthotopic models, control mice demonstrated persistent tumor growth. Mice that underwent PIT one time had tumor growth arrested for one week, after which re-growth occurred. The group that received repeated PIT exposure had persistent inhibition of tumor growth.

CONCLUSION

PIT arrests tumor growth in colon cancer orthotopic nude-mouse models. Repeated PIT arrests colon cancer growth for a longer period of time. PIT may be a useful therapy in the future as an adjunct to surgical resection or as primary therapy to suppress tumor progression.

Rapid response to COVID-19: health informatics support for outbreak management in an academic health system

OBJECTIVE

To describe the implementation of technological support important for optimizing clinical management of the COVID-19 pandemic.

MATERIALS AND METHODS

Our health system has confirmed prior and current cases of COVID-19. An Incident Command Center was established early in the crisis and helped identify electronic health record (EHR)-based tools to support clinical care.

RESULTS

We outline the design and implementation of EHR-based rapid screening processes, laboratory testing, clinical decision support, reporting tools, and patient-facing technology related to COVID-19.

DISCUSSION

The EHR is a useful tool to enable rapid deployment of standardized processes. UC San Diego Health built multiple COVID-19-specific tools to support outbreak management, including scripted triaging, electronic check-in, standard ordering and documentation, secure messaging, real-time data analytics, and telemedicine capabilities. Challenges included the need to frequently adjust build to meet rapidly evolving requirements, communication, and adoption, and to coordinate the needs of multiple stakeholders while maintaining high-quality, prepandemic medical care.

CONCLUSION

The EHR is an essential tool in supporting the clinical needs of a health system managing the COVID-19 pandemic.

General surgery training in the era of robotic surgery: a qualitative analysis of perceptions from resident and attending surgeons

BACKGROUND

The use of the surgical robot has increased annually since its introduction, especially in general surgery. Despite the tremendous increase in utilization, there are currently no validated curricula to train residents in robotic surgery, and the effects of robotic surgery on general surgery residency training are not well defined. In this study, we aim to explore the perceptions of resident and attending surgeons toward robotic surgery education in general surgery residency training.

METHODS

We performed a qualitative thematic analysis of in-person, one-on-one, semi-structured interviews with general surgery residents and attending surgeons at a large academic health system. Convenient and purposeful sampling was performed in order to ensure diverse demographics, experiences, and opinions were represented. Data were analyzed continuously, and interviews were conducted until thematic saturation was reached, which occurred after 20 residents and seven attendings.

RESULTS

All interviewees agreed that dual consoles are necessary to maximize the teaching potential of the robotic platform, and the importance of simulation and simulators in robotic surgery education is paramount. However, further work to ensure proper access to simulation resources for residents is necessary. While most recognize that bedside-assist skills are essential, most think its educational value plateaus quickly. Lastly, residents believe that earlier exposure to robotic surgery is necessary and that almost every case has a portion that is level-appropriate for residents to perform on the robot.

CONCLUSIONS

As robotic surgery transitions from novelty to ubiquity, the importance of effective general surgery robotic surgery training during residency is paramount. Through in-depth interviews, this study provides examples of effective educational tools and techniques, highlights the importance of simulation, and explores opinions regarding the role of the resident in robotic surgery education. We hope the insights gained from this study can be used to develop and/or refine robotic surgery curricula.

Making the Jump: A Qualitative Analysis on the Transition From Bedside Assistant to Console Surgeon in Robotic Surgery Training

OBJECTIVE

To determine barriers associated with the transition from bedside assistant to console surgeon for general surgery residents in the era of robotic surgery in general surgery training.

DESIGN

Qualitative thematic analysis using one-on-one interviews of general surgery residents and attendings conducted between June 2018 and February 2019.

SETTING

An urban, academic, multihospital general surgery residency program with a robust robotic surgery program.

PARTICIPANTS

Convenient and purposeful sampling was performed to ensure a variety of resident graduate-years and attending subspecialties were represented. Sample size was determined by data saturation, which occurred after 20 resident and 7 attending interviews.

RESULTS

Residents identified the low volume of general surgery robotic cases, the infrequency of exposure to robotic surgery, and attending comfort with robotic surgery (and with teaching on the robot) as potential barriers in the transition from bedside assistant to console surgeon. Residents had to find a replacement bedside assistant in order to be the console surgeon, which was challenging. In addition, residents felt that the current culture surrounding robotic surgery is very hierarchal, limiting their exposure. Attendings' trust in the residents' console skills was a major determining factor in allowing residents on the console.

CONCLUSIONS

Most robotic surgery education curricula are sequential, requiring the resident to progress from bedside assistant to console surgeon. Unfortunately, there are many potential barriers for residents in the transition from bedside assistant to console surgeon. Some barriers apply to general surgery training overall, but are amplified in robotic surgery, while others are unique to robotic surgery education. Recognition of, and rectifying, these barriers may increase resident participation as the console surgeon.

Anti-Claudin-1 Conjugated to a Near-Infrared Fluorophore Targets Colon Cancer in PDOX Mouse Models

INTRODUCTION

Claudins are tight-junction proteins, which maintain an epithelial barrier in normal colon cells. Overexpression of Claudin-1 has been implicated for development of colon cancer. We postulated that Claudin-1 may be a useful target in near-infrared imaging and fluorescence-guided surgery.

METHODS

We conjugated Claudin-1 antibody to LI-COR IR800DyeCW (Claudin-1-IRDye800CW). Western blotting of 9 human colon cancer cell lysates was performed. Animal imaging was performed with the LI-COR Pearl Trilogy Fluorescence Imaging System. A dose-response study was carried out with subcutaneous LS174T colon cancer cell line models. Increasing doses of Claudin-1-IRDye800CW via tail vein injection were administered to three groups of mice. Two groups of mice were used as controls (antibody alone, and dye alone). In vivo imaging was performed at 24, 48, and 72 h after administration of the conjugated dye. Orthotopic implantation of patient-derived tumors and cell lines was performed and peritoneal carcinomatosis models were created. After tumor growth, mice were administered Claudin-1-IRDye800CW and imaged in vivo 48 h later. The mice were euthanized and laparotomy was performed to assess internal organs and toxicity.

RESULTS

Western blotting revealed that all colon cancer cell lysates expressed varying amounts of Claudin-1. All tumors demonstrated strong and specific fluorescence labeling at 800 nm, even with the lowest dose of 12.5 μg of Claudin-1-IRDye800CW.

CONCLUSIONS

Claudin-1 is a useful target for near-infrared antibody-based imaging for visualization of colorectal tumors for future use in fluorescence-guided surgery.