Background
Accurate intraoperative assessments of tissue perfusion are essential in all forms of surgery. As traditional methods of perfusion assessments are not available during minimally invasive ...surgery, novel methods are required. Here, fluorescence angiography with indocyanine green has shown promising results. However, to secure objective and reproducible assessments, quantification of the fluorescent signal is essential (Q-ICG). This narrative review aims to provide an overview of the current status and applicability of Q-ICG for intraoperative perfusion assessment.
Results
Both commercial and custom Q-ICG software solutions are available for intraoperative use; however, most studies on Q-ICG have performed post-operative analyses. Q-ICG can be divided into inflow parameters (
ttp
,
t
0, slope, and
T
1/2
max) and intensity parameters (
F
max, PI, and DR). The intensity parameters appear unreliable in clinical settings. In comparison, inflow parameters, mainly slope, and
T
1/2
max have had superior clinical performance.
Conclusion
Intraoperative Q-ICG is clinically available; however, only feasibility studies have been performed, rendering an excellent usability score. Q-ICG in a post-operative setting could detect changes in perfusion following a range of interventions and reflect clinical endpoints, but only if based on inflow parameters. Thus, future studies should include the methodology outlined in this review, emphasizing the use of inflow parameters (slope or
T
1/2
max), a mass-adjusted ICG dosing, and a fixed camera position.
Experimental Museology scrutinizes innovative endeavours to transform museum interactions with the world. Analysing cutting-edge cases from around the globe, the volume demonstrates how museums can ...design, apply and assess new modes of audience engagement and participation. Written by an interdisciplinary group of researchers and research-led professionals, the book argues that museum transformations must be focused on conceptualizing and documenting the everyday challenges and choices facing museums, especially in relation to wider social, political and economic ramifications. In order to illuminate the complexity of these challenges, the volume is structured into three related key dimensions of museum practice - namely institutions, representations and users. Each chapter is based on a curatorial design proposed and performed in collaboration between university-based academics and a museum. Taken together, the chapters provide insights into a diversity of geographical contexts, fields and museums, thus building a comprehensive and reflexive repository of design practices and formative experiments that can help strengthen future museum research and design. Experimental Museology will be of great value to academics and students in the fields of museum, gallery and heritage studies, as well as architecture, design, communication and cultural studies. It will also be of interest to museum professionals and anyone else who is interested in learning more about experimentation and design as resources in museums.
Background
Compromised tissue perfusion is a significant risk factor for anastomotic leakage after intestinal resection, leading to prolonged hospitalization, risk of recurrence after oncologic ...resection, and reduced survival. Thus, a tool reducing the risk of leakage is highly warranted. Quantitative indocyanine green angiography (Q-ICG) is a new method that provides surgeons with an objective evaluation of tissue perfusion. In this systematic review, we aimed to determine the optimal methodology for performing Q-ICG.
Method
A comprehensive search of the literature was performed following the PRISMA guidelines. The following databases were searched: PubMed, Embase, Scopus, and Cochrane. We included all clinical studies that performed Q-ICG to assess visceral perfusion during gastrointestinal surgery. Bias assessment was performed with the Newcastle Ottawa Scale.
Results
A total of 1216 studies were screened, and finally, 13 studies were included. The studies found that
intensity
parameters (
maximum intensity and relative maximum intensity
) could not identify patients with anastomotic leakage. In contrast, the
inflow
parameters (
time-to-peak, slope,
and
t
1/2
max
) were significantly associated with anastomotic leakage. Only two studies performed intraoperative Q-ICG while the rest performed Q-ICG retrospectively based on video recordings. Studies were heterogeneous in design, Q-ICG parameters, and patient populations. No randomized studies were found, and the level of evidence was generally found to be low to moderate.
Conclusion
The results, while heterogenous, all seem to point in the same direction. Fluorescence
intensity
parameters are unstable and do not reflect clinical endpoints. Instead,
inflow
parameters are resilient in a clinical setting and superior at reflecting clinical endpoints.
In all, these findings are very interesting, especially in the context of major abdominal oncological surgery, in which multiple studies have shown that both high postoperative morbidity and severe ...postoperative complications are associated with a significantly worse short-term and long-term survival 10. ...it is clear that MTS, and especially severe MTS, has major clinical implications, and should receive more attention in future research, as interventions attenuating the incidence and impact of severe MTS potentially could lower the postoperative morbidity, as well as potentially improve long-term cancer survival following major abdominal oncological surgery. ...patients being characterized as having high 30-day postoperative morbidity in the study had significantly higher levels of all four biomarkers, indicating a possible pathophysiologic explanation behind the increased postoperative morbidity in patients developing severe MTS. ...the study also found that patients developing severe MTS had increased levels of Epinephrine, already at baseline before the first incision, possibly indicating that patients developing severe MTS could belong to a specific phenotype. First of all, such an assessment is at risk of having a low interobserver reproducibility with a risk of different assessors scoring patients differently.
The monitoring of oxygen therapy when patients are admitted to medical and surgical wards could be important because exposure to excessive oxygen administration (EOA) may have fatal consequences. We ...aimed to investigate the association between EOA, monitored by wireless pulse oximeter, and nonfatal serious adverse events (SAEs) and mortality within 30 days. We included patients in the Capital Region of Copenhagen between 2017 and 2018. Patients were hospitalized due to acute exacerbation of chronic obstructive pulmonary disease (AECOPD) or after major elective abdominal cancer surgery, and all were treated with oxygen supply. Patients were divided into groups by their exposure to EOA: no exposure, exposure for 1-59 min or exposure over 60 min. The primary outcome was SAEs or mortality within 30 days. We retrieved data from 567 patients for a total of 43,833 h, of whom, 63% were not exposed to EOA, 26% had EOA for 1-59 min and 11% had EOA for ≥60 min. Nonfatal SAEs or mortality within 30 days developed in 24%, 12% and 22%, respectively, and the adjusted odds ratio for this was 0.98 (95% CI, 0.96-1.01) for every 10 min. increase in EOA, without any subgroup effects. In conclusion, we did not observe higher frequencies of nonfatal SAEs or mortality within 30 days in patients exposed to excessive oxygen administration.
To provide the first international comparison of oesophageal and gastric cancer survival by stage at diagnosis and histological subtype across high-income countries with similar access to healthcare.
...As part of the ICBP SURVMARK-2 project, data from 28 923 patients with oesophageal cancer and 25 946 patients with gastric cancer diagnosed during 2012-2014 from 14 cancer registries in seven countries (Australia, Canada, Denmark, Ireland, New Zealand, Norway and the UK) were included. 1-year and 3-year age-standardised net survival were estimated by stage at diagnosis, histological subtype (oesophageal adenocarcinoma (OAC) and oesophageal squamous cell carcinoma (OSCC)) and country.
Oesophageal cancer survival was highest in Ireland and lowest in Canada at 1 (50.3% vs 41.3%, respectively) and 3 years (27.0% vs 19.2%) postdiagnosis. Survival from gastric cancer was highest in Australia and lowest in the UK, for both 1-year (55.2% vs 44.8%, respectively) and 3-year survival (33.7% vs 22.3%). Most patients with oesophageal and gastric cancer had regional or distant disease, with proportions ranging between 56% and 90% across countries. Stage-specific analyses showed that variation between countries was greatest for localised disease, where survival ranged between 66.6% in Australia and 83.2% in the UK for oesophageal cancer and between 75.5% in Australia and 94.3% in New Zealand for gastric cancer at 1-year postdiagnosis. While survival for OAC was generally higher than that for OSCC, disparities across countries were similar for both histological subtypes.
Survival from oesophageal and gastric cancer varies across high-income countries including within stage groups, particularly for localised disease. Disparities can partly be explained by earlier diagnosis resulting in more favourable stage distributions, and distributions of histological subtypes of oesophageal cancer across countries. Yet, differences in treatment, and also in cancer registration practice and the use of different staging methods and systems, across countries may have impacted the comparisons. While primary prevention remains key, advancements in early detection research are promising and will likely allow for additional risk stratification and survival improvements in the future.
Choosing the right simulator for tasks in simulation-based education in medicine will affect the trainees' skills. However, there is a shortage in the vocabularies used for describing medical ...simulators and the contextual usage of simulators. We propose methods for approaching the task of choosing and defining the simulators needed, regardless of it being an acquisition or development process. It is advocated that efforts are made in defining the simulator's requirements before making any choice in regards to development processes. Multiple advantages are attained by keeping the simulator simple, both educational and development wise. Issues on validating simulators are discussed and highlighted as actions where interprofessional communication is likely to fail. The following conventional terms in medical education are problematic in regard to establishing a clear communication: Virtual reality, fidelity, validation, and simulation. The text is finalized in a short discussion on applying the methods in an EUS/endobronchial ultrasound (EBUS) context. The work is the authors' interpretation of an invitation having the title "Development of EUS and EBUS training models and simulators."
Abstract Objective Intrathoracic anastomotic leakage after intended curative resection for cancer in the esophagus or gastroesophageal junction has a negative impact on long-term survival. The aim of ...this study was to investigate whether an anastomotic leakage was associated with an increased recurrence rate. Methods This nationwide study included consecutively collected data on patients undergoing curative surgical resection with intrathoracic anastomosis, alive 8 weeks postoperatively, between 2003 and 2011. Patients with incomplete resection, or metastatic disease intraoperatively, were excluded. Only biopsy-proven recurrences were accepted. Results In total, 1085 patients were included. The frequency of anastomotic leakage was 8.6%. The median follow-up time was 29 months (interquartile range IQR: 13-58 months). Overall, 369 (34%) patients had disease recurrence, of which 346 patients died of recurrent gastroesophageal carcinoma. Twenty-three patients were alive with recurrence at the censoring date. In the study period, 333 patients died without signs of recurrent disease. The overall median time to recurrence was 66 weeks (IQR: 38-109 weeks). Distant metastases were found in 267 (25%), and local disease recurrence in 102 (9%) patients. Overall, 5-year disease-free survival in patients with leakage was 27%, versus 39% in those without leakage ( P = .017). Anastomotic leakage was independently associated with higher risk of recurrence (hazard ratio HR = 1.63; 95% confidence interval CI: 1.17-2.29, P = .004) and all-cause mortality (HR = 1.57; 95% CI: 1.23-2.05, P < .0001). Conclusions Intrathoracic anastomotic leakage increased the risk of recurrence in patients who underwent curative gastroesophageal cancer resection.
To investigate the frequency and duration of hypo- and hyperglycemia, assessed by continuous glucose monitoring (CGM) during and after major surgery, in departments with implemented diabetes care ...protocols.
Inadequate glycemic control in the perioperative period is associated with serious adverse events, but monitoring currently relies on point blood glucose measurements, which may underreport glucose excursions.
Adult patients without (A) or with diabetes non-insulin-treated type 2 (B), insulin-treated type 2 (C) or type 1 (D) undergoing major surgery were monitored using CGM (Dexcom G6), with an electrochemical sensor in the interstitial fluid, during surgery and for up to 10 days postoperatively. Patients and health care staff were blinded to CGM values, and glucose management adhered to the standard diabetes care protocol. Thirty-day postoperative serious adverse events were recorded. The primary outcome was duration of hypoglycemia (glucose <70 mg/dL). Clinicaltrials.gov: NCT04473001.
Seventy patients were included, with a median observation time of 4.0 days. CGM was recorded in median 96% of the observation time. The median daily duration of hypoglycemia was 2.5 minutes without significant difference between the 4 groups (A-D). Hypoglycemic events lasting ≥15 minutes occurred in 43% of all patients and 70% of patients with type 1 diabetes. Patients with type 1 diabetes spent a median of 40% of the monitoring time in the normoglycemic range 70 to 180 mg/dL and 27% in the hyperglycemic range >250 mg/dL. Duration of preceding hypo- and hyperglycemia tended to be longer in patients with serious adverse events, compared with patients without events, but these were exploratory analyses.
Significant duration of both hypo- and hyperglycemia was detected in high proportions of patients, particularly in patients with diabetes, despite protocolized perioperative diabetes management.
Background:
The surgical treatment of gastric and esophageal cancer in Denmark is centralized in four specialized esophagogastric cancer (EGC) centers. Patients are referred after an ...esophagogastroduodenoscopy (EGD) at a secondary healthcare facility. The EGD is repeated at the specialized EGC center before determining a surgical treatment strategy. This multicenter retrospective study aimed to investigate the quality of EGDs performed at a secondary healthcare facility and evaluate the clinical value of repeated EGD at a specialized center when determining the surgical treatment strategy.
Methods:
Patients from three of the four centers, who underwent esophagectomy or gastrectomy with curative intent from 1 June 2016 to 1 May 2021, were included. EGD reports from the referral facilities and EGC centers were compared based on a predefined checklist. Furthermore, endoscopist experience, the time between examinations, and histology were registered. Finally, it was assessed whether the specialized EGD led to any substantial changes in surgical treatment. Baseline characteristics and differences in EGD reports were described and McNemar’s chi-square test was performed. A logistic regression analysis was conducted to identify risk factors for a change in surgical strategy.
Results:
The study included 953 patients who underwent both an initial EGD and EGD at referral to a specialized center. In 644 cases (68%), the information from the initial EGD was considered insufficient concerning preoperative tumor information. In 113 (12%) cases, the findings in the specialized EGD would lead to a significant alteration in the surgical strategy compared with the primary EGD.
Conclusion:
The findings suggest that repeated EGD at a specialized center is of clinical value and helps ensure proper surgical treatment for patients undergoing curative surgery for gastroesophageal cancer.
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