Objective
Robot‐assisted surgery is a recognised treatment for pelvic‐organ prolapse. Many of the surgical subgroup outcomes for apical prolapse are reported together, leading to a paucity of ...homogenous data.
Design
Prospective observational cohort study (NCT01598467, clinicaltrials.gov) assessing outcomes for homogeneous subgroups of robot‐assisted apical prolapse surgery.
Setting
Two European tertiary referral hospitals.
Population
Consecutive patients undergoing robot‐assisted sacrocolpopexy (RASC) and supracervical hysterectomy with sacrocervicopexy (RSHS).
Methods
Anatomical cure (simplified Pelvic Organ Prolapse Quantification, sPOPQ, stage 1), subjective cure (symptoms of bulge), and quality of life (Pelvic Floor Impact Questionnaire, PFIQ‐7).
Main outcome measures
Primary outcome: anatomical and subjective cure. Secondary outcomes: surgical safety and intraoperative variables.
Results
A total of 305 patients were included (RASC n = 188; RSHS n = 117). Twelve months follow‐up was available for 144 (RASC 76.6%) and 109 (RSHS 93.2%) women. Anatomical success of the apical compartment occurred for 91% (RASC) and in 99% (RSHS) of the women. In all compartments, the success percentages were 67 and 65%, respectively. Most recurrences were in the anterior compartment 15.7% RASC (symptomatic 12.1%); 22.9% RSHS (symptomatic 4.8%). Symptoms of bulge improved from 97.4 to 17.4% (P < 0.0005). PFIQ‐7 scores improved from 76.7 ± 62.3 to 13.5 ± 31.1 (P < 0.0005). The duration of surgery increased significantly for RSHS 183.1 ± 38.2 versus 145.3 ± 29.8 (P < 0.0005). Intraoperative complications and conversion rates were low (RASC, 5.3 and 4.3%; RSHS, 0.0 and 0.0%). Four severe postoperative complications occurred after RASC (2.1%) and one occurred after RSHS (1.6%).
Conclusions
This is the largest reported prospective cohort study on robot‐assisted apical prolapse surgery. Both procedures are safe, with durable results.
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European bi‐centre trial concludes that robot‐assisted surgery is a viable approach to managing apical prolapse.
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European bi‐centre trial concludes that robot‐assisted surgery is a viable approach to managing apical prolapse.
Purpose
Conservative treatment strategy without antibiotics in patients with uncomplicated diverticulitis (UD) has proven to be safe. The aim of the current study is to assess the clinical course of ...UD patients who were initially treated without antibiotics and to identify risk factors for treatment failure.
Methods
A retrospective cohort study was performed including all patients with a CT-proven episode of UD (defined as modified Hinchey 1A). Only non-immunocompromised patients who presented without signs of sepsis were included. Patients that received antibiotics within 24 h after or 2 weeks prior to presentation were excluded from analysis. Patient characteristics, clinical signs, and laboratory parameters were collected. Treatment failure was defined as (re)admittance, mortality, complications (perforation, abscess, colonic obstruction, urinary tract infection, pneumonia) or need for antibiotics, operative intervention, or percutaneous abscess drainage within 30 days after initial presentation. Multivariable logistic regression analyses were used to quantify which variables are independently related to treatment failure.
Results
Between January 2005 and January 2017, 751 patients presented at the emergency department with a CT-proven UD. Of these, 186 (25%) patients were excluded from analysis because of antibiotic treatment. A total of 565 patients with UD were included. Forty-six (8%) patients experienced treatment failure. In the multivariable analysis, a high CRP level (> 170 mg/L) was a significant predictive factor for treatment failure.
Conclusion
UD patients with a CRP level > 170 mg/L are at higher risk for non-antibiotic treatment failure. Clinical physicians should take this finding in consideration when selecting patients for non-antibiotic treatment.
Background
Virtual reality (VR) simulators have been demonstrated to improve basic psychomotor skills in endoscopic surgery. The exercise configuration settings used for validation in studies ...published so far are default settings or are based on the personal choice of the tutors. The purpose of this study was to establish consensus on exercise configurations and on a validated training program for a virtual reality simulator, based on the experience of international experts to set criterion levels to construct a proficiency-based training program.
Methods
A consensus meeting was held with eight European teams, all extensively experienced in using the VR simulator. Construct validity of the training program was tested by 20 experts and 60 novices. The data were analyzed by using the
t
test for equality of means.
Results
Consensus was achieved on training designs, exercise configuration, and examination. Almost all exercises (7/8) showed construct validity. In total, 50 of 94 parameters (53%) showed significant difference.
Conclusions
A European, multicenter, validated, training program was constructed according to the general consensus of a large international team with extended experience in virtual reality simulation. Therefore, a proficiency-based training program can be offered to training centers that use this simulator for training in basic psychomotor skills in endoscopic surgery.
Aim
The optimal diet for uncomplicated diverticulitis is unclear. Guidelines refrain from recommendation due to lack of objective information. The aim of the study was to determine whether an ...unrestricted diet during a first acute episode of uncomplicated diverticulitis is safe.
Method
A prospective cohort study was performed of patients diagnosed with diverticulitis for the first time between 2012 and 2014. Requirements for inclusion were radiologically proven modified Hinchey Ia/b diverticulitis, American Society of Anesthesiologists class I–III and the ability to tolerate an unrestricted diet. Exclusion criteria were the use of antibiotics and suspicion of inflammatory bowel disease or malignancy. All included patients were advised to take an unrestricted diet. The primary outcome parameter was morbidity. Secondary outcome measures were the development of recurrence and ongoing symptoms.
Results
There were 86 patients including 37 (43.0%) men. All patients were confirmed to have taken an unrestricted diet. There were nine adverse events in seven patients. These consisted of readmission for pain (five), recurrent diverticulitis (one) and surgery (three) for ongoing symptoms (two) and Hinchey Stage III (one). Seventeen (19.8%) patients experienced continuing symptoms 6 months after the initial episode and 4 (4.7%) experienced recurrent diverticulitis.
Conclusion
The incidence of complications among patients taking an unrestricted diet during an initial acute uncomplicated episode of diverticulitis was in line with that reported in the literature.
Aim
This study compared the diagnostic capabilities of dynamic magnetic resonance defaecography (D‐MRI) with conventional defaecography (CD, reference standard) in patients with symptoms of prolapse ...of the posterior compartment of the pelvic floor.
Method
Forty‐five consecutive patients underwent CD and D‐MRI. Outcome measures were the presence or absence of rectocele, enterocele, intussusception, rectal prolapse and the descent of the anorectal junction on straining, measured in millimetres. Cohen's Kappa, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and the positive and negative likelihood ratio of D‐MRI were compared with CD. Cohen's Kappa and Pearson's correlation coefficient were calculated and regression analysis was performed to determine inter‐observer agreement.
Results
Forty‐one patients were available for analysis. D‐MRI underreported rectocele formation with a difference in prevalence (CD 77.8% vs D‐MRI 55.6%), mean protrusion (26.4 vs 22.7 mm, P = 0.039) and 11 false negative results, giving a low sensitivity of 0.62 and a NPV of 0.31. For the diagnosis of enterocele, D‐MRI was inferior to CD, with five false negative results, giving a low sensitivity of 0.17 and high specificity (1.0) and PPV (1.0). Nine false positive intussusceptions were seen on D‐MRI with only two missed.
Conclusion
The accuracy of D‐MRI for diagnosing rectocele and enterocele is less than that of CD. D‐MRI, however, appears superior to CD in identifying intussusception. D‐MRI and CD are complementary imaging techniques in the evaluation of patients with symptoms of prolapse of the posterior compartment.
Purpose
Sigmoid resection for diverticulitis is usually the first procedure performed when starting the learning process for laparoscopic colorectal surgery. The aim of this study is to evaluate the ...difficulty of laparoscopic sigmoid resection for diverticulitis in comparison to sigmoid malignancy in order to assess its role in the residents training program.
Methods
A cohort of patients was selected who suffered either from malignancy or recurrent diverticulitis in the sigmoid colon. Laparoscopic sigmoid resection was performed. The degree of difficulty was assessed by intraoperative complications and intraoperative technical challenges. Furthermore, take-overs from assistant to surgeon, surgeon to surgeon, and conversion were reported.
Results
A total of 224 patients were included, 119 (53.1%) men and 105 (46.9%) women.
Patients suffering from diverticulitis had significantly less co-morbidities than those with malignancies. In the diverticulitis group, there were significantly more technical challenges. There was a higher rate in take-overs from residents (
p
= 0.02) as well as surgeon to surgeon (
p
= 0.04). The rate of conversions was also significantly higher in the diverticulitis group (
p
= 0.03) when compared to the malignancy group.
Conclusions
The outcomes of our study show that diverticulitis may not be the ideal condition to start the learning process for laparoscopic colorectal surgery.
This study was undertaken to investigate operating room performance of surgical residents, after participating in the Eindhoven virtual reality laparoscopic cholecystectomy training course. This ...course is the first formal surgical resident trainings course, using a variety of complementary virtual reality (VR) skills training simulation in order to prepare surgical residents for their first laparoscopic cholecystectomy. The course was granted EAES certification.
The four-day course is based on multimedia and multimodality approach. A variety of increasingly difficult simulation training sessions, next to intimate focus-group "knowledge sessions" are included. Both basic and procedural VR simulation is featured, using MIST-VR and the Xitacts' LapChol simulation software. The operating room performance of twelve surgical residents who participated in the course and twelve case-control counterparts were compared. The case-control group was matched for clinical number laparoscopic cholecystectomy performance (maximum of 4 procedures). Two observers analyzed a randomly mixed videotape, featuring the part of the "clip-and-cut" procedure of the laparoscopic cholecystectomy, and were blinded for participants' group status. Structured questionnaires including multiple observation scales were used to assess performance.
Residents of both the experimental and control group did not differ in demographic parameters, except for number of laparoscopic cholecystectomies in favor of the control group (p-value 0.008). Both observers judge the experimental group to perform significantly better (p-value 0.004 and 0.013). Experimental group residents valued their course highly in terms of their laparoscopic surgical skills improvement and the use of VR simulators in the surgical curriculum.
The Eindhoven Virtual Reality laparoscopic cholecystectomy training course improves surgical skill in the operating room above the level of residents trained by a variety of other training methods.
The surgical repair of paraesophageal hiatal hernias (PHH) can be performed by endoscopic means, but the procedure is not standardized and results have not been evaluated systematically so far. The ...aim of this review article was to clarify controversial subjects on the surgical approach and technique, i.e., recurrence rate after conventional versus laparoscopic PHH treatment, results of mesh reinforcement of the cruroplasty, the necessity for additional antireflux surgery, and indications for an esophageal lengthening procedure.
An electronic Medline search was performed to identify all publications reporting on laparoscopic and conventional PHH surgery. The computer search was followed by additional hand searches in books, journals, and related articles. All types of publications were evaluated because of a lack of high-level evidence studies such as randomized controlled trials. Critical analysis followed for all articles describing a study population of >10 patients and those reporting postoperative outcome.
A total of 32 publications were reviewed. Randomized controlled trials comparing laparoscopic and open techniques could not be identified. Nineteen of the publications described the results of retrospective series. Therefore, most of the studies retrieved were low in hierarchy of evidence (level II-c or lower). The overall median hospital time as published was 3 days for patients operated laparoscopically and 10 days in the conventional group. Postoperative complications, such as pneumonia, thrombosis, hemorrhage, and urinary and wound tract infections, appeared to be more frequent after conventional surgery. Follow-up was longer for conventional surgery (median 45 months versus 17.5 months after the laparoscopic technique). Recurrence rates reported were higher in patients operated conventionally (median 9.1% versus 7.0% for patients operated laparoscopically). Recurrences after PHH repair may decrease with usage of mesh in the hiatus, although uniform criteria for this procedure are lacking. No conclusions could be drawn regarding the necessity for an additional antireflux procedure. Furthermore, uniform specific indications for the need of an esophageal lengthening procedure or preoperative assessment methods for shortened esophagus could not be detected.
Treatment based on standardized protocols for preoperative assessment and postoperative follow-up is required to clarify the current controversies.
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