Abstract Aim Surgery for complex colorectal cancer is elaborate: preoperative assessment, patient selection, radiological interpretation, operative strategy, operative technical skills, operative ...standardization, postoperative care and management of complications are all critical components. Given this complexity, training that encompasses all these crucial aspects to generate suitably edified surgeons is essential. To date, no curriculum exists to guide training in advanced and recurrent pelvic malignancy, particularly for complex colorectal cancer. Such a curriculum would potentially offer numerous advantages, not only for individual surgeons but also for research, governance, international collaboration and benchmarking. The aim of this study was to design and develop a framework for a curriculum for fellowship training in complex colorectal cancer that encompasses pelvic exenteration surgery. Method Kern described a six‐step method for curriculum design that is now widely adopted in medical education. Our study utilizes steps 1–4 of Kern's method to develop a syllabus and assessment framework for curriculum development for fellowship training in complex colorectal cancer encompassing pelvic exenteration. A literature review was conducted to address step 1, followed by targeted needs assessment in step 2 by conducting focus groups with trainees, fellows and experts to identify learning needs and goals with objective setting for step 3. An expert consensus group then voted on these recommendations and developed educational strategy recommendations as step 4. For the purposes of brevity, ‘pelvic exenteration’ in the text is taken to also encompass extended and multivisceral resections that fall under the remit of complex colorectal cancer. Results Step 1 of Kern's method identified a gap in the literature on curricula in complex cancer surgery. Step 2 identified key areas regarded as learning needs by trainees, including anatomy, hands‐on experience and case volume. Step 3 defined the goals and objectives of a fellowship curriculum, defined in six domains including theoretical knowledge, decision‐making, technical skills, postoperative management and continuing professional development. Finally, as a prelude to stages 5 and 6, a strategy for implementation and for feedback and assessment was agreed by an expert consensus meeting that defined case volume (a minimum of 20 pelvic exenteration operations within a fellowship period) and coverage of this syllabus with derived metrics. Conclusions Our working group has developed a curriculum framework for advanced fellowship training in complex cancer in the UK. Validation is needed through implementation, and affirmation of its utility, both nationally and internationally, must be sought.
What's New in Foot and Ankle Surgery Daniels, Timothy R; Wilson, Ian R; Fu, Joyce M
Journal of bone and joint surgery. American volume,
05/2020, Letnik:
102, Številka:
10
Journal Article
Surgery is an invasive procedure evoking acute inflammatory and immune responses that can influence risk for postoperative complications including cognitive dysfunction and delirium. Although the ...specific mechanisms driving these responses have not been well-characterized, they are hypothesized to involve the epigenetic regulation of gene expression. We quantified genome-wide levels of DNA methylation in peripheral blood mononuclear cells (PBMCs) longitudinally collected from a cohort of elderly patients undergoing major surgery, comparing samples collected at baseline to those collected immediately post-operatively and at discharge from hospital. We identified acute changes in measured DNA methylation at sites annotated to immune system genes, paralleling changes in serum-levels of markers including C-reactive protein (CRP) and Interleukin 6 (IL-6) measured in the same individuals. Many of the observed changes in measured DNA methylation were consistent across different types of major surgery, although there was notable heterogeneity between surgery types at certain loci. The acute changes in measured DNA methylation induced by surgery are relatively stable in the post-operative period, generally persisting until discharge from hospital. Our results highlight the dramatic alterations in gene regulation induced by invasive surgery, primarily reflecting upregulation of the immune system in response to trauma, wound healing and anaesthesia.
Abstract Purpose Biological meshes are mostly used in infected fields within complex abdominal wall hernia repairs. There is no consensus, however, on the most appropriate material to be used in a ...given situation. Methods A literature review of published articles reporting the utilization of biological meshes in ventral/incisional hernia repair was conducted. Data were analyzed to compare the recurrence rates obtained with biological meshes. Main findings Only a few prospective comparative studies were identified. Most publications relate to AlloDerm® , Permacol™ and Surgisis™ with data from other meshes insufficient to draw conclusions. AlloDerm has a 0–100% recurrence rate among studies. It compares poorly with Surgisis and results in an unfavorable outcome when used as a ‘bridge prosthesis’. Permacol has consistent recurrence rates of 0–15%, whatever the patients' profiles or the context of infected fields, when considering the most relevant studies. The Surgisis results are more conflicting: the mesh exhibits low recurrence rates in clean fields, but in infected fields the recurrence rate is up to 39%. Conclusion Taken together, these studies suggest that the cross-linked mesh, Permacol has the lowest failure rate and the longest time to failure, particularly in contaminated or infected fields. However, this data should be confirmed by large prospective randomized studies.
With an expanding elderly population and median rectal cancer detection age of 70 years, the prevalence of rectal cancer in elderly patients is increasing. Management is based on evidence from ...younger patients, resulting in substandard treatments and poor outcomes. Modern management of rectal cancer in the elderly demands patient-centered treatment, assessing frailty rather than chronological age. The heterogeneity of this group, combined with the limited available data, impedes drafting evidence-based guidelines. Therefore, a multidisciplinary task force convened experts from the European Society of Surgical Oncology, European Society of Coloproctology, International Society of Geriatric Oncology and the American College Surgeons Commission on Cancer, with the goal of identifying the best practice to promote personalized rectal cancer care in older patients.
A crucial element for personalized care was recognized as the routine screening for frailty and geriatrician involvement and personalized care for frail patients. Careful patient selection and improved surgical and perioperative techniques are responsible for a substantial improvement in rectal cancer outcomes. Therefore, properly selected patients should be considered for surgical resection. Local excision can be utilized when balancing oncologic outcomes, frailty and life expectancy. Watch and wait protocols, in expert hands, are valuable for selected patients and adjuncts can be added to improve complete response rates. Functional recovery and patient-reported outcomes are as important as oncologic-specific outcomes in this age group. The above recommendations and others were made based on the best-available evidence to guide the personalized treatment of elderly patients with rectal cancer.
Summary
Background
Colonoscopic surveillance in patients with inflammatory bowel disease (IBD) leads to earlier detection of colorectal cancer (CRC) and reduces CRC‐associated mortality. However, it ...is limited by poor adherence in practice.
Aim
To identify missed opportunities to detect IBD‐associated CRC at our hospital
Methods
We undertook root‐cause analyses to identify patients with missed opportunities to diagnose IBD‐associated CRC. We matched patients with IBD‐associated CRC to patients with CRC in the general population to identify differences in staging at diagnosis and clinical outcomes.
Results
Compared with the general population, patients with IBD were at increased risk of developing CRC (odds ratio 2.7 95% CI 1.6‐3.9, P < 0.001). The mean incidence of IBD‐associated CRC between 1998 and 2019 was 165.4 (IQR 130.4‐199.4) per 100 000 patients and has not changed over the last 20 years. Seventy‐eight patients had IBD‐associated CRC. Forty‐two (54%) patients were eligible for CRC surveillance: 12% (5/42) and 10% (4/42) patients were diagnosed with CRC at an appropriately timed or overdue surveillance colonoscopy, respectively. Interval cancers occurred in 14% (6/42) of patients; 64% (27/42) of patients had a missed opportunity for colonoscopic surveillance where root‐cause analyses demonstrated that 10/27 (37%) patients known to secondary care had not been offered surveillance. Four (15%) patients had a delayed diagnosis of CRC due to failure to account for previous colonoscopic findings. Seventeen (63%) patients were managed by primary care including seven patients discharged from secondary care without a surveillance plan. Matched case‐control analysis did not show significant differences in cancer staging or 10‐year survival outcomes.
Conclusion
The incidence of IBD‐associated CRC has remained static. Two‐thirds of patients eligible for colonoscopic surveillance had missed opportunities to diagnose CRC. Surveillance programmes without comprehensive and fully integrated recall systems across primary and secondary care are set to fail.
With the ongoing COVID-19 (Coronavirus Disease 2019) pandemic, caused by the novel coronavirus SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2), there is a need for sensitive, specific, ...and affordable diagnostic tests to identify infected individuals, not all of whom are symptomatic. The most sensitive test involves the detection of viral RNA using RT-qPCR (quantitative reverse transcription PCR), with many commercial kits now available for this purpose. However, these are expensive, and supply of such kits in sufficient numbers cannot always be guaranteed. We therefore developed a multiplex assay using well-established SARS-CoV-2 targets alongside a human cellular control (RPP30) and a viral spike-in control (Phocine Herpes Virus 1 PhHV-1), which monitor sample quality and nucleic acid extraction efficiency, respectively. Here, we establish that this test performs as well as widely used commercial assays, but at substantially reduced cost. Furthermore, we demonstrate >1,000-fold variability in material routinely collected by combined nose and throat swabbing and establish a statistically significant correlation between the detected level of human and SARS-CoV-2 nucleic acids. The inclusion of the human control probe in our assay therefore provides a quantitative measure of sample quality that could help reduce false-negative rates. We demonstrate the feasibility of establishing a robust RT-qPCR assay at approximately 10% of the cost of equivalent commercial assays, which could benefit low-resource environments and make high-volume testing affordable.
This is a protocol for a Cochrane Review (diagnostic). The objectives are as follows:
To determine the diagnostic accuracy of biomarkers for detecting acute appendicitis in hospitalised adults with ...suspected acute appendicitis.
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