Purpose
Accurate staging of colonic cancer is important for patient stratification. We aimed to correlate the diagnostic accuracy of preoperative computed tomography (CT) with final histopathology as ...reference standard.
Methods
Data was collected retrospectively on 615 consecutive patients operated for colonic cancer. Evaluation was based upon T-stage. Patients were stratified into high-risk and low-risk groups, based on the extent of tumor invasion beyond the proper muscle layer of more or less than 5 mm. The Kendall tau correlation coefficient was used to calculate concordance between radiological (r)T-stage obtained at CT imaging and pathological (p)T-stage from the final pathology.
Results
In total, 501 patients were included. We found no significant differences in the Kendall tau values for diagnostic measures between the groups at the 95% confidence interval (CI) level: 49% (95% CI, 43–55) for all individuals, 48% (95% CI, 40–56) for screened individuals, and 47% (95% CI, 37-56) for non-screened individuals. The overall sensitivity and specificity for all individuals in identifying high-risk tumors on CT was 65% (95% CI, 56–73) and 89% (95% CI, 85–92). The risk of ending up in the high-risk group due to overstaging among all individuals was calculated as the number needed to harm 11.7 (95% CI, 9–16).
Conclusions
There is basis for improvement of CT-based preoperative staging of patients with colorectal cancer. Supplementary modalities may be needed for correct staging of patients preoperatively, especially in relation to stratification of patients into neoadjuvant treatments or tailored therapy in patients with early cancers.
Robotic-assisted laparoscopy (RAL) presents several advantages over 3-dimensional conventional laparoscopy (3D-CL) that may facilitate laparoscopic suturing especially with novice surgeons. This ...study compares novice surgeons' suturing performance by 3D-CL and RAL using Objective Structured Assessment of Technical Skill (OSATS), an objective, validated scoring tool. Twenty-two surgeons with no robotic experience completed a standardized suturing task in an experimental setup by both 3D-CL and RAL in a randomized, cross-over design. Two experienced surgeons blindly assessed their performance using OSATS. Median (interquartile range) OSATS scores for 3D-CL and RAL were, respectively, 22.8 (17.4 to 25.8) versus 25.0 (21.9 to 26.5), P=0.032. There was no association between laparoscopic experience and robotic-assisted suturing performance. Thus, this study is, to our knowledge, the first to compare novice surgeons' suturing performance by 3D-CL and RAL using an objective, validated scoring tool and to show better suturing performance when assisted by the robot regardless of experience level.
Total mesorectal excision and neoadjuvant radio-chemo-therapy is the standard treatment of locally advanced rectal cancer. In 4-12% of all patients a local recurrence will develop, with more than ...half located on the lateral pelvic side wall. It is an ongoing controversy, whether malignant lateral pelvic lymph nodes should be considered as regional or distant disease. The role of lateral pelvic lymph node dissection in a Western treatment setting is not clarified, but in this review, we argue that it may reduce the risk of local recurrence in selected patients with locally advanced disease.
Background
Securing sufficient blood perfusion to the anastomotic area after low-anterior resection is a crucial factor in preventing anastomotic leakage (AL). Intra-operative indocyanine green ...fluorescent imaging (ICG-FI) has been suggested as a tool to assess perfusion. However, knowledge of inter-observer variation among surgeons in the interpretation of ICG-FI is sparse. Our primary objective was to evaluate inter-observer variation among surgeons in the interpretation of bowel blood-perfusion assessed visually by ICG-FI. Our secondary objective was to compare the results both from the visual assessment of ICG and from computer-based quantitative analyses of ICG-FI between patients with and without the development of AL.
Method
A multicenter study, including patients undergoing robot-assisted low anterior resection with stapled anastomosis. ICG-FI was evaluated visually by the surgeon intra-operatively. Postoperatively, recorded videos were anonymized and exchanged between centers for inter-observer evaluation. Time to visibility (TTV), time to maximum visibility (TMV), and time to wash-out (TWO) were visually assessed. In addition, the ICG-FI video-recordings were analyzed using validated pixel analysis software to quantify blood perfusion.
Results
Fifty-five patients were included, and five developed clinical AL. Bland–Altman plots (BA plots) demonstrated wide inter-observer variation for visually assessed fluorescence on all parameters (TTV, TMV, and TWO). Comparing leak-group with no-leak group, we found no significant differences for TTV: Hazard Ratio; HR = 0.82 (CI 0.32; 2.08), TMV: HR = 0.62 (CI 0.24; 1.59), or TWO: HR = 1.11 (CI 0.40; 3.11). In the quantitative pixel analysis, a lower slope of the fluorescence time-curve was found in patients with a subsequent leak: median 0.08 (0.07;0.10) compared with non-leak patients: median 0.13 (0.10;0.17) (
p
= 0.04).
Conclusion
The surgeon’s visual assessment of the ICG-FI demonstrated wide inter-observer variation, there were no differences between patients with and without AL. However, quantitative pixel analysis showed a significant difference between groups.
Trial Registration
ClinicalTrials.gov Identifier: NCT04766060.
Purpose
Previous studies have shown that intracorporeal anastomosis (ICA) in minimally invasive right colectomy may improve postoperative recovery compared with extracorporeal anastomosis (ECA). It ...has been hypothesized that creating the anastomosis extracorporeally may cause mesenteric traction and compromised intestinal perfusion. The purpose of this study was to investigate the effect of either ICA or ECA on intestinal perfusion.
Method
This was a substudy to a multicenter, triple-blind randomized clinical trial comparing ICA with ECA in patients undergoing robotic right colectomy for colonic cancer. Videos from intraoperative Indocyanine Green (ICG) fluorescence imaging were analyzed with quantitative ICG perfusion assessment (q-ICG). q-ICG was performed by extracting perfusion metrics from a time-intensity curve generated from an image analysis software: F
MAX
: maximal fluorescence intensity, T
MAX
: time until maximal fluorescent signal, T
1/2MAX
: time until half-maximal fluorescent signal, time ratio (T
1/2MAX
/T
MAX
) and
slope
.
Results
A total of 68 patients (33 ICA and 35 ECA) were available for analysis. Demographics were similar between the groups, except for mean arterial blood pressure at the time of ICG infusion, which was significantly lower in the ICA group. We found a significantly steeper slope in the ICA group compared to the ECA group (6.3 vs. 4.7 AU/sec,
P
=
.048
). There were no significant differences in F
MAX
, T
MAX
, T
1/2MAX
, and time ratio.
Conclusion
We found evidence of an improved intestinal perfusion following ICA compared with ECA. This finding may be related to patient outcomes and should be explored further in the future.
Trial registration.
ClinicalTrials.gov NCT03130166.
One of the most important factors for a viable colorectal anastomosis is sufficient perfusion. The use of fluorescence angiography for perfusion assessment is a promising method which can be utilized ...in gastrointestinal surgery. We present a case with a 68-year-old male where fluorescence angiography resulted in a break down of a colorectal anastomosis resulting in a permanent ostomy.
Abstract Purpose The purpose of the study was to evaluate unenhanced Magnetic Resonance Imaging (MRI) for the diagnosis of appendicitis or another surgery-requiring condition in an adult population ...scheduled for emergency appendectomy based on a clinical diagnosis of suspected acute appendicitis. Materials and methods The prospective study included 48 consecutive patients (29 female, 19 male, 18–70 years old, mean age = 37.1 years). MRI examination was designed to be comfortable and fast; no contrast was administered. The sequences were performed during quiet respiration. The MRI findings were reviewed by two radiologists and one surgeon independent of each other and compared with surgical and pathological records. Results According to the surgical and histopathological findings 30 of 48 patients (63%) had acute appendicitis. Of the remaining 18 patients, 4 patients had no reasons for the clinical symptoms and 14 patients had other pathology. For the three reviewers the performance of MRI in the diagnosis of acute appendicitis showed the following sensitivity, specificity and accuracy ranges: 83–93%, 50–83% and 77–83%. Moderate ( κ = 0.51) and fair ( κ = 0.31) interobserver agreements in the MR diagnosis of acute appendicitis were found between the reviewers. Sensitivity, specificity and accuracy values for overall performance of MRI in detecting pelvic abnormalities were 100%, 75% (3 of 4 healthy patients were identified by MRI) and 98%, respectively. Conclusion Unenhanced fast MRI is feasible as an additional fast screening before the appendectomy. It may prevent unnecessary surgeries. The fast MRI examination can be adequately performed on an MRI unit of broad range of field strengths.
Increasing focus on patient safety makes it important to ensure surgical competency among surgeons before operating on patients. The objective was to gather validity evidence for a virtual-reality ...simulator test for robotic surgical skills and evaluate its potential as a training tool. Surgeons with varying experience in robotic surgery were recruited: novices (zero procedures), intermediates (1–50), experienced (> 50). Five experienced surgeons rated five exercises on the da Vinci Skills Simulator. Participants were tested using the five exercises. Participants were invited back 3 times and completed a total of 10 attempts per exercise. The outcome was the average simulator performance score for the 5 exercises. 32 participants from 5 surgical specialties were included. 38 participants completed all 4 sessions. A moderate correlation between the average total score and robotic experience was identified for the first attempt (Spearman
r
= 0.58;
p
= 0.0004). A difference in average total score was observed between novices and intermediates median score 61% (IQR 52–66) vs. 83% (IQR 75–91), adjusted
p
< 0.0001, as well as novices and experienced median score 61% (IQR 52–66) vs. 80 (IQR 69–85), adjusted
p
= 0.002. All three groups improved their performance between the 1st and 10th attempts (
p
< 0.00). This study describes validity evidence for a virtual-reality simulator for basic robotic surgical skills, which can be used for assessment of basic competency and as a training tool. However, more validity evidence is needed before it can be used for certification or high-stakes assessment.
A nine-year-old girl was admitted to the paediatric ward due to fever and lower abdomen pain through a day. Acute laparoscopic exploration showed a large necrotic perforation at the distal end of the ...appendix. During the appendectomy multiple small, live Enterobius vermicularis (pinworms) were observed. The patient was admitted for three days of observation and received relevant treatment with intravenous antibiotics and antihelminthic treatment. The histology showed numerous pinworms in the lumen of the appendix and invasion of the pinworms of the submucosal layer and the wall of the appendix.
CT-colonography (CTC) is recommended in the case of an incomplete conventional colonoscopy (CC). The present study was initiated to assess feasibility and outcomes in same-day CTC after incomplete ...CC.
Out of 480 consecutive patients who had CC for symptoms or for surveillance, 50 were incomplete for reasons other than insufficient preparation. If possible, CTC was performed on the same day in dual positions without contrast. Where CTC found suspected polyps, patients had a re-CC for verification and removal, and subsequent surgery in the case of cancer.
Reasons for incomplete CC were loop formation (24%), pain (48%), kinking or external compression (24%) or benign strictures (4%). 43 of 50 CTCs (86%, 95% CI 73-94%) were conclusive. The organization allowed for 25 patients (50%) to have CTC on the same day. CTC detected 17 suspected polyps/masses, 13 of which were verified in 12 patients (28%). Re-CC or surgery verified 3 out of 4 of the suspected polyps < or = 5 mm, 5 out of 6 of those sized 6-9 mm, and 5 out of 7 of the masses > 9 mm (including 2 cancers). 19 (38%) had previously undetected extra-intestinal disease, including metastases in 4 patients, a uterine cancer in one, and a 7 cm abdominal aortic aneurism in one.
Same-day CTC after incomplete CC is feasible and effective.
