Kamran Ahmed

Is minimally invasive surgery beneficial in the management of esophageal cancer? A meta-analysis

IntroductionOpen esophagectomy for cancer is a major oncological procedure, associated with significant morbidity and mortality. Recently, thoracoscopic procedures have offered a potentially advantageous alternative because of less operative trauma compared with thoracotomy. The aim of this study was to utilize meta-analysis to compare outcomes of open esophagectomy with those of minimally invasive esophagectomy (MIE) and hybrid minimally invasive esophagectomy (HMIE).MethodsLiterature search was performed using Medline, Embase, Cochrane Library, and Google Scholar databases for comparative studies assessing different techniques of esophagectomy. A random-effects model was used for meta-analysis, and heterogeneity was assessed. Primary outcomes of interest were 30-day mortality and anastomotic leak. Secondary outcomes included operative outcomes, other postoperative outcomes, and oncological outcomes in terms of lymph nodes retrieved.ResultsA total of 12 studies were included in the analysis. Studies included a total of 672 patients for MIE and HMIE, and 612 for open esophagectomy. There was no significant difference in 30-day mortality; however, MIE had lower blood loss, shorter hospital stay, and reduced total morbidity and respiratory complications. For all other outcomes, there was no significant difference between the two groups.ConclusionMinimally invasive esophagectomy is a safe alternative to the open technique. Patients undergoing MIE may benefit from shorter hospital stay, and lower respiratory complications and total morbidity compared with open esophagectomy. Multicenter, prospective large randomized controlled trials are required to confirm these findings in order to base practice on sound clinical evidence.

Observational tools for assessment of procedural skills: a systematic review

BACKGROUNDnAssessment by direct observation of procedural skills is an important source of constructive feedback. The aim of this study was to identify observational tools for technical skill assessment, to assess characteristics of these tools, and to assess their usefulness for assessment.nnnMETHODSnIncluded studies reported tools for observational assessment of technical skills. A total of 106 articles were included.nnnRESULTSnThree main categories included global assessment scales evaluating generic skills (n = 29), task-specific methods assessing procedure-specific skills (n = 30), and combinations of tools evaluating both generic and task-specific skills (n = 47). In most studies, content validity was not evaluated using an accepted scientific method. All tools were assessed for inter-rater reliability and construct validity. Data on feasibility, acceptability, and educational impact were sparse.nnnCONCLUSIONSnThere is evidence of validity and reliability for observational assessment tools at the trainee level. In most studies a comprehensive analysis of the tools was not achieved. Evaluation of technical skill using current observational assessment tools is not reliable and valid at the specialist level. Future research needs to focus on further systematic tool development and analysis, especially at the specialist level.

The role of single-incision laparoscopic surgery in abdominal and pelvic surgery: a systematic review

ObjectiveThis review aimed to determine the role of single-incision laparoscopic surgery (SILS) in abdominal and pelvic operations.Data sourcesThe Medline, EMBASE, and PsycINFO databases were systematically searched until October 2009 using “single-incision laparoscopic surgery” and related terms as keywords. References from retrieved articles were reviewed to broaden the searchStudy selectionThe study included case reports, case series, and empirical studies that reported SILS in abdominal and pelvic operations.Data extractionNumber of patients, type of instruments, operative time, blood loss, conversion rate, length of hospital stay, length of follow-up evaluation, and complications were extracted from the reviewed itemsData synthesisThe review included 102 studies classified as level 4 evidence. Most of these studies investigated SILS in cholecystectomy (nxa0=xa034), appendectomy (nxa0=xa024), and nephrectomy (nxa0=xa017). For these procedures, operative time, hospital stay, and complications were comparable with those of conventional laparoscopy. Conversion to conventional laparoscopy was seldom performed in cholecystectomy (range, 0–24%) and more frequent in appendectomy (range, 0–41%) and nephrectomy (range, 0–33%).ConclusionThe potential benefits of SILS include superior cosmesis and possibly shorter operative time, lower costs, and a shortened time to full physical recovery. Careful case selection and a low threshold of conversion to conventional laparoscopic surgery are essential. Multicenter, randomized, prospective studies are needed to compare short- and long-term outcome measures against those of conventional laparoscopic surgery.

Catastrophizing: a predictive factor for postoperative pain

BACKGROUNDnpostsurgical pain is a major cause of delayed recovery and discharge after surgery. A significant proportion of patients develop chronic postsurgical pain, which affects their quality of life. Cognitive and psychological factors are reported to play a significant role in the severity of reported postsurgical pain. High levels of catastrophizing are associated with a heightened pain experience and appear to contribute to the development of chronic pain. This article describes the concept of pain catastrophizing, its association with postsurgical pain, and its potential role in the management of postsurgical pain and postsurgical quality of life.nnnMETHODSndata for this review were identified from MEDLINE, EMBASE, and PsycINFO. Reference lists of selected articles were cross-searched for additional literature.nnnRESULTSnHigh catastrophizing levels were found to be associated with increased pain severity, increased incidence of development of chronic pain, and poorer quality of life after surgery. There was no consensus on the relation between catastrophizing and analgesia consumption.nnnCONCLUSIONSnidentifying and reducing catastrophizing levels can help to optimize pain management in surgical patients.

Metabolic surgery and cancer: protective effects of bariatric procedures.

The worldwide epidemic of obesity and the global incidence of cancer are both increasing. There is now epidemiological evidence to support a correlation between obesity, weight gain, and some cancers. Metabolic or bariatric surgery can provide sustained weight loss and reduced obesity‐related mortality. These procedures can also improve the metabolic profile to decrease cardiovascular risk and resolve diabetes in morbidly obese patients. The operations offer several physiological steps, the so‐called BRAVE effects: 1) bile flow alteration, 2) reduction of gastric size, 3) anatomical gut rearrangement and altered flow of nutrients, 4) vagal manipulation and 5) enteric gut hormone modulation. Metabolic operations are also associated with a significant reduction of cancer incidence and mortality. The cancer‐protective role of metabolic surgery is strongest for female obesity‐related tumors; however, the underlying mechanisms may involve both weight‐dependent and weight‐independent effects. These include the improvement of insulin resistance with attenuation of the metabolic syndrome as well as decreased oxidative stress and inflammation in addition to the beneficial modulation of sex steroids, gut hormones, cellular energetics, immune system, and adipokines. Elucidating the precise metabolic mechanisms of cancer prevention by metabolic surgery can increase our understanding of how obesity, diabetes, and metabolic syndrome are associated with cancer. It may also offer novel treatment strategies in the management of tumor generation and growth. Cancer 2011.

Arterial closure devices versus manual compression for femoral haemostasis in interventional radiological procedures: a systematic review and meta-analysis.

PurposeThe use of arterial closure devices (ACDs) in interventional radiology (IR) procedures has not yet been validated by large-scale randomised controlled trials or meta-analysis. Improved haemostasis and early mobilisation are publicised advantages; however, anecdotal evidence of haemorrhagic and ischaemic complications with ACDs is also apparent. Meta-analysis from interventional cardiology cannot be directly extrapolated for IR patients.Materials and MethodsSystematic review, performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines was performed to assess four ACDs: Angioseal; StarClose; Perclose; and Duett―in peripheral vascular interventions: uterine artery embolisation, transhepatic chemoembolisation, and cerebral diagnostic and interventional procedures. Procedures requiring cardiac, aortic, or nonfemoral access, as well as those requiring >8F sheath size, were excluded. The outcomes assessed were device deployment failure, haematoma, bleeding, groin pain, retroperitoneal haematoma, arteriovenous fistula, infection, distal ischaemia, need for vascular surgery, need for manual compression, and death.ResultsSearch of MEDLINE and other major databases identified 34 studies from 15,805 records. Twenty-one noncomparative studies (3,662 participants) demonstrated total complication rates of 3.1–11.4%. Thirteen comparative studies were analysed separately, and random-effects meta-analysis yielded 10 studies (2,373 participants).ConclusionMeta-analyses demonstrated no statistically significant difference, but there were marginally fewer complications with pooled ACDs compared with manual compression (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.52–1.48, pxa0=xa00.13). The Angioseal group compared with the manual-compression group (total complication rate: OR 0.84, 95% CI 0.53–1.34, pxa0=xa00.49) and the Perclose group compared with the manual-compression group (total complication rate: OR 1.29, 95% CI 0.19–8.96, pxa0=xa00.01) each demonstrated trends for and against the specified ACD, respectively. Adequately powered randomised controlled trials are required to further elucidate the efficacy of ACDs.

An evaluation of information transfer through the continuum of surgical care: a feasibility study.

Objective:To evaluate information transfer and communication (ITC) across the surgical care pathway with the use of Information Transfer and Communication Assessment Tool for Surgery (ITCAS). Background:Communication failures are the leading cause of surgical errors and adverse events. It is vital to assess the ITC across the entire surgical continuum of care to understand the process, to study teams, and to prioritize the phases for intervention. Methods:Twenty patients undergoing major gastrointestinal procedures were followed through their entire surgical care, and ITC process was assessed using ITCAS. ITCAS consisted of 4 checklists for 4 phases of the surgical care. Results:ITC failures are distributed across the entire surgical continuum of care. Preprocedural teamwork and postoperative handover phases have the maximum number of ITC failures (61.7% and 52.4%, respectively). Moreover, it was found that information degrades as it crosses from one phase to another. Of patients, 75% had clinical incidents or adverse events because of ITC failures. Conclusions:The study demonstrated that ITC failures are ubiquitous across surgical care pathway and there is an imminent need to modify current ITC practices. Standardization of ITC through use of checklists, protocols, or information technology is essential to reduce these communication failures.

Diabetes resolution and hyperinsulinaemia after metabolic Roux-en-Y gastric bypass.

The global prevalence of type 2 diabetes mellitus and impaired glucose metabolism continues to rise in conjunction with the pandemic of obesity. The metabolic Roux‐en‐Y gastric bypass operation offers the successful resolution of diabetes in addition to sustained weight loss and excellent long‐term outcomes in morbidly obese individuals. The procedure consists of the physiological BRAVE effects: (i) Bile flow alteration; (ii) Reduction of gastric size; (iii) Anatomical gut rearrangement and altered flow of nutrients; (iv) Vagal manipulation and (v) Enteric gut hormone modulation. This operation provides anti‐diabetic effects through decreasing insulin resistance and increasing the efficiency of insulin secretion. These metabolic outcomes are achieved through weight‐independent and weight‐dependent mechanisms. These include the foregut, midgut and hindgut mechanisms, decreased inflammation, fat, adipokine and bile metabolism, metabolic modulation, shifts in gut microbial composition and intestinal gluconeogenesis. In a small minority of patients, gastric bypass results in hyperinsulinaemic hypoglycaemia that may lead to nesidioblastosis (pancreatic beta‐cell hypertrophy with islet hyperplasia). Elucidating the precise metabolic mechanisms of diabetes resolution and hyperinsulinaemia after surgery can lead to improved operations and disease‐specific procedures including ‘diabetes surgery’. It can also improve our understanding of diabetes pathogenesis that may provide novel strategies for the management of metabolic syndrome and impaired glucose metabolism.

Effectiveness of Procedural Simulation in Urology: A Systematic Review

PURPOSEnWe analyzed studies validating the effectiveness and deficiencies of simulation for training and assessment in urology. We documented simulation types (synthetic, virtual reality and animal models), participant experience level and tasks performed. The feasibility, validity, cost-effectiveness, reliability and educational impact of the simulators were also evaluated.nnnMATERIALS AND METHODSnThe MEDLINE®, EMBASE™ and PsycINFO® databases were systematically searched until September 2010. References from retrieved articles were reviewed to broaden the search.nnnRESULTSnThe study included case reports, case series and empirical studies of training and assessment in urology using procedural simulation. The model name, training tasks, participant level, training duration and evaluation scoring were extracted from each study. We also extracted data on face, content and construct validity. Most studies suitably addressed content, construct and face validation as well as the feasibility, educational impact and cost-effectiveness of simulation models. Synthetic, animal and virtual reality models were demonstrated to be effective training and assessment tools for junior trainees. Few investigators looked at the transferability of skills from simulation to real patients.nnnCONCLUSIONSnCurrent simulation models are valid and reliable for the initial phase of training and assessment. For advanced and specialist level skill acquisition animal models can be used but availability is limited due to supply shortages and ethical restrictions. More research is needed to validate simulated environments for senior trainees and specialists.

Current status of robotic assisted pelvic surgery and future developments.

AIMSnThe aim of this review is to assess the role of robotics in pelvic surgery in terms of outcomes. We have also highlighted the issues related to training and future development of robotic systems.nnnMATERIALS AND METHODSnWe searched MEDLINE, EMBASE and the Cochrane Databases from 1980 to 2009 for systematic reviews of randomised controlled trials, prospective observational studies, retrospective studies and case reports assessing robotic surgery.nnnRESULTSnDuring the last decade, there has been a tremendous rise in the use of robotic surgical systems for all forms of precision operations including pelvic surgery. The short-term results of robotic pelvic surgery in the fields of urology, colorectal surgery and gynaecology have been shown to be comparable to the laparoscopic and open surgery. Robotic surgery offers an opportunity where many of these obstacles encountered during open and laparoscopic surgery can be overcome.nnnCONCLUSIONSnRobotic surgery is a continually advancing technology, which has opened new horizons for performing pelvic surgery with precision and accuracy. Although its use is rapidly expanding in all surgical disciplines, particularly in pelvic surgery, further comparative studies are needed to provide robust guidance about the most appropriate application of this technology within the surgical armamentarium.