Peter Hewett

A systematic review of skills transfer after surgical simulation training.

Objective:To determine whether skills acquired by simulation-based training transfer to the operative setting. Summary Background Data:The fundamental assumption of simulation-based training is that skills acquired in simulated settings are directly transferable to the operating room, yet little evidence has focused on correlating simulated performance with actual surgical performance. Methods:A systematic search strategy was used to retrieve relevant studies. Inclusion of articles was determined using a predetermined protocol, independent assessment by 2 reviewers, and a final consensus decision. Only studies that reported on the use of simulation-based training for surgical skills training, and the transferability of these skills to the operative setting, were included. Results:Ten randomized controlled trials and 1 nonrandomized comparative study were included in this review. In most cases, simulation-based training was in addition to normal training programs. Only 1 study compared simulation-based training with patient-based training. For laparoscopic cholecystectomy and colonoscopy/sigmoidoscopy, participants who received simulation-based training before undergoing patient-based assessment performed better than their counterparts who did not receive previous simulation training, but improvement was not demonstrated for all measured parameters. Conclusions:Skills acquired by simulation-based training seem to be transferable to the operative setting. The studies included in this review were of variable quality and did not use comparable simulation-based training methodologies, which limited the strength of the conclusions. More studies are required to strengthen the evidence base and to provide the evidence needed to determine the extent to which simulation should become a part of surgical training programs.

Short-term outcomes of the Australasian Randomized Clinical Study comparing laparoscopic and conventional open surgical treatments for colon cancer The ALCCaS Trial

Background:Laparoscopy has revolutionized many abdominal surgical procedures. Laparoscopic colectomy has become increasingly popular. The short- and long-term benefits and satisfactory surgical oncological treatment of colorectal cancer by laparoscopic-assisted resection remain topical. The long-term outcomes of all international randomized controlled trials are still awaited, and short-term outcomes are important in the interim. Methods:Between January 1998 and April 2005, a multicenter, prospective, randomized clinical trial in patients with colon cancer was conducted. Six hundred and one eligible patients were recruited by 33 surgeons from 31 Australian and New Zealand centers. Patients were allocated to colectomy by either laparoscopic-assisted surgery (n = 294) or open surgery (n = 298). Patient demographics and secondary end-points, such as operative and postoperative complications, length of hospital stay, and histopathological data, will be presented in this article. Analysis was by intention-to-treat. Survival will be reported only as the study matures. Results:Histopathological parameters were similar between the two groups, except in regard to distal resection margins. There was no statistically significant difference found in postoperative complications, reoperation rate, or perioperative mortality. Statistically significant differences in quicker return of gastrointestinal function and shorter hospital stay were identified in favor of laparoscopic-assisted resection. A statistically significant increased rate of infective complications was seen in cases converted from laparoscopic-assisted to open procedures but with no difference in reoperation or in-hospital mortality. Conclusions:Laparoscopic-assisted colonic resection gives significant improvements in return of gastrointestinal function and length of stay, with an increased operative time and no difference in the postoperative complication rate.

Effect of Laparoscopic-Assisted Resection vs Open Resection on Pathological Outcomes in Rectal Cancer: The ALaCaRT Randomized Clinical Trial

IMPORTANCE Laparoscopic procedures are generally thought to have better outcomes than open procedures. Because of anatomical constraints, laparoscopic rectal resection may not be better because of limitations in performing an adequate cancer resection. OBJECTIVE To determine whether laparoscopic resection is noninferior to open rectal cancer resection for adequacy of cancer clearance. DESIGN, SETTING, AND PARTICIPANTS Randomized, noninferiority, phase 3 trial (Australasian Laparoscopic Cancer of the Rectum; ALaCaRT) conducted between March 2010 and November 2014. Twenty-six accredited surgeons from 24 sites in Australia and New Zealand randomized 475 patients with T1-T3 rectal adenocarcinoma less than 15 cm from the anal verge. INTERVENTIONS Open laparotomy and rectal resection (n = 237) or laparoscopic rectal resection (n = 238). MAIN OUTCOMES AND MEASURES The primary end point was a composite of oncological factors indicating an adequate surgical resection, with a noninferiority boundary of Δ = -8%. Successful resection was defined as meeting all the following criteria: (1) complete total mesorectal excision, (2) a clear circumferential margin (≥1 mm), and (3) a clear distal resection margin (≥1 mm). Pathologists used standardized reporting and were blinded to the method of surgery. RESULTS A successful resection was achieved in 194 patients (82%) in the laparoscopic surgery group and 208 patients (89%) in the open surgery group (risk difference of -7.0% [95% CI, -12.4% to ∞]; P = .38 for noninferiority). The circumferential resection margin was clear in 222 patients (93%) in the laparoscopic surgery group and in 228 patients (97%) in the open surgery group (risk difference of -3.7% [95% CI, -7.6% to 0.1%]; P = .06), the distal margin was clear in 236 patients (99%) in the laparoscopic surgery group and in 234 patients (99%) in the open surgery group (risk difference of -0.4% [95% CI, -1.8% to 1.0%]; P = .67), and total mesorectal excision was complete in 206 patients (87%) in the laparoscopic surgery group and 216 patients (92%) in the open surgery group (risk difference of -5.4% [95% CI, -10.9% to 0.2%]; P = .06). The conversion rate from laparoscopic to open surgery was 9%. CONCLUSIONS AND RELEVANCE Among patients with T1-T3 rectal tumors, noninferiority of laparoscopic surgery compared with open surgery for successful resection was not established. Although the overall quality of surgery was high, these findings do not provide sufficient evidence for the routine use of laparoscopic surgery. Longer follow-up of recurrence and survival is currently being acquired. TRIAL REGISTRATION anzctr.org Identifier: ACTRN12609000663257.

Effects of video information on precolonoscopy anxiety and knowledge : a randomised trial

BACKGROUND The provision of information before medical or surgical procedures should improve knowledge and allay anxiety about the pending procedure. This trial aimed to assess the value of an information video in this process. METHODS Patients scheduled to undergo colonoscopy were approached about 1 week before the procedure. All patients were given an information leaflet about colonoscopy, and completed a Spielberger state anxiety inventory (STAI) questionnaire to assess baseline anxiety. The patients were then randomly assigned to watch or not watch the information video. Immediately before colonoscopy, all patients completed a second anxiety questionnaire and a knowledge questionnaire. FINDINGS 198 patients were screened. 31 declined to participate and 17 were unable to complete the forms. Of the remaining 150 patients, 72 were assigned the video, and 78 no video. The groups were similar with regard to age, sex, educational attainment, and initial anxiety score. Female patients had higher baseline anxiety than male patients (mean STAI 46.3 [95% CI 44.9-47.7] vs 36.9 [35.5-38.3]; difference 9.4 [7.8-12.2], p=0.0008). Patients who had not had a previous colonoscopy had higher baseline anxiety scores than those who had prior experience of the procedure (46.9 [45.4-48.5] vs 36.3 [34.7-37.9]; difference 10.6 [7.5-13.8], p=0.0008). Patients who watched the video were significantly less anxious before colonoscopy than those who did not. The former also scored more highly in the knowledge questionnaire than the latter with regard to the purpose of the procedure, procedural details, and potential complications of colonoscopy. INTERPRETATION An information video increases knowledge and decreases anxiety in patients preparing for colonoscopy.

Laparoscopic-Assisted Resection of Colorectal Malignancies: A Systematic Review

ObjectiveTo compare the safety and efficacy of laparoscopic-assisted resection of colorectal malignancies with open colectomy. MethodsTwo search strategies were devised to retrieve literature from the Medline, Current Contents, Embase, and Cochrane Library databases until July 1999. Inclusion of papers was determined using a predetermined protocol, independent assessments by two reviewers, and a final consensus decision. English language papers were selected. Acceptable study designs included randomized controlled trials, controlled clinical trials, case series, or case reports. Fifty-two papers met the inclusion criteria. They were tabulated and critically appraised in terms of methodology and design, outcomes, and the possible influence of bias, confounding, and chance. ResultsLittle high-level evidence was available. Laparoscopic resection of colorectal malignancy was more expensive and time-consuming, but little evidence suggests high rates of port site recurrence. The new procedure’s advantages revolve around early recovery from surgery and reduced pain. ConclusionsThe evidence base for laparoscopic-assisted resection of colorectal malignancies is inadequate to determine the procedure’s safety and efficacy. Because of inadequate evidence detailing circumferential marginal clearance of tumors and the necessity of determining a precise incidence of cardiac and other major complications, along with wound and port site recurrence, it is recommended that a controlled clinical trial, ideally with random allocation to an intervention and control group, be conducted. Long-term survival rates need to be a primary aim of such a trial.

Molecular detection of blood-borne epithelial cells in colorectal cancer patients and in patients with benign bowel disease

In colorectal cancer (CRC), a proportion of patients with early stage disease still die of metastatic or recurrent disease within 5 years of “curative” resection. Detection of carcinoma cells in the peripheral circulation at presentation may identify a subgroup of patients with micro‐metastatic disease who may benefit from adjuvant chemotherapy or radiotherapy. Our aim was to determine the presence and clinical significance of colon carcinoma cells in peripheral blood at the time of surgery. Preoperative peripheral blood samples were collected from 94 patients with CRC and 64 patients undergoing bowel resection for benign conditions (adenoma, diverticular disease or Crohns colitis). Blood was also obtained from 20 normal donors not undergoing bowel surgery. Immunomagnetic beads were used to isolate epithelial cells followed by reverse transcription‐polymerase chain reaction (RT‐PCR) analysis of expression of cytokeratin (CK) 19, CK 20, mucin (MUC) 1 and MUC 2. Nineteen of 94 (20%) CRC patients were positive for epithelial cells in preoperative blood, including 6 with early stage disease. Kaplan–Meier survival analysis showed that detection of epithelial cells in preoperative blood was associated with reduced disease‐free and overall survival (log‐rank test, p = 0.0001). Surprisingly, circulating epithelial cells were detected in 3/30 (10%) patients resected for adenoma, and in 4/34 (12%) patients resected for benign inflammatory conditions, suggesting that cells from nonmalignant colonic epithelium may also gain entry into the bloodstream in the presence of bowel pathology. All 20 normal control bloods were negative for epithelial cells. Int. J. Cancer (Pred. Oncol.) 89:8–13, 2000.

Systematic review of skills transfer after surgical simulation‐based training

Simulation‐based training assumes that skills are directly transferable to the patient‐based setting, but few studies have correlated simulated performance with surgical performance.

Intraperitoneal cell movement during abdominal carbon dioxide insufflation and laparoscopy

PURPOSE: Possible mechanisms of movement of malignant cells within the peritoneal cavity during CO2 insufflation and laparoscopy involve direct transfervia laparoscopic instruments or dispersion of cells by CO2 or water vapor. Anin vivo model has been developed to study these mechanisms. METHODS: Laparoscopy was performed on an animal model (domestic white pig). Cells derived from colorectal cancer cell line Lim 1215 were injected to lie free within the peritoneal cavity. A polycarbonate filter system with a 5-micron pore diameter was used to examine CO2 expelled from the peritoneal cavity, during laparoscopy and manipulation of abdominal viscera, for malignant cells. Laparoscopic instruments and laparoscopic ports were washed independently, and fluid was centrifuged and examined for malignantcells. RESULTS: Malignant cells were identified on 1 of 30 filters used to examine exhaust carbon dioxide. Malignant cells also were identified from 2 of 10 washings from laparoscopic ports and from 4 of 10 washings of laparoscopic instruments. CONCLUSIONS: These results suggest that movement of cells throughout the peritoneal cavity during laparoscopy isvia contaminated instruments, but local cell movement by dispersion possibly within water vapor from the port may also occur.

Receptor protein tyrosine kinase EphB4 is up-regulated in colon cancer

BackgroundWe have used commercially available cDNA arrays to identify EphB4 as a gene that is up-regulated in colon cancer tissue when compared with matched normal tissue from the same patient.ResultsQuantitative RT-PCR analysis of the expression of the EphB4 gene has shown that its expression is increased in 82% of tumour samples when compared with the matched normal tissue from the same patient. Using immunohistochemistry and Western analysis techniques with an EphB4-specific antibody, we also show that this receptor is expressed in the epithelial cells of the tumour tissue and either not at all, or in only low levels, in the normal tissue.ConclusionThe results presented here supports the emerging idea that Eph receptors play a role in tumour formation and suggests that further elucidation of this signalling pathway may identify useful targets for cancer treatment therapies.

Identification of Early-Stage Colorectal Cancer Patients at Risk of Relapse Post-Resection by Immunobead Reverse Transcription-PCR Analysis of Peritoneal Lavage Fluid for Malignant Cells

Purpose: Colorectal cancer patients diagnosed with stage I or II disease are not routinely offered adjuvant chemotherapy following resection of the primary tumor. However, up to 10% of stage I and 30% of stage II patients relapse within 5 years of surgery from recurrent or metastatic disease. The aim of this study was to determine if tumor-associated markers could detect disseminated malignant cells and so identify a subgroup of patients with early-stage colorectal cancer that were at risk of relapse. Experimental Design: We recruited consecutive patients undergoing curative resection for early-stage colorectal cancer. Immunobead reverse transcription-PCR of five tumor-associated markers (carcinoembryonic antigen, laminin γ2, ephrin B4, matrilysin, and cytokeratin 20) was used to detect the presence of colon tumor cells in peripheral blood and within the peritoneal cavity of colon cancer patients perioperatively. Clinicopathologic variables were tested for their effect on survival outcomes in univariate analyses using the Kaplan-Meier method. A multivariate Cox proportional hazards regression analysis was done to determine whether detection of tumor cells was an independent prognostic marker for disease relapse. Results: Overall, 41 of 125 (32.8%) early-stage patients were positive for disseminated tumor cells. Patients who were marker positive for disseminated cells in post-resection lavage samples showed a significantly poorer prognosis (hazard ratio, 6.2; 95% confidence interval, 1.9-19.6; P = 0.002), and this was independent of other risk factors. Conclusion: The markers used in this study identified a subgroup of early-stage patients at increased risk of relapse post-resection for primary colorectal cancer. This method may be considered as a new diagnostic tool to improve the staging and management of colorectal cancer.