Rolv-Ole Lindsetmo

Overcoming distance: video-conferencing as a clinical and educational tool among surgeons.

BackgroundSince the 1960s, there has been substantial development in the uses of video-conferencing (VC) among medical personnel, including surgeons who have adopted the technology.MethodsA report on our own experience with VC was combined with a comprehensive PubMed search with the key words telepresence, video-conferencing, video-teleconferencing, telementoring and surgery, trauma, follow-up, education, and multidisciplinary teams. A search through two peer-reviewed telemedicine journals—Journal of Telemedicine and Telecare and Telemedicine and e-Health Journal—and references of all included papers and identified additional reports was conducted.ResultsA total of 517 articles were identified with 51 relevant manuscripts, which included the key phrases. VC is widely used among surgeons for telementoring surgical procedures and in trauma and emergency medicine. Furthermore, VC is widely used by multidisciplinary teams and for the follow-up of patients after surgery.ConclusionsVC is a common clinical tool for surgeons and provides a great opportunity to alter surgical practice and to offer patients the best expertise in surgical treatment despite long distances, especially in rural areas.

International preoperative rectal cancer management: staging, neoadjuvant treatment, and impact of multidisciplinary teams.

BackgroundLittle is known regarding variations in preoperative treatment and practice for rectal cancer (RC) on an international level, yet practice variation may result in differences in recurrence and survival rates.MethodsOne hundred seventy-three international colorectal centers were invited to participate in a survey of preoperative management of rectal cancer.ResultsOne hundred twenty-three (71%) responded, with a majority of respondents from North America, Europe, and Asia. Ninety-three percent have more than 5xa0years’ experience with rectal cancer surgery. Fifty-five percent use CT scan, 35% MRI, 29% ERUS, 12% digital rectal examination and 1% PET scan in all RC cases. Seventy-four percent consider threatened circumferential margin (CRM) an indication for neoadjuvant treatment. Ninety-two percent prefer 5-FU-based long-course neoadjuvant chemoradiation therapy (CRT). A significant difference in practice exists between the US and non-US surgeons: poor histological differentiation as an indication for CRT (25% vs. 7.0%, pxa0=xa00.008), CRT for stage II and III rectal cancer (92% vs. 43%, pxa0=xa00.0001), MRI for all RC patients (20% vs. 42%, pxa0=xa00.03), and ERUS for all RC patients (43% vs. 21%, pxa0=xa00.01). Multidisciplinary team meetings significantly influence decisions for MRI (RRxa0=xa03.62), neoadjuvant treatment (threatened CRM, RRxa0=xa05.67, stage IIxa0+xa0III RRxa0=xa02.98), quality of pathology report (RRxa0=xa04.85), and sphincter-saving surgery (RRxa0=xa03.81).ConclusionsThere was little consensus on staging, neoadjuvant treatment, and preoperative management of rectal cancer. Regular multidisciplinary team meetings influence decisions about neoadjuvant treatment and staging methods.

Chronic abdominal wall pain—A diagnostic challenge for the surgeon

BACKGROUNDnChronic abdominal wall pain (CAWP) occurs in about 30% of all patients presenting with chronic abdominal pain.nnnMETHODSnThe authors review the literature identified in a PubMed search regarding the abdominal wall as the origin of chronic abdominal pain.nnnRESULTSnCAWP is frequently misinterpreted as visceral or functional abdominal pain. Misdiagnosis often leads to a variety of investigational procedures and even abdominal operations with negative results. With a simple clinical test (Carnetts test), >90% of patients with CAWP can be recognized, without risk for missing intra-abdominal pathology.nnnCONCLUSIONnThe condition can be confirmed when the injection of local anesthetics in the trigger point(s) relieves the pain. A fasciotomy in the anterior abdominal rectus muscle sheath through the nerve foramina of the affected branch of one of the anterior intercostal nerves heals the pain.

Standardized postoperative pathway: Accelerating recovery after ileostomy closure

PurposeIn this study we evaluated the outcome of a standardized enhanced recovery program in patients undergoing ileostomy closure.MethodsForty-two patients underwent ileostomy closure by a single surgeon and were managed by a standardized postoperative care pathway. On the first postoperative day, patients received oral analgesia and a soft diet. Discharge was based on standard criteria previously published for laparoscopic colectomy patients. Results were recorded prospectively in an Institutional Review Board-approved database, including demographics, operative time, blood loss, complications, length of stay, and readmission data.ResultsThe median operative time and blood loss were 60 minutes and 17.5xa0mL, respectively, and median hospital stay was 2xa0days. Twenty-nine patients (69 percent) were discharged by postoperative Day 2. The complication rate was 23.8 percent; complications included prolonged postoperative ileus (nu2009=u20093), early postoperative small-bowel obstruction (nu2009=u20091), mortality not related to ileostomy closure (nu2009=u20091), minor bleeding (nu2009=u20091), wound infection (nu2009=u20091), incisional hernia (nu2009=u20091), diarrhea (nu2009=u20091), dehydration (nu2009=u20091). The 30-day readmission rate was 9.5 percent (nu2009=u20094). Two patients had reoperation within 30xa0days for small-bowel obstruction and a wound infection.ConclusionsIleostomy closure patients managed with postoperative care pathways can have a short hospital stay with acceptable morbidity and readmission rates.

Cost-effectiveness and quality of life in surgeon versus general practitioner-organised colon cancer surveillance: a randomised controlled trial

Objective To assess whether colon cancer follow-up can be organised by general practitioners (GPs) without a decline in the patients quality of life (QoL) and increase in cost or time to cancer diagnoses, compared to hospital follow-up. Design Randomised controlled trial. Setting Northern Norway Health Authority Trust, 4 trusts, 11 hospitals and 88 local communities. Participants Patients surgically treated for colon cancer, hospital surgeons and community GPs. Intervention 24-month follow-up according to national guidelines at the community GP office. To ensure a high follow-up guideline adherence, a decision support tool for patients and GPs were used. Main outcome measures Primary outcomes were QoL, measured by the global health scales of the European Organisation for Research and Treatment of Cancer QoL Questionnaire (EORTC QLQ C-30) and EuroQol-5D (EQ-5D). Secondary outcomes were cost-effectiveness and time to cancer diagnoses. Results 110 patients were randomised to intervention (n=55) or control (n=55), and followed by 78 GPs (942 follow-up months) and 70 surgeons (942 follow-up months), respectively. Compared to baseline, there was a significant improvement in postoperative QoL (p=0.003), but no differences between groups were revealed (mean difference at 1, 3, 6, 9, 12, 15, 18, 21 and 24-month follow-up appointments): Global Health; Δ−2.23, p=0.20; EQ-5D index; Δ−0.10, p=0.48, EQ-5D VAS; Δ−1.1, p=0.44. There were no differences in time to recurrent cancer diagnosis (GP 35u2005days vs surgeon 45u2005days, p=0.46); 14 recurrences were detected (GP 6 vs surgeon 8) and 7 metastases surgeries performed (GP 3 vs surgeon 4). The follow-up programme initiated 1186 healthcare contacts (GP 678 vs surgeon 508), 1105 diagnostic tests (GP 592 vs surgeon 513) and 778 hospital travels (GP 250 vs surgeon 528). GP organised follow-up was associated with societal cost savings (£8233 vs £9889, p<0.001). Conclusions GP-organised follow-up was associated with no decline in QoL, no increase in time to recurrent cancer diagnosis and cost savings. Trial registration ClinicalTrials.gov identifier NCT00572143.

Nationwide improvement of rectal cancer treatment outcomes in Norway, 1993–2010

Background. The Norwegian Rectal Cancer Project was initated in 1993 with the aims of improving surgery, decreasing local recurrence rates, improving survival, and establishing a national rectal cancer registry. Here we present results from the Norwegian Colorectal Cancer Registry (NCCR) from 1993 to 2010. Material and methods. A total of 15 193 patients were diagnosed with rectal cancer in Norway 1993–2010, and were registered with clinical data regarding diagnosis, treatment, locoregional recurrences and distant metastases. Of these, 10 796 with non-metastatic disease underwent tumour resection. The results were stratified into five time periods, and the treatment outcomes were compared. Recurrence rates are presented for the 9785 patients who underwent curative major resection (R0/R1). Results. Among all 15 193 patients, relative five-year survival increased from 54.1% in 1993–1997 to 63.4% in 2007–2010 (p < 0.001). Among the 10 796 patients with stage I–III disease who underwent tumour resection, from 1993–1997 to 2007–2010, relative five-year survival improved from 71.2% to 80.6% (p < 0.001). An increasing proportion of these patients underwent surgery at large-volume hospitals; and 30- and 100-day mortality rates, respectively, decreased from 3.0% to 1.4% (p < 0.001) and from 5.1% to 3.0% (p < 0.011). Use of preoperative chemoradiotherapy increased from 6.5% in 1993 to 39.0% in 2010 (p < 0.001). Estimated local recurrence rate after major resection (R0/R1) decreased from 14.5% in 1993–1997 to 5.0% in 2007–2009 (p < 0.001), and distant recurrence rate decreased from 26.0% to 20.2% (p < 0.001). Conclusion. Long-term outcomes from a national population-based rectal cancer registry are presented. Improvements in rectal cancer treatment have led to decreased recurrence rates of 5% and increased survival on a national level.

Laparoscopic rectal resections and fast-track surgery: what can be expected?

BACKGROUNDnWe present the results of combining protocols of standardized laparoscopic rectal resection (LRR) and perioperative fast track care.nnnMETHODSnPatients undergoing LRRs were identified from a prospectively maintained, institutional review board-approved database. Perioperative fast track care and laparoscopic operations were performed according to a standardized system.nnnRESULTSnThirty-seven patients were included. Conversion was performed in 2 males (5%). The mean operative time was 184 minutes (range 109 to 410 minutes). The mean hospital stay was 3.0 days (range 1 to 8 days) with 90% of patients discharged less than 5 days after surgery. No anastomotic leaks or mortality occurred and the in-hospital complications rate was 8%. Readmission occurred in 3 patients (8%). No specimen had involved distal or circumferential resection margins.nnnCONCLUSIONSnLRRs can be performed safely and effectively for rectal pathologies. Laparoscopy in conjunction with modern perioperative care provides rapid recovery with efficient use of hospital resources.

International trends in surgical treatment of rectal cancer

BACKGROUNDnSurgical technique might influence rectal cancer survival, yet international practices for surgical treatment of rectal cancer are poorly described.nnnMETHODSnWe performed a cross-sectional survey in a cohort of experienced colorectal surgeons representing 123 centers.nnnRESULTSnSeventy-one percent responded, 70% are from departments performing more than 50 proctectomies annually. More than 50% defined the rectum as 15 cm from the verge. Seventy-two percent perform laparoscopic proctectomy, 80% use oral bowel preparation, 69% perform high ligation of the inferior mesenteric artery, 76% divert stomas as routine for colo-anal anastomosis, and 63% use enhanced recovery protocols. Different practices exist between US and non-US surgeons: 15 cm from the verge to define the rectum (34% vs 59%; P = .03), personally perform laparoscopic resection (82% vs 66%; P = .05), rectal stump washout (36% vs 73%; P = .0001), always drain after surgery (23% vs 42%; P = .03), transanal endoscopic microsurgery for T2N0 in medically unfit patients (39% vs 61%; P = .0001).nnnCONCLUSIONSnWide international variations in rectal cancer management make outcome comparisons challenging, and consensus development should be encouraged.

Telementoring in education of laparoscopic surgeons: An emerging technology

Laparoscopy, minimally invasive and minimal access surgery with more surgeons performing these advanced procedures. We highlight in the review several key emerging technologies such as the telementoring and virtual reality simulators, that provide a solid ground for delivering surgical education to rural area and allow young surgeons a safety net and confidence while operating on a newly learned technique.

Surgical Telementoring in Knowledge Translation—Clinical Outcomes and Educational Benefits A Comprehensive Review

Background. Surgical telementoring has been reported for decades. However, there exists limited evidence of clinical outcome and educational benefits. Objective. To perform a comprehensive review of surgical telementoring surveys published in the past 2 decades. Results. Of 624 primary identified articles, 34 articles were reviewed. A total of 433 surgical procedures were performed by 180 surgeons. Most common telementored procedures were laparoscopic cholecystectomy (57 cases, 13%), endovascular treatment of aortic aneurysm (48 cases, 11%), laparoscopic colectomy (32 cases, 7%), and nefrectomies (41 cases, 9%). In all, 167 (38%) cases had a laparoscopic approach, and 8 cases (5%) were converted to open surgery. Overall, 20 complications (5%) were reported (liver bleeding, trocar port bleeding, bile collection, postoperative ileus, wound infection, serosa tears, iliac artery rupture, conversion open surgery). Eight surveys (23%) have structured assessment of educational outcomes. Telementoring was combined with simulators (n = 2) and robotics (n = 3). Twelve surveys (35%) were intercontinental. Technology satisfaction was high among 83% of surgeons. Conclusion. Few surveys have a structured assessment of educational outcome. Telementoring has improved impact on surgical education. Reported complication rate was 5%.