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Cizmic A, Romic I, Balla A, Barabino N, Anania G, Baiocchi GL, Bakula B, Balagué C, Berlth F, Bintintan V, Bracale U, Egberts JH, Fuchs HF, Gisbertz SS, Gockel I, Grimminger P, van Hillegersberg R, Inaki N, Immanuel A, Korr D, Lingohr P, Mascagni P, Melling N, Milone M, Mintz Y, Morales-Conde S, Moulla Y, Müller-Stich BP, Nakajima K, Nilsson M, Reeh M, Sileri P, Targarona EM, Ushimaru Y, Kim YW, Markar S, Nickel F, Mitra AT. An international Delphi consensus for surgical quality assessment of lymphadenectomy and anastomosis in minimally invasive total gastrectomy for gastric cancer. Surg Endosc 2024; 38:488-498. [PMID: 38148401 PMCID: PMC10830761 DOI: 10.1007/s00464-023-10614-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/26/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND Minimally invasive total gastrectomy (MITG) is a mainstay for curative treatment of patients with gastric cancer. To define and standardize optimal surgical techniques and further improve clinical outcomes through the enhanced MITG surgical quality, there must be consensus on the key technical steps of lymphadenectomy and anastomosis creation, which is currently lacking. This study aimed to determine an expert consensus from an international panel regarding the technical aspects of the performance of MITG for oncological indications using the Delphi method. METHODS A 100-point scoping survey was created based on the deconstruction of MITG into its key technical steps through local and international expert opinion and literature evidence. An international expert panel comprising upper gastrointestinal and general surgeons participated in multiple rounds of a Delphi consensus. The panelists voted on the issues concerning importance, difficulty, or agreement using an online questionnaire. A priori consensus standard was set at > 80% for agreement to a statement. Internal consistency and reliability were evaluated using Cronbach's α. RESULTS Thirty expert upper gastrointestinal and general surgeons participated in three online Delphi rounds, generating a final consensus of 41 statements regarding MITG for gastric cancer. The consensus was gained from 22, 12, and 7 questions from Delphi rounds 1, 2, and 3, which were rephrased into the 41 statetments respectively. For lymphadenectomy and aspects of anastomosis creation, Cronbach's α for round 1 was 0.896 and 0.886, and for round 2 was 0.848 and 0.779, regarding difficulty or importance. CONCLUSIONS The Delphi consensus defined 41 steps as crucial for performing a high-quality MITG for oncological indications based on the standards of an international panel. The results of this consensus provide a platform for creating and validating surgical quality assessment tools designed to improve clinical outcomes and standardize surgical quality in MITG.
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Affiliation(s)
- Amila Cizmic
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Ivan Romic
- Department of Hepatobiliary Surgery & Liver Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Andrea Balla
- Coloproctology and Inflammatory Bowel Disease Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicolò Barabino
- Department of Surgical Sciences & Integrated Diagnostic, University of Genoa, Genoa, Italy
| | - Gabriele Anania
- Department of Medical Science, University of Ferrara, 4121, Ferrara, Italy
| | - Gian Luca Baiocchi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Branko Bakula
- Department of Surgery, University Hospital Sveti Duh, Zagreb, Croatia
| | - Carmen Balagué
- Department of General and Digestive Surgery, Hospital de la Santa Creu I Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - Felix Berlth
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Vasile Bintintan
- Department of Surgery, University Hospital Cluj Napoca, Cluj-Napoca, Romania
| | - Umberto Bracale
- General and Emergency Surgical Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, AOU San Giovanni and Ruggi D'Aragona, Salerno, Italy
| | | | - Hans F Fuchs
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital Cologne, Cologne, Germany
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam UMC Location, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Peter Grimminger
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Noriyuki Inaki
- Department of Gastrointestinal Surgery/Breast Surgery, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Arul Immanuel
- Northern Oesophago-Gastric Unit, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
| | - Daniel Korr
- Department of Surgery, Israelit Hospital, Hamburg, Germany
| | - Philipp Lingohr
- Department for General, Visceral, Thoracic and Vascular Surgery, University Hospital of Bonn, Bonn, Germany
| | - Pietro Mascagni
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Institute of Image-Guided Surgery, IHU-Strasbourg, Strasbourg, France
| | - Nathaniel Melling
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Marco Milone
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", 80131, Naples, Italy
| | - Yoav Mintz
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Salvador Morales-Conde
- Department of General and Digestive Surgery, University Hospital Virgen Macarena, School of Medicine of the University of Seville, Seville, Spain
- Unit of General and Digestive Surgery, Hospital Quironsalud Sagrado Corazon, Seville, Spain
| | - Yusef Moulla
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Beat P Müller-Stich
- Department of Digestive Surgery, University Digestive Healthcare Center Basel, Basel, Switzerland
| | - Kiyokazu Nakajima
- Department of Next Generation Endoscopic Intervention, Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Magnus Nilsson
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Matthias Reeh
- Department of General, Visceral and Vascular Surgery, Marienkrankenhaus, Hamburg, Germany
| | - Pierpaolo Sileri
- Coloproctology and Inflammatory Bowel Disease Surgery Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | | | - Yuki Ushimaru
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Young-Woo Kim
- Center for Gastric Cancer, National Cancer Center, Goyang, Gyeonggi, Republic of Korea
| | - Sheraz Markar
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Felix Nickel
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Anuja T Mitra
- Department of Surgery & Cancer, Imperial College London, London, UK
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van Veenendaal N, Poelman M, Apers J, Cense H, Schreurs H, Sonneveld E, van der Velde S, Bonjer J. The INCH-trial: a multicenter randomized controlled trial comparing short- and long-term outcomes of open and laparoscopic surgery for incisional hernia repair. Surg Endosc 2023; 37:9147-9158. [PMID: 37814167 PMCID: PMC10709221 DOI: 10.1007/s00464-023-10446-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/02/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND Laparoscopic incisional hernia repair is increasingly performed worldwide and expected to be superior to conventional open repair regarding hospital stay and quality of life (QoL). The INCisional Hernia-Trial was designed to test this hypothesis. METHODS A multicenter parallel randomized controlled open-label trial with a superiority design was conducted in six hospitals in the Netherlands. Patients with primary or recurrent incisional hernias were randomized by computer-guided block-randomization to undergo either conventional open or laparoscopic repair. Primary endpoint was postoperative length of hospital stay in days. Secondary endpoints included QoL, complications, and recurrences. Patients were followed up for at least 5 years. RESULTS Hundred-and-two patients were recruited and randomized. In total, 88 patients underwent surgery and were included in the intention-to-treat analysis (44 in the open group, 44 in the laparoscopic group). Mean age was 59.5 years, gender division was equal, and BMI was 28.8 kg/m. The trial was concluded early for futility after an unplanned interim analysis, which showed that the hypothesis needed to be rejected. There was no difference in primary outcome: length of hospital stay was 3 (range 1-36) days in the open group and 3 (range 1-12) days in the laparoscopic group (p = 0.481). There were no significant between-group differences in QoL questionnaires on the short and long term. Satisfaction was impaired in the open group. Overall recurrence rate was 19%, of which 16% in the open and 23% in the laparoscopic group (p = 0.25) at a mean follow-up of 6.6 years. CONCLUSIONS In a randomized controlled trial, short- and long-term outcomes after laparoscopic incisional hernia repair were not superior to open surgery. The persisting high recurrence rates, reduced QoL, and suboptimal satisfaction warrant the need for patient's expectation management in the preoperative process and individualized surgical management. TRIAL REGISTRATION Netherlands Trial Register NTR2808.
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Affiliation(s)
- Nadine van Veenendaal
- Department of Surgery, Amsterdam University Medical Center, Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
- Department of Anesthesiology, University Medical Center, Groningen, The Netherlands.
| | - Marijn Poelman
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - Jan Apers
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - Huib Cense
- Department of Surgery, Red Cross Hospital, Beverwijk, The Netherlands
| | - Hermien Schreurs
- Department of Surgery, Northwest Clinics, Alkmaar, The Netherlands
| | - Eric Sonneveld
- Department of Surgery, Dijklander Hospital, Hoorn, The Netherlands
| | - Susanne van der Velde
- Department of Surgery, Amsterdam University Medical Center, Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Jaap Bonjer
- Department of Surgery, Amsterdam University Medical Center, Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
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Robertson D, Sterke F, van Weteringen W, Arezzo A, Mintz Y, Horeman T. Escape of surgical smoke particles, comparing conventional and valveless trocar systems. Surg Endosc 2023; 37:8552-8561. [PMID: 37794124 PMCID: PMC10615925 DOI: 10.1007/s00464-023-10444-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 09/02/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND During minimal access surgery, surgical smoke is produced which can potentially be inhaled by the surgical team, leading to several health risks. This smoke can escape from the abdominal cavity into the operating room due to trocar leakage. The trocars and insufflator that are used during surgery influence gas leakage. Therefore, this study compares particle escape from a valveless (Conmed AirSeal iFS), and a conventional (Karl Storz Endoflator) system. MATERIALS AND METHODS Using an in vitro model, a conventional and a valveless trocar system were compared. A protocol that simulated various surgical phases was defined to assess the surgical conditions and particle leakage. Insufflation pressures and instrument diameters were varied as these are known to affect gas leakage. RESULTS The conventional trocar leaked during two distinct phases. Removal of the obturator caused a sudden release of particles. During instrument insertion, an average of 211 (IQR 111) particles per second escaped when using the 5 mm diameter instrument. With the 10 mm instrument, 50 (IQR 13) particles per second were measured. With the conventional trocar, a higher abdominal pressure increased particle leakage. The valveless trocar demonstrated a continuously high particle release during all phases. After the obturator was removed, particle escape increased sharply. Particle escape decreased to 1276 (IQR 580) particles per second for the 5 mm instrument insertion, and 1084 (IQR 630) particles per second for 10 mm instrument insertion. With the valveless trocar system, a higher insufflation pressure lowered particle escape. CONCLUSIONS This study shows that a valveless trocar system releases more particles into the operating room environment than a conventional trocar. During instrument insertion, the leakage through the valveless system is 6 to 20 times higher than the conventional system. With a valveless trocar, leakage decreases with increasing pressure. With both trocar types leakage depends on instrument diameter.
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Affiliation(s)
- Daniel Robertson
- Department of Biomechanical Engineering, Faculty of Mechanical Engineering, Delft University of Technology, Mekelweg 2, 2628 CD, Delft, The Netherlands.
| | - Frank Sterke
- Department of Biomechanical Engineering, Faculty of Mechanical Engineering, Delft University of Technology, Mekelweg 2, 2628 CD, Delft, The Netherlands
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Willem van Weteringen
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Anesthesiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Turin, Italy
| | - Yoav Mintz
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Tim Horeman
- Department of Biomechanical Engineering, Faculty of Mechanical Engineering, Delft University of Technology, Mekelweg 2, 2628 CD, Delft, The Netherlands
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Sikkenk DJ, Sterkenburg AJ, Burghgraef TA, Akol H, Schwartz MP, Arensman R, Verheijen PM, Nagengast WB, Consten ECJ. Robot-assisted fluorescent sentinel lymph node identification in early-stage colon cancer. Surg Endosc 2023; 37:8394-8403. [PMID: 37721591 PMCID: PMC10615938 DOI: 10.1007/s00464-023-10394-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/13/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Patients with cT1-2 colon cancer (CC) have a 10-20% risk of lymph node metastases. Sentinel lymph node identification (SLNi) could improve staging and reduce morbidity in future organ-preserving CC surgery. This pilot study aimed to assess safety and feasibility of robot-assisted fluorescence-guided SLNi using submucosally injected indocyanine green (ICG) in patients with cT1-2N0M0 CC. METHODS Ten consecutive patients with cT1-2N0M0 CC were included in this prospective feasibility study. Intraoperative submucosal, peritumoral injection of ICG was performed during a colonoscopy. Subsequently, the near-infrared fluorescence 'Firefly' mode of the da Vinci Xi robotic surgical system was used for SLNi. SLNs were marked with a suture, after which a segmental colectomy was performed. The SLN was postoperatively ultrastaged using serial slicing and immunohistochemistry, in addition to the standard pathological examination of the specimen. Colonoscopy time, detection time (time from ICG injection to first SLNi), and total SLNi time were measured (time from the start of colonoscopy to start of segmental resection). Intraoperative, postoperative, and pathological outcomes were registered. RESULTS In all patients, at least one SLN was identified (mean 2.3 SLNs, SLN diameter range 1-13 mm). No tracer-related adverse events were noted. Median colonoscopy time was 12 min, detection time was 6 min, and total SLNi time was 30.5 min. Two patients had lymph node metastases present in the SLN, and there were no patients with false negative SLNs. No patient was upstaged due to ultrastaging of the SLN after an initial negative standard pathological examination. Half of the patients unexpectedly had pT3 tumours. CONCLUSIONS Robot-assisted fluorescence-guided SLNi using submucosally injected ICG in ten patients with cT1-2N0M0 CC was safe and feasible. SLNi was performed in an acceptable timespan and SLNs down to 1 mm were detected. All lymph node metastases would have been detected if SLN biopsy had been performed.
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Affiliation(s)
- Daan J Sikkenk
- Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
| | - Andrea J Sterkenburg
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Thijs A Burghgraef
- Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
| | - Halil Akol
- Department of Gastroenterology, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
| | - René Arensman
- Department of Pathology, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
| | - Paul M Verheijen
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Esther C J Consten
- Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands.
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Robertson D, van Duijn M, Arezzo A, Mintz Y, Horeman-Franse T. The influence of prolonged instrument manipulation on gas leakage through trocars. Surg Endosc 2023; 37:7325-7335. [PMID: 37442835 PMCID: PMC10462547 DOI: 10.1007/s00464-023-10240-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/22/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND During laparoscopic surgery, CO2 insufflation gas could leak from the intra-abdominal cavity into the operating theater. Medical staff could therefore be exposed to hazardous substances present in leaked gas. Although previous studies have shown that leakage through trocars is a contributing factor, trocar performance over longer periods remains unclear. This study investigates the influence of prolonged instrument manipulation on gas leakage through trocars. METHODS Twenty-five trocars with diameters ranging from 10 to 15 mm were included in the study. An experimental model was developed to facilitate instrument manipulation in a trocar under loading. The trocar was mounted to a custom airtight container insufflated with CO2 to a pressure of 15 mmHg, similar to clinical practice. A linear stage was used for prolonged instrument manipulation. At the same time, a fixed load was applied radially to the trocar cannula to mimic the reaction force of the abdominal wall. Gas leakage was measured before, after, and during instrument manipulation. RESULTS After instrument manipulation, leakage rates per trocar varied between 0.0 and 5.58 L/min. No large differences were found between leakage rates before and after prolonged manipulation in static and dynamic measurements. However, the prolonged instrument manipulation did cause visible damage to two trocars and revealed unintended leakage pathways in others that can be related to production flaws. CONCLUSION Prolonged instrument manipulation did not increase gas leakage rates through trocars, despite damage to some individual trocars. Nevertheless, gas leakage through trocars occurs and is caused by different trocar-specific mechanisms and design issues.
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Affiliation(s)
- Daniel Robertson
- Department of Biomechanical Engineering, Faculty of Mechanical Engineering, Delft University of Technology, Mekelweg 2, 2628 CD, Delft, The Netherlands.
| | - Matthijs van Duijn
- Department of Biomechanical Engineering, Faculty of Mechanical Engineering, Delft University of Technology, Mekelweg 2, 2628 CD, Delft, The Netherlands
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Turin, Italy
| | - Yoav Mintz
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Tim Horeman-Franse
- Department of Biomechanical Engineering, Faculty of Mechanical Engineering, Delft University of Technology, Mekelweg 2, 2628 CD, Delft, The Netherlands
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Huisman DE, Bootsma BT, Ingwersen EW, Reudink M, Slooter GD, Stens J, Daams F. Fluid management and vasopressor use during colorectal surgery: the search for the optimal balance. Surg Endosc 2023:10.1007/s00464-023-09980-1. [PMID: 37126191 PMCID: PMC10338618 DOI: 10.1007/s00464-023-09980-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 02/25/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Although it is known that excessive intraoperative fluid and vasopressor agents are detrimental for anastomotic healing, optimal anesthesiology protocols for colorectal surgery are currently lacking. OBJECTIVE To scrutinize the current hemodynamic practice and vasopressor use and their relation to colorectal anastomotic leakage. DESIGN A secondary analysis of a previously published prospective observational study: the LekCheck study. STUDY SETTING Adult patients undergoing a colorectal resection with the creation of a primary anastomosis. OUTCOME MEASURES Colorectal anastomotic leakage (CAL) within 30 days postoperatively, hospital length of stay and 30-day mortality. RESULTS Of the 1548 patients, 579 (37%) received vasopressor agents during surgery. Of these, 201 were treated with solely noradrenaline, 349 were treated with phenylephrine, and 29 received ephedrine. CAL rate significantly differed between the patients receiving vasopressor agents during surgery compared to patients without (11.8% vs 6.3%, p < 0.001). CAL was significantly higher in the group receiving phenylephrine compared to noradrenaline (14.3% vs 6%, p < 0.001). Vasopressor agents were used more often in patients treated with Goal Directed Therapy (47% vs 34.6%, p < 0.001). There was a higher mortality rate in patients with vasopressors compared to the group without (2.8% vs 0.4%, p = 0.01, OR 3.8). Mortality was higher in the noradrenaline group compared to the phenylephrine and those without vasopressors (5% vs. 0.4% and 1.7%, respectively, p < 0.001). In multivariable analysis, patients with intraoperative vasopressor agents had an increased risk to develop CAL (OR 2.1, CI 1.3-3.2, p = 0.001). CONCLUSION The present study contributes to the evidence that intraoperative use of vasopressor agents is associated with a higher rate of CAL. This study helps to create awareness on the (necessity to) use of vasopressor agents in colorectal surgery patients in striving for successful anastomotic wound healing. Future research will be required to balance vasopressor agent dosage in view of colorectal anastomotic leakage.
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Affiliation(s)
- Daitlin E Huisman
- Department of Surgery, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands.
| | - Boukje T Bootsma
- Department of Surgery, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Erik W Ingwersen
- Department of Surgery, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Muriël Reudink
- Department of Surgery, Máxima Medical Center, Veldhoven/Eindhoven, The Netherlands
| | - Gerrit D Slooter
- Department of Surgery, Máxima Medical Center, Veldhoven/Eindhoven, The Netherlands
| | - Jurre Stens
- Department of Anesthesiology, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
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Antoniou GA, Mavridis D, Tsokani S, López-Cano M, Flórez ID, Brouwers M, Markar SR, Silecchia G, Francis NK, Antoniou SA. Protocol of an interdisciplinary consensus project aiming to develop an AGREE II extension for guidelines in surgery. BMJ Open 2020; 10:e037107. [PMID: 32784259 PMCID: PMC7418673 DOI: 10.1136/bmjopen-2020-037107] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 05/26/2020] [Accepted: 07/13/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Appraisal of Guidelines for Research and Evaluation (AGREE II) is an instrument that informs development, reporting and assessment of clinical practice guidelines. Previous research has demonstrated the need for improvement in methodological and reporting quality of clinical practice guidelines specifically in surgery. We aimed to develop an AGREE II extension document for application in surgical guidelines. METHODS AND ANALYSIS We have performed a structured literature review and assessment of guidelines in surgery using the AGREE II instrument. In exploratory analyses, we have identified factors associated with guideline quality. We have performed reliability and factor analyses to inform the development of an extension document. We will summarise this information and present it to a Delphi panel of stakeholders. We will perform iterative Delphi rounds and we will summarise the final results to develop the extension instrument in a dedicated consensus conference. ETHICS AND DISSEMINATION Funding bodies will not be involved in the development of the instrument. Research ethics committee and Health Research Authority approval was waived, since this is a professional staff study only and no duty of care lies with the National Health Service to any of the participants. Conflicts of interest, if any, will be addressed by reassigning functions or replacing participants with relevant conflicts. The results will be disseminated through publication in peer reviewed journals, the funders' websites, social media and direct contact with guideline development organisations and peer-reviewed journals that publish guidelines.
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Affiliation(s)
- George A Antoniou
- Department of Vascular and Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Northern Care Alliance NHS Group, Manchester, UK
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, UK
| | - Dimitris Mavridis
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
- Faculté de Médecine, Université Paris Descartes, Paris, France
| | - Sofia Tsokani
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
| | - Manuel López-Cano
- Abdominal Wall Surgery Unit, Department of General Surgery, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Iván D Flórez
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Pediatrics, Universidad de Antioquia, Medellin, Colombia
| | - Melissa Brouwers
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Sheraz R Markar
- Department of Surgery and Cancer, Imperial College London, London, UK
| | | | - Nader K Francis
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK
| | - Stavros A Antoniou
- Medical School, European University Cyprus, Nicosia, Cyprus
- Department of Surgery, Mediterranean Hospital of Cyprus, Limassol, Cyprus
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Di Lorenzo N, Antoniou SA, Batterham RL, Busetto L, Godoroja D, Iossa A, Carrano FM, Agresta F, Alarçon I, Azran C, Bouvy N, Balaguè Ponz C, Buza M, Copaescu C, De Luca M, Dicker D, Di Vincenzo A, Felsenreich DM, Francis NK, Fried M, Gonzalo Prats B, Goitein D, Halford JCG, Herlesova J, Kalogridaki M, Ket H, Morales-Conde S, Piatto G, Prager G, Pruijssers S, Pucci A, Rayman S, Romano E, Sanchez-Cordero S, Vilallonga R, Silecchia G. Clinical practice guidelines of the European Association for Endoscopic Surgery (EAES) on bariatric surgery: update 2020 endorsed by IFSO-EC, EASO and ESPCOP. Surg Endosc 2020; 34:2332-2358. [PMID: 32328827 PMCID: PMC7214495 DOI: 10.1007/s00464-020-07555-y] [Citation(s) in RCA: 211] [Impact Index Per Article: 52.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/07/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Surgery for obesity and metabolic diseases has been evolved in the light of new scientific evidence, long-term outcomes and accumulated experience. EAES has sponsored an update of previous guidelines on bariatric surgery. METHODS A multidisciplinary group of bariatric surgeons, obesity physicians, nutritional experts, psychologists, anesthetists and a patient representative comprised the guideline development panel. Development and reporting conformed to GRADE guidelines and AGREE II standards. RESULTS Systematic review of databases, record selection, data extraction and synthesis, evidence appraisal and evidence-to-decision frameworks were developed for 42 key questions in the domains Indication; Preoperative work-up; Perioperative management; Non-bypass, bypass and one-anastomosis procedures; Revisional surgery; Postoperative care; and Investigational procedures. A total of 36 recommendations and position statements were formed through a modified Delphi procedure. CONCLUSION This document summarizes the latest evidence on bariatric surgery through state-of-the art guideline development, aiming to facilitate evidence-based clinical decisions.
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Affiliation(s)
- Nicola Di Lorenzo
- Department of Surgical Sciences, University of Rome "Tor Vergata", Rome, Italy
| | - Stavros A Antoniou
- Department of Surgery, European University of Cyprus, Nicosia, Cyprus
- Department of Surgery, Mediterranean Hospital of Cyprus, Limassol, Cyprus
| | - Rachel L Batterham
- Centre for Obesity Research, University College London, London, UK
- Biomedical Research Centre, National Institute of Health Research, London, UK
| | - Luca Busetto
- Internal Medicine 3, Department of Medicine, DIMED, Center for the Study and the Integrated Treatment of Obesity, University Hospital of Padua, Padua, Italy
| | - Daniela Godoroja
- Department of Anesthesiology, Ponderas Academic Hospital Regina Maria, Bucharest, Romania
| | - Angelo Iossa
- Department of Medical-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, "La Sapienza" University of Rome-Polo Pontino, Bariatric Centre of Excellence IFSO-EC, Via F. Faggiana 1668, 04100, Latina, Italy
| | - Francesco M Carrano
- Department of Endocrine and Metabolic Surgery, University of Insubria, Ospedale di Circolo and Fondazione Macchi, ASST Sette Laghi, Varese, Italy
| | | | - Isaias Alarçon
- Unit of Innovation in Minimally Invasive Surgery, Department of General and Digestive Surgery, University Hospital "Virgen del Rocío", 41010, Sevilla, Spain
| | | | - Nicole Bouvy
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Maura Buza
- Department of General Surgery, Ponderas Academic Hospital Regina Maria, Bucharest, Romania
| | - Catalin Copaescu
- Department of General Surgery, Ponderas Academic Hospital Regina Maria, Bucharest, Romania
| | - Maurizio De Luca
- Division of General Surgery, Castelfranco and Montebelluna Hospitals, Treviso, Italy
| | - Dror Dicker
- Department of Internal Medicine D, Hasharon Hospital, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Angelo Di Vincenzo
- Internal Medicine 3, Department of Medicine, DIMED, Center for the Study and the Integrated Treatment of Obesity, University Hospital of Padua, Padua, Italy
| | - Daniel M Felsenreich
- Division of General Surgery, Department of Surgery, Vienna Medical University, Vienna, Austria
| | - Nader K Francis
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK
| | - Martin Fried
- Center for Treatment of Obesity and Metabolic Disorders, OB Klinika, Prague, Czech Republic
| | | | - David Goitein
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Surgery C, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Jason C G Halford
- Department of Psychological Sciences, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Jitka Herlesova
- Center for Treatment of Obesity and Metabolic Disorders, OB Klinika, Prague, Czech Republic
| | | | - Hans Ket
- VU Amsterdam, Amsterdam, Netherlands
| | - Salvador Morales-Conde
- Unit of Innovation in Minimally Invasive Surgery, Department of General and Digestive Surgery, University Hospital "Virgen del Rocío", 41010, Sevilla, Spain
| | - Giacomo Piatto
- Division of General Surgery, Castelfranco and Montebelluna Hospitals, Treviso, Italy
| | - Gerhard Prager
- Division of General Surgery, Department of Surgery, Vienna Medical University, Vienna, Austria
| | - Suzanne Pruijssers
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Andrea Pucci
- Centre for Obesity Research, University College London, London, UK
- Biomedical Research Centre, National Institute of Health Research, London, UK
| | - Shlomi Rayman
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Surgery C, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Eugenia Romano
- Department of Psychological Sciences, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | | | - Ramon Vilallonga
- Endocrine, Metabolic and Bariatric Unit, General Surgery Department, Vall D'Hebron University Hospital, Center of Excellence for the EAC-BC, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Gianfranco Silecchia
- Department of Medical-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, "La Sapienza" University of Rome-Polo Pontino, Bariatric Centre of Excellence IFSO-EC, Via F. Faggiana 1668, 04100, Latina, Italy.
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Francis NK, Sylla P, Abou-Khalil M, Arolfo S, Berler D, Curtis NJ, Dolejs SC, Garfinkle R, Gorter-Stam M, Hashimoto DA, Hassinger TE, Molenaar CJL, Pucher PH, Schuermans V, Arezzo A, Agresta F, Antoniou SA, Arulampalam T, Boutros M, Bouvy N, Campbell K, Francone T, Haggerty SP, Hedrick TL, Stefanidis D, Truitt MS, Kelly J, Ket H, Dunkin BJ, Pietrabissa A. Sexual dysfunction, erectile impotence and obstructive azoospermia in respiratory disease. Relevance of lung-mediated regulation of prostaglandins. Chest 1983; 33:2726-2741. [PMID: 31250244 PMCID: PMC6684540 DOI: 10.1007/s00464-019-06882-z] [Citation(s) in RCA: 95] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 05/29/2019] [Indexed: 01/06/2023] Open
Abstract
Background Acute diverticulitis (AD) presents a unique diagnostic and therapeutic challenge for general surgeons. This collaborative project between EAES and SAGES aimed to summarize recent evidence and draw statements of recommendation to guide our members on comprehensive AD management. Methods Systematic reviews of the literature were conducted across six AD topics by an international steering group including experts from both societies. Topics encompassed the epidemiology, diagnosis, management of non-complicated and complicated AD as well as emergency and elective operative AD management. Consensus statements and recommendations were generated, and the quality of the evidence and recommendation strength rated with the GRADE system. Modified Delphi methodology was used to reach consensus among experts prior to surveying the EAES and SAGES membership on the recommendations and likelihood to impact their practice. Results were presented at both EAES and SAGES annual meetings with live re-voting carried out for recommendations with < 70% agreement. Results A total of 51 consensus statements and 41 recommendations across all six topics were agreed upon by the experts and submitted for members’ online voting. Based on 1004 complete surveys and over 300 live votes at the SAGES and EAES Diverticulitis Consensus Conference (DCC), consensus was achieved for 97.6% (40/41) of recommendations with 92% (38/41) agreement on the likelihood that these recommendations would change practice if not already applied. Areas of persistent disagreement included the selective use of imaging to guide AD diagnosis, recommendations against antibiotics in non-complicated AD, and routine colonic evaluation after resolution of non-complicated diverticulitis. Conclusion This joint EAES and SAGES consensus conference updates clinicians on the current evidence and provides a set of recommendations that can guide clinical AD management practice. Electronic supplementary material The online version of this article (10.1007/s00464-019-06882-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nader K. Francis
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK
| | - Patricia Sylla
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY USA
| | - Maria Abou-Khalil
- Division of Colon and Rectal Surgery, Jewish General Hospital, McGill University, Montreal, Canada
| | - Simone Arolfo
- Department of Surgical Sciences, University of Torino, Toriano, Italy
| | - David Berler
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY USA
| | - Nathan J. Curtis
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of General Surgery, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Scott C. Dolejs
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN USA
| | - Richard Garfinkle
- Division of Colon and Rectal Surgery, Jewish General Hospital, McGill University, Montreal, Canada
| | | | | | - Taryn E. Hassinger
- Department of Surgery, The University of Virginia Health System, Charlottesville, VA USA
| | | | - Philip H. Pucher
- Department of General Surgery, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Valérie Schuermans
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Toriano, Italy
| | | | | | - Tan Arulampalam
- Department of General Surgery, Colchester General Hospital, Colchester, UK
| | - Marylise Boutros
- Division of Colon and Rectal Surgery, Jewish General Hospital, McGill University, Montreal, Canada
| | - Nicole Bouvy
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Kenneth Campbell
- Department of Surgery, Ninewells Hospital, Dundee, UK
- School of Medicine, University of Dundee, Dundee, UK
| | - Todd Francone
- Division of Colon & Rectal Surgery, Newton-Wellesley Hospital, Newton, MA USA
| | - Stephen P. Haggerty
- Division of General Surgery, NorthShore University Health System, Evanston, IL USA
- Pritzker School of Medicine, University of Chicago, Chicago, IL USA
| | - Traci L. Hedrick
- Department of Surgery, The University of Virginia Health System, Charlottesville, VA USA
| | - Dimitrios Stefanidis
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN USA
| | | | | | - Hans Ket
- Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Brian J. Dunkin
- Department of Surgery, Houston Methodist Hospital, Houston, TX USA
| | - Andrea Pietrabissa
- Department of Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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