Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score

Background

Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score.

Methods

This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally.

Results

Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification.

Conclusion

The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.

Fit-for-Discharge Criteria after Esophagectomy: An International Expert Delphi Consensus

There are no internationally recognized criteria available to determine preparedness for hospital discharge after esophagectomy. This study aims to achieve international consensus using Delphi methodology. The expert panel consisted of 40 esophageal surgeons spanning 16 countries and 4 continents. During a 3-round, web-based Delphi process, experts voted for discharge criteria using 5-point Likert scales. Data were analyzed using descriptive statistics. Consensus was reached if agreement was ≥75% in round 3. Consensus was achieved for the following basic criteria: nutritional requirements are met by oral intake of at least liquids with optional supplementary nutrition via jejunal feeding tube. The patient should have passed flatus and does not require oxygen during mobilization or at rest. Central venous catheters should be removed. Adequate analgesia at rest and during mobilization is achieved using both oral opioid and non-opioid analgesics. All vital signs should be normal unless abnormal preoperatively. Inflammatory parameters should be trending down and close to normal (leucocyte count ≤12G/l and C-reactive protein ≤80 mg/dl). This multinational Delphi survey represents the first expert-led process for consensus criteria to determine 'fit-for-discharge' status after esophagectomy. Results of this Delphi survey may be applied to clinical outcomes research as an objective measure of short-term recovery. Furthermore, standardized endpoints identified through this process may be used in clinical practice to guide decisions regarding patient discharge and may help to reduce the risk of premature discharge or prolonged admission.

Ni-Doped ZnO Thin Films: Deposition, Characterization and Photocatalytic Applications

Root like structured Ni-doped zinc oxide [Zn_(1-x)Ni_xO (x = 0.09)] thin films were deposited on a non-conducting glass substrate by indigenously developed spray pyrolysis system at optimized substrate hotness of 573±5 K. Thus obtained Ni-doped ZnO thin films were characterized by UV-visible spectroscopy, X-ray diffraction (XRD), scanning electron microscopy (SEM), energy-dispersive X-ray spectroscopy (EDX), Atomic Force Microscopy (AFM). XRD result revealed that Ni-doped ZnO has a polycrystalline nature with a hexagonal wurtzite structure. For pure ZnO and Ni-doped ZnO thin films, the particle sizes were 60.9 and 53.3 nm while lattice strain values were 1.56×10^-3 and 1.14×10^-3, respectively. The film surface showed characteristic root-like structure as observed by the SEM. It was observed that the Ni-doped ZnO thin films were grown in high density along with more extent of branching as compared to pure ZnO thin films but retained the root-like morphologies, however, the branches were more-thinner and of shorter lengths. AFM analysis showed that the surface grains of the Ni-doped samples are homogeneous with less RMS roughness values compared with the undoped ZnO samples. The photocatalytic activity of the prepared thin films was evaluated by the degradation of methyl orange (MO) dye under UV light irradiation. Pure ZnO and Ni-doped ZnO thin films took 150 min and 100 min to degrade about 60% MO dye, respectively.

Long-term oncological outcomes following completely minimally invasive esophagectomy versus open esophagectomy

Open esophagectomy (OE) for esophageal and gastroesophageal junctional cancers is associated with high morbidity. Completely minimally invasive esophagectomy (CMIE) techniques have evolved over the last two decades and significantly reduce surgical trauma compared to open surgery. Despite this, long-term oncological outcomes following CMIE compared to OE remain unclear. This systematic review and meta-analysis aimed to compare overall 5-year survival (OFS) and disease-free 5-year survival (DFFS) between CMIE and OE. It was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive electronic literature search from MEDLINE, EMBASE, Web of Science, Scopus and the Cochrane Central Register of Controlled Trials was conducted. The PROSPERO database was also searched for studies comparing OFS and DFFS between CMIE and OE. The Newcastle Ottawa Scale was used to assess study quality for included studies. Overall, seven studies (containing 949 patients: 527 OE and 422 CMIE) were identified from screening. On pooled meta-analysis, there was no significant difference in OFS or DFFS between CMIE and OE cohorts ([odds ratio 1.12; 95% CI: 0.85 to 1.48; P = 0.41] and [odds ratio 1.34; 95% CI: 0.81-2.22; P = 0.25] respectively). Sensitivity and subgroup analysis with high-quality studies, three highest sample sized studies, and three most recent studies also revealed no difference in long-term oncological outcomes between the two operative groups. This review demonstrates long-term oncological outcomes following CMIE appear equivalent to OE based on amalgamation of existing published literature. Limited high-level evidence comparing OFS and DFFS between CMIE and OE exists. Further research with a randomized controlled trial is required to clinically validate these findings.

Variation in esophageal anastomosis technique-the role of collaborative learning

Centralization of care has improved outcomes in esophagogastric (EG) cancer surgery. However, specialist surgical centers often work within clinical silos, with little transfer of knowledge and experience. Although variation exists in multiple dimensions of perioperative care, the differences in operative technique are rarely studied. An esophageal anastomosis workshop was held to identify areas of common and differing practice within the operative technique. Surgeons showed videos of their anastomosis technique by open and minimally invasive surgery. Each video was followed by a discussion. Surgeons from 10 different EG cancer centers attended. Eight key technical differences and learning points were identified and discussed: the optimum diameter of the gastric conduit; avoiding ischemia in the gastric conduit; minimizing esophageal trauma; the use of an esophageal mucosal collar; omental wrapping; intraoperative leak testing; ideal diameter of the circular stapler and the growing use of linear stapled anastomoses. The workshop received positive feedback from participants and on 2 years follow-up, 40% stated that they believed that the learning of tips and techniques during the workshop has contributed to lowering their anastomotic leak rate. Many differences exist in surgical technique. The reasons for, and crucially the significance of, these differences must be discussed and examined. Workshops provide a forum for peer-to-peer collaborative learning to reflect on one's own practice and improve surgical technique. These changes can, in turn, generate incremental improvements in patient care and postoperative outcomes.

Diagnostic criteria and symptom grading for delayed gastric conduit emptying after esophagectomy for cancer: international expert consensus based on a modified Delphi process

Delayed gastric conduit emptying (DGCE) after esophagectomy for cancer is associated with adverse outcomes and troubling symptoms. Widely accepted diagnostic criteria and a symptom grading tool for DGCE are missing. This hampers the interpretation and comparison of studies. A modified Delphi process, using repeated web-based questionnaires, combined with live interim group discussions was conducted by 33 experts within the field, from Europe, North America, and Asia. DGCE was divided into early DGCE if present within 14 days of surgery and late if present later than 14 days after surgery. The final criteria for early DGCE, accepted by 25 of 27 (93%) experts, were as follows: >500 mL diurnal nasogastric tube output measured on the morning of postoperative day 5 or later or >100% increased gastric tube width on frontal chest x-ray projection together with the presence of an air-fluid level. The final criteria for late DGCE accepted by 89% of the experts were as follows: the patient should have 'quite a bit' or 'very much' of at least two of the following symptoms; early satiety/fullness, vomiting, nausea, regurgitation or inability to meet caloric need by oral intake and delayed contrast passage on upper gastrointestinal water-soluble contrast radiogram or on timed barium swallow. A symptom grading tool for late DGCE was constructed grading each symptom as: 'not at all', 'a little', 'quite a bit', or 'very much', generating 0, 1, 2, or 3 points, respectively. For the five symptoms retained in the diagnostic criteria for late DGCE, the minimum score would be 0, and the maximum score would be 15. The final symptom grading tool for late DGCE was accepted by 27 of 31 (87%) experts. For the first time, diagnostic criteria for early and late DGCE and a symptom grading tool for late DGCE are available, based on an international expert consensus process.

Prospective Risk Factor Analysis for the Development of Post-operative Urinary Retention Following Ambulatory General Surgery

Aims

Post-operative urinary retention (POUR) is a common cause of unplanned admission following day-case surgery and has negative effects on both patient and surgical institution. We aimed to prospectively evaluate potential risk factors for the development of POUR following day-case general surgical procedures.

Methods

Over a 24-week period, consecutive adult patients undergoing elective day-case general surgery at a single institution were prospectively recruited. Data regarding urinary symptoms, comorbidities, drug history, surgery and perioperative anaesthetic drug use were collected. The primary outcome was the incidence of POUR, defined as an impairment of bladder voiding requiring either urethral catheterisation, unplanned overnight admission or both. Potential risk factors for the development of POUR were analysed by logistic regression.

Results

A total of 458 patients met the inclusion criteria during the study period, and data were collected on 382 (83%) patients (74.3% male). Sixteen patients (4.2%) experienced POUR. Unadjusted analysis demonstrated three significant risk factors for the development of POUR: age ≥ 56 years (OR 7.77 [2.18–27.78], p = 0.002), laparoscopic surgery (OR 3.37 [1.03–12.10], p = 0.044) and glycopyrrolate administration (OR 5.56 [2.00–15.46], p = 0.001). Male sex and lower urinary tract symptoms were not significant factors. Multivariate analysis combining type of surgery, age and glycopyrrolate use revealed that only age ≥ 56 years (OR 8.14 [2.18–30.32], p = 0.0018) and glycopyrrolate administration (OR 3.48 [1.08–11.24], p = 0.0370) were independently associated with POUR.

Conclusions

Patients aged at least 56 years and/or requiring glycopyrrolate—often administered during laparoscopic procedures—are at increased risk of POUR following ambulatory general surgery.

Electronic supplementary material

The online version of this article (10.1007/s00268-018-4697-4) contains supplementary material, which is available to authorized users.

2-Fluoro-5-nitroaniline

In the title compound, C6H5FN2O2, the dihedral angle between the nitro group and the benzene ring is 3.68 (2)°, and an intramolecular N—H...F hydrogen bond is observed. The crystal packing is consolidated by C—H...O and N—H...O hydrogen bonds; together, these generate [110] double chains.

A structured training program for minimally invasive esophagectomy for esophageal cancer- a Delphi consensus study in Europe

Evidence suggests that structured training programs for laparoscopic procedures can ensure a safe standard of skill acquisition prior to independent practice. Although minimally invasive esophagectomy (MIO) is technically demanding, no consensus on requirements for training for the MIO procedure exists. The aim of this study is to determine essential steps required for a structured training program in MIO using the Delphi consensus methodology. Eighteen MIO experts from 13 European hospitals were asked to participate in this study. The consensus process consisted of two structured meetings with the expert panel, and two Delphi questionnaire rounds. A list of items required for training MIO were constructed for three key domains of MIO, including (1) requisite criteria for units wishing to be trained and (2) to proctor MIO, and (3) a framework of a MIO training program. Items were rated by the experts on a scale 1-5, where 1 signified 'not important' and 5 represented 'very important.' Consensus for each domain was defined as achieving Cronbach alpha ≥0.70. Items were considered as fundamental when ≥75% of experts rated it important (4) or very important (5). Both Delphi rounds were completed by 16 (89%) of the 18 invited experts, with a median experience of 18 years with minimally invasive surgery. Consensus was achieved for all three key domains. Following two rounds of a 107-item questionnaire, 50 items were rated as essential for training MIO. A consensus among European MIO experts on essential items required for training MIO is presented. The identified items can serve as directive principles and core standards for creating a comprehensive training program for MIO.

Component analysis of enhanced recovery pathways for esophagectomy

The objective of this systematic review is to identify key components of enhanced recovery protocols (ERP) that lead to improved length of hospital stay (LOS) following esophagectomy. Relevant electronic databases were searched for studies comparing clinical outcome from esophagectomy followed by a conventional pathway versus ERP. Relevant outcome measures were compared and metaregression was performed to identify the key ERP components associated with reduced in LOS. Thirteen publications were included, ERP was associated with no changes in in-hospital mortality, total complications, anastomotic leak, or pulmonary complications compared with a conventional pathway, however LOS was reduced in the ERP group. Metaregression identified that immediate extubation was associated with reduced LOS (OR = -0.51, 95%CI -0.77 to -0.25; P < 0.01). Several postoperative factors were associated with a significant reduction in length of hospital stay, and in order of most important were (i) gastrograffin swallow ≤5 days (OR = -4.27, 95%CI -4.50 to -4.03); (ii) mobilization on postoperative day ≤1 (OR = -2.49, 95%CI -2.63 to -2.34); (iii) removal of urinary catheter ≤2 days (OR = -0.99, 95%CI -1.15 to -0.84); (iv) oral intake with at least sips of fluid ≤1 day (OR = -0.96, 95%CI -1.24 to -0.68); (v) enteral diet with feeding jejunostomy or gastrostomy ≤ 1 day (OR = -0.57, 95%CI -0.80 to -0.35) and (vi) epidural removal ≤ 4 days (OR = -0.17, 95%CI -0.27 to -0.07). Several core ERP components and principles appear to be associated with LOS reduction. These elements should form a part of the core ERP for the specialty, while surgical teams incorporate other elements through an iterative process.

Systematic review of psychological, emotional and behavioural impacts of surgical incidents on operating theatre staff

BACKGROUND

Adverse surgical incidents affect both patients and health professionals. This study sought to explore the effect of surgical incidents on operating theatre staff and their subsequent behaviours.

METHODS

Eligible studies were primary research or reviews that focused on the effect of incidents on operating theatre staff in primary, secondary or tertiary care settings. MEDLINE, Embase, CINALH and PsycINFO were searched. A data extraction form was used to capture pertinent information from included studies and the Critical Appraisal Skills Programme (CASP) tool to appraise their quality. PRISMA-P reporting guidelines were followed and the review is registered with PROSPERO.

RESULTS

A total of 3918 articles were identified, with 667 duplicates removed and 3230 excluded at the title, abstract and full-text stages. Of 21 included articles, eight focused on the impact of surgical incidents on surgeons and anaesthetists. Only two involved theatre nurses and theatre technicians. Five key themes emerged: the emotional impact on health professionals, organization culture and support, individual coping strategies, learning from surgical complications and recommended changes to practice.

CONCLUSION

Health professionals suffered emotional distress and often changed their behaviour following a surgical incident. Both organizations and individual clinicians can do a great deal to support staff in the aftermath of serious incidents.

Prehabilitation in perioperative care

More work needed on improving fitness for surgery

Management of hypertriglyceridaemia-induced acute pancreatitis in pregnancy

INTRODUCTION

Acute pancreatitis is a recognised rare complication in pregnancy. The reported incidence varies between 3 and 7 in 10 000 pregnancies and is higher in the third trimester. The commonest causes in pregnancy include gallstones, alcohol and hypertriglyceridaemia. Non-gallstone pancreatitis is associated with more complications and poorer outcome with hypertriglyceridaemia-induced acute pancreatitis having mortality rates ranging from 7.5 to 9.0% and 10.0 to 17.5% for mother and foetus, respectively.

CASE HISTORY

A 40-year-old para 4 woman, who presented at 15(+4) weeks' gestation, was diagnosed with acute pancreatitis. Past medical history included Graves' disease and hypertriglyceridaemia. Fenofibrate was discontinued immediately after discovery of the pregnancy. Initial investigations showed elevated amylase (475.0 µ/L) and triglycerides (46.6 mmol/L). Imaging revealed an inflamed pancreas without evidence of biliary obstruction/gallstones hence confirming the diagnosis of hypertriglyceridaemia-induced acute pancreatitis. Laboratory tests gradually improved (triglyceride 5.2 mmol/L on day 17). On day 18, ultrasound confirmed foetal demise (18(+1) weeks) and a hysterotomy was performed as she had had four previous caesarean sections.

CONCLUSION

Management of acute pancreatitis in pregnancy requires a multi-disciplinary approach. Hypertriglyceridaemia-induced acute pancreatitis has poor outcomes when diagnosed in early pregnancy. Identifying those at risk pre-pregnancy and antenatally can allow close monitoring through pregnancy to optimise care.

Mortality in high-risk emergency general surgical admissions

Background

There is increasing evidence of variable standards of care for patients undergoing emergency general surgery in the National Health Service (NHS). The aim of this study was to quantify and explore variability in mortality amongst high-risk emergency general surgery admissions to English NHS hospital Trusts.

Methods

The Hospital Episode Statistics (HES) database was used to identify high-risk emergency general surgery diagnoses (greater than 5 per cent national 30-day mortality rate). Adults admitted to English NHS Trusts with these diagnoses between 2000 and 2009 were included in the study. Thirty-day in-hospital mortality was adjusted for patient and hospital factors. Trusts were grouped into high- and low-mortality outliers, and resource availability was compared between high- and low-mortality outlier institutions.

Results

Some 367 796 patients admitted to 145 hospital Trusts were included in the study; the 30-day mortality rate was 15·6 per cent (institutional range 9·2–18·2 per cent). Fourteen and 24 hospital Trusts were identified as high- and low-mortality outlier institutions respectively. Intensive care and high-dependency bed resources, as well as greater institutional use of computed tomography (CT), were independent predictors of reduced mortality (P &lt; 0·001). Low-mortality outlying Trusts had significantly more intensive care beds per 1000 hospital beds (20·8 versus 14·0; P = 0·017) and made significantly greater use of CT (24·6 versus 17·2 scans per bed per year; P &lt; 0·001) and ultrasonography (42·5 versus 30·2 scans per bed per year; P &lt; 0·001).

Conclusion

There is significant variability in mortality risk between hospital Trusts treating high-risk emergency general surgery patients. Equitable access to essential hospital resources may reduce variability in outcomes.

Delayed presentation of diaphragmatic rupture as intra-thoracic gastric volvulus

Diaphragmatic injuries are quite rare and result from either blunt or penetrating trauma. They are not always recognized at the time of injury and there is often a delay between the trauma and the diagnosis The diagnosis is confirmed by chest X-ray, USG, CT Scan and barium studies This case report discusses the delayed presentation of diaphragmatic rupture as an intrathoracic gastric volvulus observed in a 36-year-old man.

Peritoneal lavage cytology in patients with oesophagogastric adenocarcinoma

BACKGROUND

The aim of the study was to determine the value of performing peritoneal lavage cytology during laparoscopy in the management of oesophagogastric adenocarcinoma.

METHODS

Laparoscopy combined with peritoneal cytology was performed in patients with potentially resectable oesophagogastric adenocarcinoma. Macroscopic peritoneal findings at laparoscopy and the presence of free peritoneal tumour cells were recorded. All patients were followed to death or the census point. Patients with overt peritoneal disease or positive cytology were offered palliative chemotherapy, subject to performance status.

RESULTS

Forty-eight (18.8 per cent) of 255 patients had overt peritoneal metastases at staging laparoscopy. Fifteen (7.2 per cent) of the remaining 207 patients had positive cytology; these patients had a median (95 per cent confidence interval) survival of 13 (3.1 to 22.9) months, versus 9 (7.4 to 10.6) months for those with overt peritoneal metastases (P = 0.517). Of patients receiving chemotherapy, those without overt metastases had a slight survival advantage over patients with metastases (median 15 (10.8 to 19.2) versus 9 (7.4 to 10.7) months; P = 0.045).

CONCLUSION

Positive peritoneal cytology in the absence of overt peritoneal metastases is not uncommon in oesophagogastric adenocarcinoma. It is a marker of poor prognosis even in the absence of overt peritoneal metastases.

Effect of hormone replacement therapy in normalizing age related neuronal markers in different age groups of naturally menopausal rats

Aging of the normal brain is accompanied by changes in its structure, function, and metabolism. There are significant gender differences in aging brain. Most of these changes increase during menopausal condition in females when the level of estradiol and progesterone are decreased. The objective of this study was to determine the effect of estradiol and progesterone (separate as well as combined) hormones in neuronal tissues from naturally menopausal rats of different age groups. Results show decreased activity of Acetylcholine esterase (AChE) whereas the level of lipid peroxidation increased with age, and after the hormone treatments both AChE activity and level of lipid peroxidation returned to control values. The deposition of lipofuscin, a pigment that accumulated intraneuronally in brain and other tissues and is considered a marker of aging, was increased with aging and the hormone treatment decreased this deposition. The present study clearly shows reduction in risk factors associated with aging in the murine model system by hormone treatments, namely estrogen and progesterone by increasing the activity of acetylcholine esterase and decreasing the levels of lipid peroxidation and lipofuscin deposition in different parts of aging brain. This study suggests that hormone replacement therapy may either reduce or delay the onset of age related diseases like Alzheimer's, Parkinson's and other neurological disorders.

Neuroprotective Role of Neurokinin B (NKB) on β-amyloid (25–35) Induced Toxicity in Aging Rat Brain Synaptosomes: Involvement in Oxidative Stress and Excitotoxicity

The brain tissue has a large oxidative capacity, but its ability to combat oxidative stress is limited. In aging brain tissue the oxidative stress increases due to decreased activity of antioxidant enzymes and increased oxidative stress leading to neurodegeneration associated with excitotoxicity. The aim of the present study was to determine the effect of neuropeptides, neurokinin B (NKB) and amyloid beta protein fragment Abeta (25-35) and neurotransmitters N-methyl D-aspartate (NMDA) and Glutamate on rat brain synaptosomes of different age groups. Aging brain functions were assessed by measuring the activities of superoxide dismutase (Mn-SOD) and monoamine oxidase (MAO) and intrasynaptosomal [Ca(2+)](i )levels in presence of neuropeptides and neurotransmitters. Increase in age decreased the SOD and MAO enzyme activities; Abeta (25-35) addition further had damaging/toxic effects on the enzymes, whereas NKB alone and in combination with amyloid lowered the toxic effects caused by Abeta (25-35) addition, which was concentration (peptide) and age dependent. Oxidative stress and excitotoxicity are major consequences associated with the age, [Ca(2+)](i )was increased with the age and the neuropeptides and neurotransmitters elicited significant modulatory effects on it. Our study elucidates an increased activity of SOD, decreased activity of MAO and restoration of [Ca(2+)](i) levels in the presence of NKB and suggests an antioxidant, neuromodulatory and neuroprotective role of tachykinin peptide NKB against the beta amyloid induced toxicity.

Membrane Associated Functions of Neurokinin B (NKB) on Aβ (25–35) Induced Toxicity in Aging Rat Brain Synaptosomes

The effect of different concentrations (0.1-5 microM) of neurokinin B (NKB) and Abeta (25-35) on acetylcholine esterase (AChE), Na(+)-K(+) ATPase and membrane fluidity (DPH anisotropy) were investigated in rat brain synaptosomes of 3, 9, 18 and 30 months old. An age dependent decrease was observed for all the three parameters studied. An in vitro incubation of isolated brain synaptosomes with Abeta (25-35) showed toxic effects on all the parameters studied and the peptide had concentration and age dependent effects, while NKB showed stimulating effect on the parameters and the combined NKB+Abeta (25-35) incubations showed a partial reversal effect as compared to the Abeta (25-35) alone. Thus, the results suggest a membrane mediated function for NKB and its role in neuromodulation, neuroprotection and antioxidant property against Abeta (25-35) induced toxicity in aging brain functions.

Amelioration of altered antioxidant status and membrane linked functions by vanadium andTrigonella in alloxan diabetic rat brains

Trigonella foenum graecum seed powder (TSP) and sodium orthovanadate (SOV) have been reported to have antidiabetic effects. However, SOV exerts hypoglycemic effects at relatively high doses with several toxic effects. We used low doses of vanadate in combination with TSP and evaluated their antidiabetic effects on anti-oxidant enzymes and membrane-linked functions in diabetic rat brains. In rats, diabetes was induced by alloxan monohydrate (15 mg/100 g body wt.) and they were treated with 2 IU insulin, 0.6 mg/ml SOV, 5% TSP and a combination of 0.2 mg/ml SOV with 5% TSP for 21 days. Blood glucose levels, activity of superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx), Na+/K+ ATPase, membrane lipid peroxidation and fluidity were determined in different fractions of whole brain after 21 days of treatment. Diabetic rats showed high blood glucose (P less than 0.001), decreased activities of SOD, catalase and Na+/K+ ATPase (P less than 0.01, P less than 0.001 and P less than 0.01), increased levels of GPx and MDA (P less than 0.01 and P less than 0.001) and decreased membrane fluidity (P less than 0.01). Treatment with different antidiabetic compounds restored the above-altered parameters. Combined dose of Trigonella and vanadate was found to be the most effective treatment in normalizing these alterations. Lower doses of vanadate could be used in combination with TSP to effectively counter diabetic alterations without any toxic effects.

Estradiol and progesterone treatments change the lipid profile in naturally menopausal rats from different age groups

The effect of estradiol and progesterone therapy in serum and liver on the lipid profile of naturally menopausal albino rats of the Wistar strain of different age groups (12,18 and 24 months) have been measured and compared with the age matched groups. Three months old rats were used as young controls. The aged rats were administered subcutaneous injection of 17-beta-estradiol (0.1 microg/g body weight), progesterone (2.5 microg/g body weight) and similar concentrations of both in combined treatment for 1 month and the level of triglycerides (TG), total lipids (TL), total cholesterol (TC), high density lipoprotein (HDL), low density lipoprotein (LDL) and very low density lipoprotein (VLDL) were measured in serum and liver of 3, 12, 18 and 24 months old control as well as treated groups. The results show that TG, HDL, VLDL levels were increased significantly by 71%, 155%, 54%, respectively in liver of 24 months old rats by combination treatment when compared with age matched control animals. The levels of TL, TC and LDL were decreased by 20%, 31%, and 30%, respectively in serum of 12 months old rats in combination treatment group. The effect was more significant in 12 and 24 months old female rats with administration of estrogen and combined (EP) treatments. The results indirectly suggest that hormone replacement therapy (HRT) can reduce the risk of cardiovascular disease (CVD) thereby playing a cardio-protective role by restoring lipid and hormone levels to the similar levels as found in young female animals.

Administration of estradiol and progesterone modulate the activities of antioxidant enzyme and aminotransferases in naturally menopausal rats

In aging tissues the oxidative stress increases due to decreased activity of antioxidant enzymes and proteolysis increases due to decreased activity of aminotransferases, which can be modified by hormonal replacement therapy (HRT). The aim of the present study was to determine the effect of HRT on the activities of an antioxidant enzyme superoxide dismutase (SOD) and aminotransferases like alanine aminotransferase (Ala-AT) and aspartate aminotransferase in different age groups (12, 18 and 24 months) of naturally menopausal rats. The rats were given the subcutaneous injection of 17beta-estradiol, progesterone and combination of estradiol and progesterone for 1 month. The activity of SOD, Ala-AT and Asp-AT was measured in the brain (cerebral hemisphere, CH), heart, liver, kidney and uterus. The activity of SOD decreased with age in all the tissues taken particularly in liver. After HRT the enzyme activities were increased as compared to age-matched controls in all the tissues of aging rats. The activities of transaminases (Ala-AT and Asp-AT) showed a decrease with age in all the tissues and administration of estradiol and combination of estradiol and progesterone further decreased both the aminotransferases. Our study elucidates that increased activity of SOD contributes in protection of cells from oxygen toxicity by catalyzing the dismutation of free radicals in tissues. Furthermore, the HRT probably decreases gluconeogenesis and proteolysis by decreasing the activities of Ala-AT and Asp-AT in aging rat tissues.

Effect of estradiol and progesterone treatment on carbohydrate metabolizing enzymes in tissues of aging female rats

The aim of this study was to determine the effect of administration of estradiol (E2), progesterone (P4), and combination of estradiol and progesterone (EP) in aging female rats. The changes in the activities of hexokinase (HK), glucose-6-phosphatase (G6P'tase) and glucose-6-phosphate dehydrogenase (G6PDH) enzymes, and in protein levels in tissues of rats namely brain (cerebral hemisphere), heart, liver, kidney and uterus have been measured in different age groups. The random blood sugar level was measured in serum and liver. The different age groups of rats were given 0.1 microg/g body weight estradiol, 2.5 microg/g body weight progesterone and a similar concentration of both in a combined treatment for 1 month. This dose was selected after determining estrogen and progesterone levels in 3 month adult female animals so that the aging female animals had circulating hormone levels nearly the same as those of young female animals. The random sugar level was determined in serum and liver cytosolic fractions, and it was increased by combination treatment. The protein content in tissues showed significant changes only with combined hormone administration when compared with age-matched controls. The activity of HK decreased in aged animals and significantly increased by hormone treatments in all the tissues of the aged rats studied. The activity of G6P'tase increased with age up to 1.5 years and decreased in 2 years. Treatment with E2 and EP further decreased the activity significantly in all the tissues. G6PDH showed a similar pattern as was observed in HK in all the age groups. Therefore, the E2 and EP treatments caused an entire series of growth-related responses, including an increased uptake of glucose, increased the protein level in the tissues of aging rats, thereby reducing the risk factors associated with aging by normalizing hormone levels which decreased with aging and resulted in diseases such as Alzheimer's diseases and diabetes.

Combined treatment of sodium orthovanadate and Momordica charantia fruit extract prevents alterations in lipid profile and lipogenic enzymes in alloxan diabetic rats

Momordica charantia Linn., commonly called bitter gourd, is a medicinal plant used in the Ayurvedic system of medicine for treating various diseases including diabetes mellitus. Sodium orthovanadate (SOV) is also well-known insulin mimetic and an antidiabetic compound. Our laboratory has been using reduced doses of SOV along with administration of herbal extracts to alloxan diabetic rats and has established this combination as a good antihyperglycemic agent. The present study was undertaken to investigate the effects of treatment of Momordica fruit extract (MFE) and sodium orthovanadate, separately and in combination, on serum and tissue lipid profile and on the activities of lipogenic enzymes in alloxan induced diabetic rats. The results show that there was a significant (p < 0.01) increase in serum total lipids, triglycerides and total cholesterol levels after 21 days of alloxan diabetes. In the liver and kidney of diabetic rats the levels of total lipids and triglycerides also increased significantly (p < 0.01) while levels of total cholesterol decreased significantly (p < 0.01 and p < 0.05, respectively). The lipogenic enzymes showed decreased activity in the diabetic liver, while in kidney they showed an increased activity. When compared with the controls these changes were significant. The treatment of alloxan diabetic rats with MFE and SOV prevented these alterations and maintained all parameters near control values. Most effective prevention was however observed in a combined treatment of Momordica with a reduced dose of SOV (0.2%). The results suggest that Momordica fruit extract and SOV exhibit hypolipidemic as well as hypoglycemic effect in diabetic rats and their effect is pronounced when administered in combination.

Laparoscopic skills training and assessment

BACKGROUND

The introduction of laparoscopic techniques to general surgery was associated with many unnecessary complications, which led to the development of skills laboratories to train novice laparoscopic surgeons. This article reviews the tools currently available for training and assessment in laparoscopic surgery.

METHODS

Medline searches were performed to identify articles with combinations of the following key words: laparoscopy, training, curriculum, virtual reality and assessment. Further articles were obtained by manually searching the reference lists of identified papers.

RESULTS

Current training involves the use of box trainers with either innate models or animal tissues; it lacks objective assessment of skill acquisition. Virtual reality simulators have the ability to teach laparoscopic psychomotor skills, and objective assessment is now possible using dexterity-based and video analysis systems.

CONCLUSION

The tools are now available for the development of a structured, competency-based, laparoscopic surgical training programme.

The simulated operating theatre: comprehensive training for surgical teams

Surgical excellence is traditionally defined in terms of technical performance, with little regard for the importance of interpersonal communication and leadership skills. Studies in the aviation industry have stressed the role of human factors in causing error and, in an attempt to reduce the occurrence of adverse events, led to the organisation of simulation based training scenarios. Similar strategies have recently been employed for the surgical team with the development of a simulated operating theatre project. This enables technical and non-technical performance of the surgeon and circulating staff to be assessed by experts situated in an adjacent control room, and provides an opportunity for constructive feedback. The scenarios have good face validity and junior surgeons can benefit from the process of learning new technical skills in a realistic environment. The effect of external influences such as distractions, new technology, or a crisis scenario can also be defined, with the ultimate aim of reducing the number of adverse events arising in the real operating room.

The simulated operating theatre: comprehensive training for surgical teams

Surgical excellence is traditionally defined in terms of technical performance, with little regard for the importance of interpersonal communication and leadership skills. Studies in the aviation industry have stressed the role of human factors in causing error and, in an attempt to reduce the occurrence of adverse events, led to the organisation of simulation based training scenarios. Similar strategies have recently been employed for the surgical team with the development of a simulated operating theatre project. This enables technical and non-technical performance of the surgeon and circulating staff to be assessed by experts situated in an adjacent control room, and provides an opportunity for constructive feedback. The scenarios have good face validity and junior surgeons can benefit from the process of learning new technical skills in a realistic environment. The effect of external influences such as distractions, new technology, or a crisis scenario can also be defined, with the ultimate aim of reducing the number of adverse events arising in the real operating room.

Robot-assisted laparoscopic Heller cardiomyotomy: preliminary UK results

BACKGROUND/AIM

Laparoscopic Heller cardiomyotomy is an established modality in the surgical treatment of patients having achalasia cardia. We present our initial experience in robot-assisted laparoscopic Heller cardiomyotomy without addition of an antireflux procedure and discuss the relative merits and disadvantages of the procedure.

PATIENTS AND METHODS

Five patients underwent robot-assisted laparoscopic Heller cardiomyotomy between August 2001 and October 2002. The diagnosis had been confirmed by radiology and manometry in all patients prior to surgery.

RESULTS

All procedures were completed successfully using the robotic system, without conversion to open procedure. Mucosal perforation occurred in 1 patient and was sutured robotically. The average operative time was 114.8 (range 65-160) min which is comparable to laparoscopic procedures. After a mean follow-up period of 9.4 (range 3-17) months, 4 patients remained completely asymptomatic, and 1 patient has benefited from symptomatic improvement.

CONCLUSIONS

The enhanced dexterity and the high-quality three-dimensional vision available with robot-assisted surgery make the application of this technology highly suitable for Heller cardiomyotomy. The minimal lateral and posterior dissection due to the wristed instruments avoids the need for an antireflux procedure.

Bimodal assessment of laparoscopic suturing skills: construct and concurrent validity

BACKGROUND

The assessment of technical skills should provide objective feedback and judge suitability of progress during training. The aim of this study was to validate two objective assessment techniques for laparoscopic suturing and demonstrate a correlation between them.

METHODS

Six experts, seven surgeons skilled in laparoscopic suturing, and 13 with no laparoscopic suturing skills were asked to place two or three intracorporeal sutures on a synthetic suture pad. The latter group was given video-based instructions prior to the execution of the sutures. Ergonomic conditions were standardized for all subjects. The procedures were recorded on videotape and two blinded observers rated the first suture of each subject on a 29-point checklist. A motion analysis system, Imperial College Surgical Assessment Device, was used to assess psychomotor skills.

RESULTS

There was a significant difference in the time taken (p = 0.000) and total path length (p = 0.000) per suture across the groups. There were also a significant difference in the total checklist score (p = 0.000) and its individual categories. The was a strong correlation between the total path length and the total checklist score (coefficient, 0.78; p < 0.001).

CONCLUSIONS

A combination of the motion analysis system and the checklist would make the process of formative feedback during the learning of intracorporeal suturing objective and comprehensive.

An innovative method for the assessment of skills in lower gastrointestinal endoscopy

BACKGROUND

Although virtual reality (VR) simulators can be used ability to objectively assess skills in endoscopy, the evaluation is solely quantitative. We have developed a novel method for the objective assessment of technical skills in lower gastrointestinal (GI) endoscopy that incorporates qualitative as well as quantitative measures.

METHODS

We developed a virtual endoscopy suite by deconstructing the VR simulator to enable a more realistic and ergonomic placement of the monitor. Trainee endoscopists with varying levels of experience performed the case 4 task of the simulator. Ten essential components of endoscopic performance were rated on a five-point Likert scale (global score) by three independent observers. These observers viewed two videos (one showing scope handling and the other showing the monitor image), which were synchronized and played simultaneously.

RESULTS

The study population comprised six experts (group 1, > 200 procedures), seven subjects with intermediate experience (group 2, 20-80 procedures), and seven novices (group 3, 1-10 procedures). The global score was found to discriminate the level of skills across all three groups (p < 0.001). There were significant differences between groups 1 and 2 (p = 0.003) and groups 2 and 3 (p = 0.004). There was a significant correlation between the global score and the percentage of red-out (without vision) as recorded by the simulator (correlation coefficients = -0.61, p = 0.004).

CONCLUSION

This novel method for the assessment of technical skills in lower GI endoscopy has construct validity and high interrater reliability.

Objective evaluation of the effect of noise on the performance of a complex laparoscopic task

BACKGROUND

Noise in operating rooms has been found to be much higher than the recommended level of 45 dB. The aim of this study was to objectively evaluate the effect of noise and music on the performance of a complex surgical task.

METHODS

Twelve surgeons with varying experience in laparoscopic suturing undertook 3 sutures in a laparoscopic trainer under 3 conditions: quiet, noise at 80 to 85 dB, and music. Other than the test conditions, all other conditions were standardized. A validated motion analysis system was used to assess performance. The tasks were recorded by video and played back to 2 blinded observers who rated the surgeons' performance on a global rating scale by observing the tasks for accuracy, knot quality, and number of nonpurposeful movements.

RESULTS

Time taken for the tasks (P=.78), total number of movements (P=.78), total path length (P=.47), global score (P=.54), accuracy, and knot quality remained unchanged across the 3 conditions. The main study measures had a high test-retest reliability and internal consistency. No learning effect was seen across the 3 conditions.

CONCLUSIONS

Surgeons can effectively "block out" noise and music. This is probably due to the high levels of concentration required for the performance of a complex surgical task. Future research should focus on the effect of these conditions on communication in the operating room.

Dexterity enhancement with robotic surgery

BACKGROUND

The aim of this study was to quantify the extent of dexterity enhancement in robotic surgery as compared to laparoscopic surgery.

METHODS

Ten surgeons with varying laparoscopic suturing experience were asked to place three sutures on a suture pad. The sutures were placed laparoscopically, robotically with 2-D vision and robotically with 3-D vision. The da Vinci systems Application Programming Interface (API) was used for positional data. A validated motion analysis system was used for data retrieval for the laparoscopic task. Custom software was developed for data analysis.

RESULTS

Compared to laparoscopic suturing, when the task was undertaken robotically with 2-D vision there was a 20% reduction in the time taken but this was not significant (p = 0.07). There was a 55% reduction in the path traveled by the right hand (p = 0.01) and a 45% reduction in the path traveled by the left hand (p = 0.008). When the task was undertaken robotically with 3-D vision, there was a 40% reduction in the time taken (p = 0.01). There was a 70% reduction in the path traveled by right hand (p = 0.008) and a 55% reduction by the left hand (p = 0.08).

CONCLUSIONS

The presence of wristed instrumentation, tremor abolition, and motion scaling enhance dexterity by nearly 50% as compared to laparoscopic surgery. 3-D vision enhances dexterity by a further 10-15%. In addition, the presence of 3-D vision results in a 93% reduction in skills-based errors.

Effects of sodium-orthovanadate andTrigonella foenum-graecum seeds on hepatic and renal lipogenic enzymes and lipid profile during alloxan diabetes

Sodium-orthovanadate (SOV) and seed powder of Trigonella foenum graecum Linn. (common name: fenugreek, family: Fabaceae) (TSP) besides being potential hypoglycemic agents have also been shown to ameliorate altered lipid metabolism during diabetes. This study evaluates the short-term effect of oral administration of SOV and TSP separately and in concert (for 21 days) on total lipid profile and lipogenic enzymes in tissues of alloxan diabetic rats. Diabetic rats showed 4-fold increase in blood glucose. The level of total lipids, triglycerides and total cholesterol in blood serum increased significantly during diabetes. During diabetes the level of total lipids increased significantly (P < 0.001) in liver and in kidney by 48% and 55%, respectively, compared to control. Triglycerides level increased by 32% (P < 0.01) in liver and by 51% (P < 0.005) in kidney, respectively, compared to control. Total cholesterol level also increased significantly in both liver and kidney (P < 0.01 and P < 0.001, respectively). The activities of NADP-linked enzymes; namely glucose-6-phosphate dehydrogenase (G6PDH), malic enzyme (ME), isocitrate dehydrogenase (ICDH), and the activities of lipogenic enzymes namely ATP-citrate lyase (ATP-CL) and fatty acid synthase (FAS) were decreased significantly in liver and increased in kidney during diabetes as compared to control. SOV and TSP administration to diabetic animals prevented the development of hyperglycemia and alteration in lipid profile in plasma and tissues and maintained it near normal. Maximum prevention was observed in the combined treatment with lower dose of SOV (0.2%) after 21 days. We are presenting for the first time effectiveness of combined treatment of SOV and TSP in amelioration of altered lipid metabolism during experimental type-I diabetes.

Qualitative and quantitative analysis of the learning curve of a simulated surgical task on the da Vinci system

BACKGROUND

Robotic telemanipulation systems provide solutions to the problems of less dexterity and visual constraints of minimally invasive surgery (MIS). However, their influence over surgeons' dexterity and learning curve needs to be assessed. We present motion analysis as an objective method to measure performance and learning progress.METHODS. Thirteen surgeons completed five synthetic small bowel anastomoses using the da Vinci system. Objective Structured Assessment of Technical Skills (OSATS) allowed qualitative analysis. Quantitative analysis used API software of the system to retrieve real-time robotic signal data of time, path length, and number of movements. Wilcoxon signed ranks test was used for statistical analysis. A p value <0.05 was considered significant.RESULTS. OSATS global scores were 18.6 points for the first attempt and 26 for the fifth attempt ( p < 0.02, Cronbach's alpha = 0.894). Paired data of motion analysis for attempts 1 vs 5 showed significant change: time taken 3507 sec and 2287 sec ( p < 0.008), total number of movements 2411 and 1387 ( p = 0.01), total path length 21,630 cm and 13,941 cm ( p = 0.01).CONCLUSIONS. A rapid learning curve to a competent level using the da Vinci system is possible aided by the system's intuitive motion. Motion analysis is a useful tool to measure performance in the da Vinci system compared to OSATS and time alone.

Laparoscopic virtual reality and box trainers: is one superior to the other?

BACKGROUND

Virtual reality (VR) simulators now have the potential to replace traditional methods of laparoscopic training. The aim of this study was to compare the VR simulator with the classical box trainer and determine whether one has advantages over the other.

METHODS

Twenty four novices were tested to determine their baseline laparoscopic skills and then randomized into the following three group: LapSim, box trainer, and no training (control). After 3 weekly training sessions lasting 30-min each, all subjects were reassessed. Assessment included motion analysis and error scores. Nonparametric tests were applied, and p < 0.05 was deemed significant.

RESULTS

Both trained groups made significant improvements in all parameters measured ( p < 0.05). Compared to the controls, the box trainer group performed significantly better on most of the parameters, whereas the LapSim group performed significantly better on some parameters. There were no significant differences between the LapSim and box trainer groups.

CONCLUSIONS

LapSim is effective in teaching skills that are transferable to a real laparoscopic task. However, there appear to be no substantial advantages of one system over the other.

The benefits of stereoscopic vision in robotic-assisted performance on bench models

BACKGROUND

Previous studies have failed to establish clear advantages for the use of stereoscopic visualization systems in minimal-access surgery. The aim of this study was to objectively assess whether stereoscopic visualization improves performance on bench models using the da Vinci robotic system.

METHODS

Eleven surgeons carried out a series of four tasks. Positional data streamed from the da Vinci system was analyzed by means of a previously validated custom-designed software-package. An independent blinded observer scored errors. Statistical analysis included the Wilcoxon signed rank test. A p < 0.05 was deemed significant.

RESULTS

We found significant improvements in all tasks and for all parameters (p < 0.05). In addition, a significantly lower number of errors was scored using the stereoscopic mode as compared to the standard two-dimensional image (p < 0.001).

CONCLUSION

Robotic-assisted performance on bench models is more efficient and accurate using stereoscopic visualization.

Validity and reliability of a virtual reality upper gastrointestinal simulator and cross validation using structured assessment of individual performance with video playback

BACKGROUND

This study aims to evaluate the ability of an upper gastrointestinal virtual reality simulator to assess skills in endoscopy, and to validate its metrics using a video-endoscopic (VES) technique.

METHODS

The 32 participants in this study were requested to undertake two cases on the simulator (Simbionix, Israel). Each module was repeated twice. The simulator's metrics of performance were used for analysis. two blinded observers rated performance watching the simulator's playback feature.

RESULTS

There were 11 novices (group 1), 11 trainees with intermediate experience (10-50 procedures, group 2), and 10 experienced endoscopists (>200 procedures, group 3). There was a significant difference in the total time required to perform the procedure (p < 0.001), percentage of mucosa visualized (p < 0.001), percentage of pathologies visualized (p < 0.001), and number of inappropriate retroflexions (p = 0.015) across the three groups. The reliability of assessment on the simulator was greater than 0.80 for all parameters. The VES assessment also was able to discriminate performance across the groups (p < 0.001). There was a significant correlation between the VES score and the percentage of mucosa visualized (rho = 0.60; p < 0.001).

CONCLUSIONS

The upper gastrointestinal simulator may be a useful tool for determining whether a trainee has achieved a desired level of competence in endoscopy. The next step will be to validate the VES score in real procedures.