TY - BOOK T1 - The National Bowel Cancer Audit Project. Knowing your results. A1 - PP Tekkis A1 - JJ Smith A1 - V Constantinides A1 - MR Thmpson A1 - JD Stamatakis Y1 - 2005/07// PB - CPL Associates CY - London N2 - - ER - TY - BOOK T1 - The ACPGBI Bowel Cancer Study 2004. A1 - JJ Smith A1 - PP Tekkis A1 - MR Thompson Y1 - 2004/// PB - CPL Associates CY - London N2 - - ER - TY - BOOK T1 - ACPGBI Colorectal Cancer Study 2002. Part B: The ACPGBI Colorectal Cancer Model. A1 - PP Tekkis A1 - JD Poloniecki A1 - MR Thompson A1 - JD Stamatakis Y1 - 2003/06// PB - CPL Assocaites CY - London N2 - - ER - TY - BOOK T1 - The ACPGBI Colorectal Cancer Study 2002. Part A: Unadjusted outcomes. A1 - PP Tekkis A1 - JD Poloniecki A1 - MR Thompson A1 - JD Stamatakis Y1 - 2002/06// PB - CPL Associates CY - 2002 N2 - - ER - TY - CHAP T1 - Hands-on Robotic Unicompartmental Knee Replacement A1 - J Cobb ED - James B Stiehl, Werner H Konermann, Rolf G Haaker anthony M DiGioia lll T2 - Navigation and MIS Y1 - 2007/// VL - First M2 - 1 PB - Springer CY - Germany SP - 284 EP - 296 N2 - - ER - TY - CHAP T1 - The malignant colon polyp. A1 - PP Tekkis A1 - JMA Northover ED - VP Khatri T2 - In Clinical scenarios of surgical oncology. Y1 - 2006/// PB - Lippincott, Williams & Wilkins N2 - - ER - TY - CHAP T1 - Sarcomas of Bone and Soft Tissue A1 - Cobb, J P ED - Kevin G. Burnand, Young Anthony E., Jonathan D. Lucas T2 - The New Aird's Companion in Surgical Studies Y1 - 2005/06/09/ VL - 3rd PB - Churchill Livingstone CY - London SN - 0443072116 N2 - - ER - TY - CHAP T1 - Subspecialization and the management of emergencies. A1 - O Aziz A1 - PP Tekkis ED - RKS Phillips, S Clarke T2 - Frontiers in Colorectal Surgery Y1 - 2005/// N2 - - ER - TY - CHAP T1 - Technology in surgical education A1 - Kneebone R A1 - Bello F ED - Taylor I, Johnson C T2 - Recent Advances in Surgery Y1 - 2005/// M2 - 28 PB - Royal Society of Medicine Press Ltd CY - London SN - 1-85315-610-8 SP - 9 EP - 21 N2 - - ER - TY - CHAP T1 - Risk Adjustment in Colorectal Surgery. The role in hierarchical model in comparative clinical audit. A1 - PP Tekkis A1 - MR Thompson A1 - JD Stamatakis A1 - CG Marks ED - D Cunningham, C Topham, A Miles T2 - The Effective Management of Colorectal Cancer. Y1 - 2005/// PB - Aesculapius Medical Pres N2 - - ER - TY - CHAP T1 - Principles and practice of image-guided neurosurgery A1 - Aquilina K A1 - Edwards PJ A1 - Strong AJ ED - Anne J Moore, David W. Newell T2 - Springer Specialist Surgical Series: Neurosurgery Y1 - 2005/// SN - 1-85233-522-X N2 - - ER - TY - CHAP T1 - Ulcerative Colitis A1 - RJ Nicholls A1 - PP Tekkis ED - RKS Phillips T2 - A companion to specialist surgical practice. Colorectal Surgery Y1 - 2005/// VL - 3rd PB - Saunders N2 - - ER - TY - CHAP T1 - Colorectal Cancer follow up. A1 - S Purkayastha A1 - PP Tekkis ED - RKS Phillips, S Clarke Y1 - 2005/// N2 - - ER - TY - CHAP T1 - The Spleen A1 - Spalding, D R C A1 - Williamson, R C N ED - Henry & Thompson T2 - Clinical Surgery Y1 - 2004/// VL - 2 PB - Saunders N2 - - ER - TY - CHAP T1 - Chapter 51: Pediatric Oncology A1 - Tam PKH, Lin CL ED - Aljafri A Majid, Andrew N Kingnorth T2 - Surgical Practice Y1 - 2002/// PB - Greenwich Medical Media CY - UK SP - 807 EP - 820 N2 - - ER - TY - CHAP T1 - Chapter 50: Pediatric Trauma A1 - Tam PKH, Lin CL ED - Aljafri A Majid, Andrew N Kingsnorth T2 - Surgical Practice Y1 - 2002/// PB - Greebwich Medical Media CY - UK SP - 795 EP - 806 N2 - - ER - TY - CHAP T1 - Guiding therapeutic procedures A1 - Edwards PJ A1 - Hawkes DJ A1 - Penney GP A1 - Clarkson MJ ED - Jo Hajnal, David J Hawkes, Derek LG Hill T2 - Medical Image Registration Y1 - 2001/// PB - CRC Press N2 - - ER - TY - CHAP T1 - Chapter 2: Dendritic cells A1 - Austyn JM, Chao D, Lin CL, Roake JA, Suri RM ED - Dallman MJ and Lamb JR T2 - Handbooks in Practical Animal Cell Biology Y1 - 2000/// PB - Cambridge University Press CY - UK N2 - - ER - TY - CHAP T1 - The role of Chemokines in the regulation od dendritic cell chemotaxis and transendothelial migration in vivo A1 - Lin CL T2 - Oxford University Press Y1 - 1998/// N2 - - ER - TY - CONF T1 - Segmentation of cardiac MR and CT image sequences using model based registration of a 4D statistical model - art. no. 65121D A1 - Perperidis, D A1 - Mohiaddin, R A1 - Edwards, P A1 - Rueckert, D U1 - Medical Imaging 2007 Conference Y1 - 2007/// Y2 - // VL - 6512 SP - D5121 EP - D5121 N2 - - ER - TY - CONF T1 - The use of computer tomography (CT) to measure the accuracy of computer assisted knee arthroplasty A1 - Harris,S. A1 - Jakopec,M. A1 - Rodriguez y Baena,F. A1 - Davies,B. A1 - Barrett,A.R.W. A1 - Cobb,J.P. A1 - Gomes,P. A1 - Henckel,J. U1 - Computer Assisted Orthopaedic Surgery UK, 1st Annual Meeting of CAOSUK, 10 - 11 February 2006, London Heathrow, UK Y1 - 2006/// N2 - - ER - TY - CONF T1 - Results of a regulated clinical trial of the Acrobot Sculptor Hands-On Robotic System for unicompartmental knee arthroplasty A1 - Harris,S. A1 - Jakopec,M. A1 - Rodriguez y Baena,F. A1 - Davies,B. A1 - Barrett,A.R.W. A1 - Cobb,J.P. A1 - Gomes,P. A1 - Henckel,J. U1 - Computer Assisted Orthopaedic Surgery UK, 1st Annual Meeting of CAOSUK, 10 - 11 February 2006, London Heathrow, UK Y1 - 2006/// N2 - - ER - TY - CONF T1 - Very low dose computer tomography (CT) for planning and measuring outcome in computer assisted knee arthroplasty A1 - Harris,S. A1 - Jakopec,M. A1 - Rodriguez y Baena,F. A1 - Davies,B. A1 - Barrett,A.R.W. A1 - Cobb,J.P. A1 - Gomes,P. A1 - Henckel,J. U1 - Computer Assisted Orthopaedic Surgery UK, 1st Annual Meeting of CAOSUK, 10 - 11 February 2006, London Heathrow, UK Y1 - 2006/// N2 - - ER - TY - CONF T1 - Computer based planning for hip resurfacing surgery A1 - Harris,S. A1 - Jakopec,M. A1 - Rodriguez y Baena,F. A1 - Davies,B. A1 - Barrett,A.R.W. A1 - Cobb,J.P. A1 - Gomes,P. U1 - Computer Assisted Orthopaedic Surgery UK, 1st Annual Meeting of CAOSUK, 10 - 11 February 2006, London Heathrow, UK Y1 - 2006/// SP - 48 EP - 48 N2 - - ER - TY - CONF T1 - Minimally invasive computer assisted hip resurfaxcing surgery using the Acrobot navigation system A1 - Harris,S. A1 - Jakopec,M. A1 - Rodriguez y Baena,F. A1 - Davies,B. A1 - Barrett,A.R.W. A1 - Cobb,J.P. A1 - Gomes,P. U1 - Computer Assisted Orthopaedic Surgery UK, 1st Annual Meeting of CAOSUK, 10 - 11 February 2006, London Heathrow, UK Y1 - 2006/// SP - 32 EP - 32 N2 - - ER - TY - CONF T1 - Robot assistance improves outcomes in small incision unicompartmental knee arthroplasty (Article no.75) A1 - Cobb,J. A1 - Henckel,J. A1 - Richards,R.W. A1 - Harris,S. A1 - Jakopec,M. A1 - Rodriguez y Baena,F. A1 - Davies,B. U1 - American Academy of Orthopaedic Surgeons, 23 - 27 February 2005, Washington DC, USA Y1 - 2005/// N2 - - ER - TY - CONF T1 - The Tubes system for minimally invasive computer assisted hip resurfacing surgery, computer assisted orthopaedic surgery A1 - Cobb,J. A1 - Barrett,A.R.W. A1 - Harris,S. A1 - Jakopec,M. A1 - Rodriguez y Baena,F. A1 - Davies,B. U1 - Computer Assisted Orthopaedic Surgery, 5th International Annual Meeting of CAOS, 19 - 22 June 2005, Helsinki, Finland Y1 - 2005/// PB - Pro BUSINESS GmbH SP - 22 EP - 25 N2 - - ER - TY - CONF T1 - Robust registration in robotic assisted unicompartmental knee arthroplasty - the region-based point acquisition protocol A1 - Rodriguez y Baena,F. A1 - Cobb,J. A1 - Henckel,J. A1 - Barrett,A.R.W. A1 - Jakopec,M. A1 - Davies,B. U1 - Computer Assisted Orthopaedic Surgery, 5th International Annual Meeting of CAOS, 19 - 22 June 2005, Helsinki, Finland Y1 - 2005/// PB - Pro BUSINESS GmbH SP - 386 EP - 389 N2 - - ER - TY - CONF T1 - Validation of PET imaging by alignment to histology slices A1 - Edwards PJ A1 - Nijmeh AD A1 - McGurk M A1 - Odell E A1 - Fenlon MR A1 - Marsden PK A1 - Hawkes DJ A2 - James S. Duncan, Guido Gerig U1 - MICCAI AD - Palm Springs J1 - Lecture Notes in Computer Science Y1 - 2005/// Y2 - 2005/10/26/ VL - 3750 PB - Springer Verlag CY - Berlin Heidelberg SN - 0302-9743 SP - 968 EP - 975 N2 - - ER - TY - CONF T1 - Very low dose computer tomography (CT) based planning and outcome measurement in knee arthroplasty A1 - Cobb,J. A1 - Barrett,A.R.W. A1 - Harris,S. A1 - Henckel,J. A1 - Rodriguez y Baena,F. A1 - Davies,B. U1 - Computer Assisted Orthopaedic Surgery, 5th International Annual Meeting of CAOS, 19 - 22 June 2005, Helsinki, Finland Y1 - 2005/// PB - Pro BUSINESS GmbH SP - 162 EP - 164 N2 - - ER - TY - CONF T1 - Accuracy in arthroplasty - a three-dimensional CT based measurement study A1 - Cobb,J. A1 - Henckel,J. A1 - Harris,S. A1 - Jakopec,M. A1 - Rodriguez y Baena,F. A1 - Davies,B. U1 - Computer Assisted Orthopaedic Surgery, 5th International Annual Meeting of CAOS, 19 - 22 June 2005, Helsinki, Finland Y1 - 2005/// PB - Pro BUSINESS GmbH SP - 165 EP - 167 N2 - - ER - TY - CONF T1 - Computer assisted arthroplasty; Appropriate imaging for assessment of implant position A1 - Cobb,J. A1 - Henckel,J. A1 - Harris,S. A1 - Jakopec,M. A1 - Rodriguez y Baena,F. A1 - Davies,B. A1 - Barrett,A.R.W. U1 - Computer Assisted Orthopaedic Surgery, 4th Annual Meeting of CAOS International, 17 - 19 June 2004, Chicago, USA Y1 - 2004/// PB - CAOS SP - 281 EP - 282 N2 - - ER - TY - CONF T1 - Robotic surgery: are hands-on robots the future? A1 - Harris,S. A1 - Jakopec,M. A1 - Rodriguez y Baena,F. A1 - Davies,B. A1 - Barrett,A.R.W. A1 - Gomes,P. U1 - Mechatronics and Robotics, 13 - 15 September 2004, Aachen, Germany Y1 - 2004/// SP - 1441 EP - 1445 N2 - - ER - TY - CONF T1 - Robot assisted minimally invasive unicompartmental knee arthroplasty: results of first clinical trials A1 - Cobb,J. A1 - Henckel,J. A1 - Richards,R.W. A1 - Harris,S. A1 - Jakopec,M. A1 - Rodriguez y Baena,F. A1 - Davies,B. A1 - Gomes,P. U1 - Computer Assisted Orthopaedic Surgery, 4th Annual Meeting of CAOS International, 17 - 19 June 2004, Chicago, USA Y1 - 2004/// PB - CAOS SP - 4 EP - 6 N2 - - ER - TY - CONF T1 - An active constraint robot improves outcomes in total knee arthroplasty A1 - Cobb,J. A1 - Henckel,J. A1 - Gomes,P. A1 - Harris,S. A1 - Jakopec,M. A1 - Rodriguez y Baena,F. A1 - Davies,B. U1 - Computer Assisted Orthopaedic Surgery, 3rd International Annual Meeting of CAOS, 18 - 21 June 2003, Marbella, Spain Y1 - 2003/// PB - Springer CY - Marbella SP - 64 EP - 65 N2 - - ER - TY - CONF T1 - The use of X-ray computerized tomography to measure the accuracy of total knee arthroplasty A1 - Cobb,J. A1 - Henckel,J. A1 - Gomes,P. A1 - Harris,S. A1 - Jakopec,M. A1 - Rodriguez y Baena,F. A1 - Davies,B. A1 - Richards,R.W. U1 - Computer Assisted Orthopaedic Surgery, 3rd International Annual Meeting of CAOS, 18 - 21 June 2003, Marbella, Spain Y1 - 2003/// PB - Springer CY - Marbella SP - 142 EP - 143 N2 - - ER - TY - CONF T1 - Evolution of the next generation acrobot orthopaedic surgery robot, computer assisted orthopaedic surgery A1 - Cobb,J. A1 - Henckel,J. A1 - Gomes,P. A1 - Harris,S. A1 - Jakopec,M. A1 - Rodriguez y Baena,F. A1 - Davies,B. U1 - Computer Assisted Orthopaedic Surgery, 3rd International Annual Meeting of CAOS, 18 - 21 June 2003, Marbella, Spain Y1 - 2003/// PB - Springer CY - Marbella SP - 152 EP - 153 N2 - - ER - TY - CONF T1 - Fast and efficient registration for hands-on robotic assisted knee surgery A1 - Rodriguez y Baena,F. A1 - Cobb,J. A1 - Gomes,P. A1 - Harris,S. A1 - Jakopec,M. A1 - Davies,B. U1 - Computer Assisted Orthopaedic Surgery, 3rd International Annual Meeting of CAOS, 18 - 21 June 2003, Marbella, Spain Y1 - 2003/// PB - Springer CY - Marbella SP - 74 EP - 75 N2 - - ER - TY - CONF T1 - ROVIMAS: A software package for assessing surgical skills using the da Vinci telemanipulator system A1 - Dosis, A A1 - Bello, F A1 - Rockall, T A1 - Munz, Y A1 - Moorthy, K A1 - Martin, S A1 - Darzi, A U1 - 4th International Conference on Information Technology Applications in Biomedicine (ITAB 2003) Y1 - 2003/// Y2 - // SP - 326 EP - 329 N2 - - ER - TY - CONF T1 - A planning system for active constraint robot knee surgery A1 - Cobb,J. A1 - Gomes,P. A1 - Harris,S. A1 - Jakopec,M. A1 - Rodriguez y Baena,F. U1 - Computer Assisted Orthopaedic Surgery, 2nd International Annual Meeting of CAOS, 19 - 22 June 2002, Santa Fe, USA Y1 - 2002/// PB - Sweeney Convention Center SP - 252 EP - 253 N2 - - ER - TY - CONF T1 - Intraoperative user interface of a "hands-on" surgical robot A1 - Jakopec,M. A1 - Rodriguez y Baena,F. A1 - Jakopec,H. A1 - Harris,S.J. A1 - Gomes,M.P.S.F. A1 - Cobb,J. A1 - Davies,B.L. U1 - 2nd Annual conference CAOS, Santa Fe, June 2002 Y1 - 2002/// PB - Sweeney Convention Center CY - Santa Fe SP - 115 EP - 116 N2 - - ER - TY - CONF T1 - First clinical trials of a "hands-on" Active Constraint robot A1 - Cobb,J. A1 - Henckel,J. A1 - Harris,S.J. A1 - Jakopec,M. A1 - Rodriguez y Baena,F. A1 - Gomes,M.P.S.F. A1 - Davies,B.L. U1 - 2nd annual conference CAOS, Santa Fe June 2002 Y1 - 2002/// PB - Sweeney Convention Center CY - Santa Fe SP - 46 EP - 47 N2 - - ER - TY - JFULL T1 - Multidisciplinary Crisis Simulations: The Way Forward for Training Surgical Teams. A1 - Undre, S A1 - Koutantji, M A1 - Sevdalis, N A1 - Gautama, S A1 - Selvapatt, N A1 - Williams, S A1 - Sains, P A1 - McCulloch, P A1 - Darzi, A A1 - Vincent, C J1 - World J Surg Y1 - 2007/09// VL - 31 SN - 0364-2313 SP - 1843 EP - 1853 N2 - BACKGROUND: High-reliability organizations have stressed the importance of nontechnical skills for safety and of regularly providing such training to their teams. Recently safety skills training has been applied in the practice of medicine. In this study, we developed and piloted a module using multidisciplinary crisis scenarios in a simulated operating theatre to train entire surgical teams. METHODS: Twenty teams participated (n = 80); each consisted of a trainee surgeon, anesthetist, operating department practitioner (ODP), and scrub nurse. Crisis scenarios such as difficult intubation, hemorrhage, or cardiac arrest were simulated. Technical and nontechnical skills (leadership, communication, team skills, decision making, and vigilance), were assessed by clinical experts and by two psychologists using relevant technical and human factors rating scales. Participants received technical and nontechnical feedback, and the whole team received feedback on teamwork. RESULTS: Trainees assessed the training favorably. For technical skills there were no differences between surgical trainees' assessment scores and the assessment scores of the trainers. However, nurses overrated their technical skill. Regarding nontechnical skills, leadership and decision making were scored lower than the other three nontechnical skills (communication, team skills, and vigilance). Surgeons scored lower than nurses on communication and teamwork skills. Surgeons and anesthetists scored lower than nurses on leadership. CONCLUSIONS: Multidisciplinary simulation-based team training is feasible and well received by surgical teams. Nontechnical skills can be assessed alongside technical skills, and differences in performance indicate where there is a need for further training. Future work should focus on developing team performance measures for training and on the development and evaluation of systematic training for technical and nontechnical skills to enhance team performance and safety in surgery. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17610109&query_hl=1 ER - TY - JFULL T1 - Comparison of clinical and economic outcomes of two antibiotic prophylaxis regimens for sternal wound infection in high-risk patients following coronary artery bypass grafting surgery: a prospective randomised double-blind controlled trial. A1 - Dhadwal, K A1 - Al-Ruzzeh, S A1 - Athanasiou, T A1 - Choudhury, M A1 - Tekkis, P A1 - Vuddamalay, P A1 - Lyster, H A1 - Amrani, M A1 - George, S J1 - Heart Y1 - 2007/09// VL - 93 SN - 1468-201X SP - 1126 EP - 1133 N2 - OBJECTIVE: Prospective studies show a 10% incidence of sternal wound infection (SWI) after 90 days of follow-up, compared with infection rates of 5% reported by the National Nosocomial Infections Surveillance System after only 30 days of follow-up. This incidence increases 2-3 times in high-risk patients. DESIGN: Prospective randomised double-blind controlled clinical trial. SETTING: Cardiothoracic centre, UK. PATIENTS: Patients were eligible if they were undergoing median sternotomy for primary isolated coronary artery bypass grafting, with at least one internal thoracic artery used for coronary grafting and having one or more of the following three risk factors: (1) obesity, defined as body mass index 30 kg/m(2); (2) diabetes mellitus; or (3) bilateral internal thoracic artery grafts (ie, the use of the other internal thoracic artery). INTERVENTIONS: The study group received a single dose of gentamicin 2 mg/kg, rifampicin 600 mg and vancomycin 15 mg/kg, with three further doses of 7.5 mg/kg at 12-hour intervals. The control group received cefuroxime 1.5 g at induction and three further doses of 750 mg at 8-hour intervals. MAIN OUTCOME MEASURES: The primary end point was the incidence of SWI at 90 days. The secondary end point was the antibiotic and hospital costs. RESULTS: During the study period, 486 patients underwent isolated coronary artery bypass grafting with a 30-day SWI of 7.6%. 186 high-risk patients were recruited and analysed: 87 in the study group and 99 in the control group. 90-day SWI was significantly reduced in 8 patients in the study group (9.2%; 95% CI 3.5% to 15.3%) compared with 25 patients in the control group (25.2%; 95% CI 19.5% to 39.4%; p = 0.004). The study group had a significantly lower cost of antibiotics (21.2% reduction--US$96/patient; p<0.001), and a significantly lower hospital cost (20.4% reduction in cost--US$3800/patient; p = 0.04). CONCLUSIONS: Longer and broader-spectrum antibiotic prophylaxis significantly reduces the incidence of SWI in high-risk patients, with a significant economic benefit in costs of antibiotics as well as hospital costs. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17309908&query_hl=1 ER - TY - JFULL T1 - A Meta-Analysis Comparing Conventional End-to-End Anastomosis vs. Other Anastomotic Configurations After Resection in Crohn's Disease. A1 - Simillis, C A1 - Purkayastha, S A1 - Yamamoto, T A1 - Strong, SA A1 - Darzi, AW A1 - Tekkis, PP J1 - Dis Colon Rectum Y1 - 2007/08/08/ SN - 0012-3706 N2 - PURPOSE: This study compared outcomes between end-to-end anastomosis and other anastomotic configurations after intestinal resection for patients with Crohn's disease by using meta-analytical techniques. METHODS: Comparative studies published between 1992 and 2005 of end-to-end anastomosis vs. other anastomotic configurations were included. Using a random effects model, end points evaluated were short-term complications and perianastomotic recurrence of Crohn's disease. Heterogeneity was assessed and sensitivity analysis was performed to account for bias in patient selection. RESULTS: Eight studies (2 prospective, randomized, controlled trials; 1 nonrandomized, prospective; 5 nonrandomized, retrospective studies) reported on 661 patients who underwent 712 anastomoses, of which 383 (53.8 percent) were sutured end-to-end anastomosis and 329 (46.2 percent) were other anastomotic configurations (259 stapled side-to-side, 59 end-to-side or side-to-end, 11 stapled circular end-to-end). Anastomotic leak rate was significantly reduced in the other anastomotic configurations group (odds ratio (OR), 4.37; P = 0.02) and remained significantly lower in studies comparing only side-to-side anastomosis vs. end-to-end anastomosis (OR, 4.37; P = 0.02) and studies including only ileocolonic anastomosis (OR, 3.8; P = 0.05). Overall postoperative complications (OR, 2.64; P < 0.001), complications other than anastomotic leak (OR, 1.89; P = 0.04), and postoperative hospital stay (weighted mean difference, 2.81; P = 0.007) were significantly reduced in the side-to-side anastomosis group when considering studies comparing only side-to-side anastomosis vs. end-to-end anastomosis. There was no significant difference between the groups in perianastomotic recurrence and reoperation needed because of perianastomotic recurrence. CONCLUSIONS: End-to-end anastomosis after resection for Crohn's disease may be associated with increased anastomotic leak rates. Side-to-side anastomosis may lead to fewer anastomotic leaks and overall postoperative complications, a shorter hospital stay, and a perianastomotic recurrence rate comparable to end-to-end anastomosis. Further randomized, controlled trials should be performed for confirmation. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17682822&query_hl=1 ER - TY - JFULL T1 - Laparoscopic cholecystectomy versus mini-laparotomy cholecystectomy: a meta-analysis of randomised control trials. A1 - Purkayastha, S A1 - Tilney, HS A1 - Georgiou, P A1 - Athanasiou, T A1 - Tekkis, PP A1 - Darzi, AW J1 - Surg Endosc Y1 - 2007/08// VL - 21 SN - 1432-2218 SP - 1294 EP - 1300 N2 - AIMS: To use meta-analytic techniques to compare peri-operative and short term post-operative outcomes for patients undergoing cholecystectomy via the laparoscopic or mini-open approach. METHODS: Randomised control trials published between 1992 and 2005, cited in the literature of elective laparoscopic (LC) versus mini-open cholecystectomy (MoC) for symptomatic gallstone disease were included. End points evaluated were adverse events, operative and functional outcomes. A random effects meta-analytical model was used and between-study heterogeneity assessed. Subgroup analysis was performed to evaluate the difference in results for study size and quality and data reported from 2000. RESULTS: Nine randomised studies of 2032 patients were included in the analysis. There was considerable variation in the size and type of incision used for MoC in the studies. There was a significantly longer operating time for the LC group, by 14.14 minutes (95% CI 2.08, 26.19; p < 0.0001). Length of stay was reduced in the LC group by 0.37 days (95% CI -0.53, -0.21; p < 0.0001), with no significant heterogeneity for either outcome. For all other operative and post-operative outcomes, there was no significant difference between the two groups. CONCLUSION: MoC appeared to have similar outcomes compared to LC, however LC did reduce the length of hospital stay. MoC is a viable and safe option for healthcare providers without the financial resources for laparoscopic equipment and appropriately trained surgical teams. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17516122&query_hl=1 ER - TY - JFULL T1 - Using multimedia and Web3D to enhance anatomy teaching A1 - Brenton, H A1 - Hernandez, J A1 - Bello, F A1 - Strutton, P A1 - Purkayastha, S A1 - Firth, T A1 - Darzi, A J1 - COMPUT EDUC Y1 - 2007/08// VL - 49 SN - 0360-1315 SP - 32 EP - 53 N2 - Anatomy teaching is undergoing significant changes due to time constraints, limited availability of cadavers and technological developments in the areas of three-dimensional modelling and computer-assisted learning. This paper gives an overview of methods used to teach anatomy to undergraduate medical students and discusses the educational advantages and disadvantages of using three-dimensional computer models. A 'work in progress' account is then given of a project to develop two Web3D resources to enhance undergraduate tuition of the nervous system. Our approach is to support existing curricula using advanced modelling tools and a variety of delivery mechanisms.The first resource is a three-dimensional model of the adult brachial plexus: a network of nerves extending from the neck down to the shoulder, arm, hand, and fingers. This will be incorporated into existing didactic classroom teaching under the supervision of an anatomy teacher. The second resource is a piece of online courseware which will teach the embryological development of the brachial plexus. The delivery method will be the WebSET framework, a collaborative environment that allows a teacher to manipulate 3D models over the Web in real time whilst providing explanation and help to students. In this way the courseware can be used for both self-directed study and 'virtual anatomy demonstrations' within an online peer group. (c) 2005 Elsevier Ltd. All rights reserved. ER - TY - JFULL T1 - The effect of restorative proctocolectomy on sexual function, urinary function, fertility, pregnancy and delivery: a systematic review. A1 - Cornish, JA A1 - Tan, E A1 - Teare, J A1 - Teoh, TG A1 - Rai, R A1 - Darzi, AW A1 - Paraskevas, P A1 - Clark, SK A1 - Tekkis, PP J1 - Dis Colon Rectum Y1 - 2007/08// VL - 50 SN - 0012-3706 SP - 1128 EP - 1138 N2 - PURPOSE: This study was designed to evaluate the effect of restorative proctocolectomy on sexual function, urinary function, fertility, pregnancy, and delivery in patients with ulcerative colitis. METHODS: A systematic literature search was performed of articles published between 1980 and 2005 on patients undergoing restorative proctocolectomy for ulcerative colitis reporting data on the outcomes of interest. A random-effect, meta-analytical model was used for pooled estimates and 95 percent confidence intervals. RESULTS: A total of 22 studies, with 1,852 females, were included. Infertility rate was 12 percent before restorative proctocolectomy and 26 percent after, among 945 patients in seven studies. The incidence of sexual dysfunction was 8 percent preoperatively and 25 percent postoperatively (7 studies, n = 419). Two studies (n = 62) reported no urinary dysfunction in patients undergoing restorative proctocolectomy. There was an increased incidence of cesarean section after restorative proctocolectomy. During the third trimester of pregnancy, there was an increase in stool frequency by 1.15 stools per day compared with before pregnancy frequency (n = 49 95 percent confidence interval, 0.28-2.03 P = 0.01 chi-squared statistic, 0.04 P = 0.84). No significant differences were seen in pouch function after vaginal delivery (n = 456; weighted mean difference, 0.23; 95 percent confidence interval, 0.43-0.88; P = 0.49; chi-squared statistic, 1.29; P = 0.26). CONCLUSIONS: The incidence of dyspareunia increases after restorative proctocolectomy. There was a decrease in fertility after restorative proctocolectomy. Pregnancy after restorative proctocolectomy was not associated with an increase in complications. There was an increase in stool frequency and pad usage during the third trimester. Vaginal delivery is safe after restorative proctocolectomy. Pouch function after delivery returns to pregestational function within six months. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17588223&query_hl=1 ER - TY - JFULL T1 - Complexity, risk and simulation in learning procedural skills. A1 - Kneebone, RL A1 - Nestel, D A1 - Vincent, C A1 - Darzi, A J1 - Med Educ Y1 - 2007/08// VL - 41 SN - 0308-0110 SP - 808 EP - 814 N2 - BACKGROUND: A complex chain of events underpins every clinical intervention, especially those involving invasive procedures. Safety requires high levels of awareness and vigilance. In this paper we propose a structured approach to procedural training, mapping each learner's evolving experience within a matrix of clinical risk and procedural complexity. We use a traffic light analogy to conceptualize a dynamic awareness of prevailing risk and the implications of moving between zones. THE IMPORTANCE OF CONTEXT: We argue that clinical exposure can be consolidated by simulation where appropriate, ensuring that each learner gains the skills for safe care within the increasingly limited time available for training. To be effective, however, such simulation must be realistic, patient-focused, structured and grounded in an authentic clinical context. Challenge comes not only from technical difficulty but also from the need for interpersonal skills and professionalism within clinical encounters. PATIENT FOCUSED SIMULATION: Many existing simulations focus on crises, so clinicians are in a heightened state of expectation that may not reflect their usual practice. We argue that simulation should also reflect commonly occurring non-crisis situations, allowing clinicians to develop an awareness of the complex events that underpin clinical encounters. We describe a patient-focused approach to simulation, using simulated patients and inanimate models within realistic scenarios, to ground experience in authentic clinical practice and bring together the complex elements that underpin clinical events. APPLICATIONS: Although our argument has evolved from surgical practice and operating theatre teams, we believe it can be widely applied to the increasing number of health care professionals who perform clinical interventions. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17661889&query_hl=1 ER - TY - JFULL T1 - What is the Role of Leukocyte Depletion in Cardiac Surgery? A1 - Warren, O A1 - Darzi, A A1 - Athanasiou, T J1 - Heart Lung Circ Y1 - 2007/07/27/ SN - 1443-9506 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17660043&query_hl=1 ER - TY - JFULL T1 - Development of force measurement system for clinical use in minimal access surgery. A1 - Hanna, GB A1 - Drew, T A1 - Arnold, G A1 - Fakhry, M A1 - Cuschieri, A J1 - Surg Endosc Y1 - 2007/07/11/ SN - 1432-2218 N2 - BACKGROUND: Analysis of force in minimal access surgery (MAS) is important for instrument design, surgical simulators, and in the understanding of tissue trauma incurred during surgery. The aim of this study is to develop a force measuring system for use with different instruments in clinical practice. METHODS: Strain gauges were connected to both arms of a standard -5 mm interchangeable forceps handle. A rotational sensor was used to indicate the relative position of the handle arms, and consequently the jaws' position. A generic force-direction assembly was manufactured to determine the force direction at the port site. Interface electronics included signal conditioning and patient isolation circuits. Dedicated software was used for data acquisition, display, and analysis. To test their performance after sterilization, repeated force measures were obtained with the instruments after 10 cycles of autoclaving. Graduated weights were used to calibrate the strain gauges and a spring balance was employed to calibrate the force applied at the instrument tip. Calibration tests were also carried out to determine the effect of mounting the force direction assembly onto the access port. RESULTS: Gripping, dissecting, pushing, and pulling forces, along with the vector sum of forces acting at the port site, were synchronously displayed with the operative video record. Repeated autoclaving caused no deterioration in force sensing or signal transmission. The accuracy of the strain gauge readings was +/-0.05 V for the jaw force and +/-0.1 V for the force at the access port. The additional force created by the force direction assembly force was 7% of the port force alone. CONCLUSION: Force measurement system has been developed for clinical use. The system measures the gripping, dissecting, pulling and pushing forces as well as the force vector at port site. It also determines the position of instrument's jaws. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17623237&query_hl=1 ER - TY - JFULL T1 - Does systemic leukocyte filtration affect perioperative hemorrhage in cardiac surgery? A systematic review and meta-analysis. A1 - Warren, O A1 - Wallace, S A1 - Massey, R A1 - Tunnicliffe, C A1 - Alexiou, C A1 - Powell, J A1 - Meisuria, N A1 - Darzi, A A1 - Athanasiou, T J1 - ASAIO J Y1 - 2007/07// VL - 53 SN - 1538-943X SP - 514 EP - 521 N2 - Cardiopulmonary bypass causes a systemic inflammatory reaction. Activation of leukocytes is an important part of this process, and is known to directly contribute to the development of postoperative coagulopathy, and thus hemorrhage. The removal of leukocytes from the cardiopulmonary bypass circulation, using specialized filters, has been proposed as one method for attenuating this inflammatory response. However, there is no consensus on its effectiveness. We used meta-analytical techniques to systematically assess the literature reporting on the potential effect of systemic leukofiltration on perioperative hemorrhage. Random effects modeling was used to calculate overall estimate, and heterogeneity was assessed. Systemic leukofiltration made no significant impact on chest tube drainage in the first 24 hours (weighted mean difference [WMD], x23.9 ml; 95% confidence interval [CI], x95.48-47.61; p = 0.51) or on the total packed red cell transfusion requirements of each patient (WMD, 7.84 ml; 95% CI, x80.13-95.81; p = 0.86). The studies performed in this area thus far are highly heterogeneous, due in part to relatively poor-quality design and inadequate matching of their study groups. Although further high-quality trials on systemic leukofiltration may be appropriate, other strategies to reduce the coagulopathy associated with cardiopulmonary bypass should be sought and evaluated. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17667241&query_hl=1 ER - TY - JFULL T1 - A Meta-Analysis of Quality of Life for Abdominoperineal Excision of Rectum versus Anterior Resection for Rectal Cancer. A1 - Cornish, JA A1 - Tilney, HS A1 - Heriot, AG A1 - Lavery, IC A1 - Fazio, VW A1 - Tekkis, PP J1 - Ann Surg Oncol Y1 - 2007/07// VL - 14 SN - 1068-9265 SP - 2056 EP - 2068 N2 - BACKGROUND: Avoiding a permanent stoma following rectal cancer excision is believed to improve quality of life (QoL), but evidence from comparative studies is contradictory. The aim of this study was to compare QoL following abdominoperineal excision of rectum (APER) with that after anterior resection (AR) in patients with rectal cancer. METHODS: A literature search was performed to identify studies published between 1966 and 2006 comparing values of QoL following APER and AR. Random-effect meta-analysis was used to combine the data. Sensitivity analyses were performed for larger studies, those of higher quality and those using self-administered QoL questionnaires. RESULTS: The outcomes for 1,443 patients from 11 studies, of whom 486 (33%) underwent APER, were included. QoL assessments were made at periods of up to 2 years following surgery. There was no significant difference in global health scores between APER and AR. Vitality (WMD -9.82; 95% CI -27.01, -2.04, P = 0.01) and sexual function (WMD -2.73; 95% CI -4.93, -0.64, P = 0.01) were improved in the AR patients. Patients with low AR had improved physical function scores in comparison with APER patients (WMD -4.67; 95% CI -9.10, -0.23; P = 0.004). Cognitive (WMD 3.57; 95% CI 1.41, 5.73; P < 0.001) and emotional function scores (WMD 3.51; 95% CI 1.40, 5.62; P < 0.001) were higher for APER patients. CONCLUSION: Overall, when comparing APER with AR, we identified no differences in general QoL following the procedures. Individualisation of care for rectal cancer patients is essential, but a policy of avoidance of APER cannot currently be justified on the grounds of QoL alone. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17431723&query_hl=1 ER - TY - JFULL T1 - The impact of technical factors on outcome of restorative proctocolectomy for familial adenomatous polyposis. A1 - von Roon, AC A1 - Tekkis, PP A1 - Clark, SK A1 - Heriot, AG A1 - Lovegrove, RE A1 - Truvolo, S A1 - Nicholls, RJ A1 - Phillips, RK J1 - Dis Colon Rectum Y1 - 2007/07// VL - 50 SN - 0012-3706 SP - 952 EP - 961 N2 - PURPOSE: This study was designed to assess the impact of technical factors on functional outcomes and complications in patients undergoing restorative proctocolectomy for familial adenomatous polyposis. METHODS: This was a descriptive study on 189 patients undergoing restorative proctocolectomy in a single tertiary referral center between 1977 and 2003. Primary outcomes were major complications, pouch function, and neoplastic transformation in the anal transitional zone. RESULTS: Pouch construction was J-reservoir (60 percent), W-reservoir (34 percent), or S-reservoir (6 percent), with double-stapled (31 percent) or handsewn anastomosis with mucosectomy (69 percent). Overall pouch survival was 96 percent at five years and 89 percent at ten years, with no differences according to pouch design or anastomotic technique. The incidence of pelvic sepsis was unaffected by anastomotic technique (stapled vs. handsewn; 12 vs. 13 percent) or type of reservoir (J- vs. W- vs. S-pouch; 16 vs. 9 vs. 10 percent). Fistula formation was independent of anastomotic technique (stapled vs. handsewn; 8 vs. 8 percent) and type of reservoir (J- vs. W- vs. S-pouch; 9 vs. 7 vs. 0 percent). The night-time and 24-hour bowel frequencies were similar with the two anastomotic techniques and types of reservoirs. The incidence of polyps at the anal transitional zone was lower with handsewn than with stapled anastomosis (19 vs. 38 percent; P=0.047). CONCLUSIONS: Restorative proctocolectomy in patients with familial adenomatous polyposis has good functional outcomes and an acceptable rate of complications, which are independent of choice of technique. Handsewn ileoanal anastomosis with mucosectomy seems to reduce the incidence of subsequent neoplasia in the anal transitional zone but does not eliminate the risk of cancer. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17464542&query_hl=1 ER - TY - JFULL T1 - Observational teamwork assessment for surgery (OTAS): refinement and application in urological surgery. A1 - Undre, S A1 - Sevdalis, N A1 - Healey, AN A1 - Darzi, A A1 - Vincent, CA J1 - World J Surg Y1 - 2007/07// VL - 31 SN - 0364-2313 SP - 1373 EP - 1381 N2 - BACKGROUND: Teamwork in surgical teams is at the forefront of good practice guidelines and empirical research as an important aspect of safe surgery. We have developed a comprehensive assessment for teamwork in surgery-the Observational Teamwork Assessment for Surgery (OTAS)-and we have tested it for general surgical procedures. The aim of the research reported here was to extend the assessment to urology procedures. METHODS: After refining the original assessment, we used it to observe 50 urology procedures. The OTAS comprises a procedural task checklist that assesses patient, equipment/provisions, and communication tasks as well as ratings on five team behavior constructs (communication, cooperation, coordination, leadership, and monitoring). Teamwork was assessed separately in the surgical, anesthesia, and nursing subteams in the operating theater. We also assessed the reliability of the behavioral scoring. RESULTS: Regarding task completion, a number of communication and equipment/provisions tasks were not routinely performed during the operations we observed. Regarding teamwork-related behaviors, adequate reliability was obtained in the scoring of behaviors. Anesthetists and nurses obtained their lowest scores on communication. Surgeons' scores revealed a more complex pattern. In addition to low scores on communication, surgeons' teamwork behaviors appeared to deteriorate as the procedures were finishing. CONCLUSIONS: Our findings suggest that OTAS is applicable to various branches of surgery. Separate assessment of the subteams in the operating theater provides useful information that can be used to build targeted teamwork training aiming to improve surgical patients' safety and outcomes. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17487527&query_hl=1 ER - TY - JFULL T1 - Apoptosis and chemo-resistance in colorectal cancer. A1 - Prabhudesai, SG A1 - Rekhraj, S A1 - Roberts, G A1 - Darzi, AW A1 - Ziprin, P J1 - J Surg Oncol Y1 - 2007/07/01/ VL - 96 SN - 0022-4790 SP - 77 EP - 88 N2 - Systemic chemotherapy plays an integral part in treating advanced colorectal cancer. However 50% of patients respond poorly or have disease progression due to resistance to chemotherapeutic agents. This article reviews the pathways that regulate apoptosis, apoptotic mechanisms through which chemotherapeutic agents mediate their effect and how deregulation of apoptotic proteins may contribute to chemo-resistance. Also discussed are potential therapeutic strategies designed to target these proteins and thereby improve response rates to chemotherapy in colorectal cancer. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17443738&query_hl=1 ER - TY - JFULL T1 - Laparoscopic colorectal surgery and postoperative opioid requirements. A1 - Tilney, HS A1 - Tekkis, PP J1 - Surg Endosc Y1 - 2007/07// VL - 21 SN - 1432-2218 SP - 1251 EP - 1251 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17436121&query_hl=1 ER - TY - JFULL T1 - Antioxidant Properties of the Internal Thoracic Artery and the Radial Artery. A1 - Mangoush, O A1 - Athanasiou, T A1 - Nakamura, K A1 - Johnson, P A1 - Smoienski, R A1 - Sarathchandra, P A1 - Oury, T A1 - Chester, AH A1 - Amrani, M J1 - Heart Lung Circ Y1 - 2007/06/29/ SN - 1443-9506 N2 - BACKGROUND: The antioxidant properties of blood vessels contribute to their performance and patency of that vessel when used as a bypass conduit. Despite increased use of the radial artery (RA) in recent years, very little is known about its antioxidant properties. We compared the ability of the RA to generate superoxide and assessed its antioxidant protective capacity with that of the internal thoracic artery (ITA). METHODS: Vascular segments of the ITA and the RA were obtained from patients undergoing coronary artery bypass grafting (CABG) incubated in culture media for 2, 24, 48 and 72 hours. The amount of superoxide generated by each artery, and the deterioration of the endothelial function were assessed by using chemiluminescence (CL) and organ bath techniques. We also assessed the expression, localisation and the activity of superoxide dismutase (SOD) in both arteries; using reverse transcription-polymerase chain reaction (RT-PCR), immunolocalisation techniques and standard biochemical assessment of SOD activity. RESULTS: Under stress, the RA generated more superoxide (133.6+/-54.7 at 72h vs. 16.8+/-6.4 at 2h; P<0.01) and its endothelial function deteriorated faster (56.3+/-7.3 at 72h vs. 20.2+/-1.5 at 2h; P<0.0001) than that of ITA. Cu/Zn-SOD was found to be prevalent in the endothelium, while Ec-SOD was distributed evenly in the endothelium and media of both arteries. The activity of SOD was less in the RA compared with that of the ITA (510.2+/-219.8 vs. 808.6+/-343.7, respectively; P=0.03). CONCLUSIONS: Our study shows that the RA is less equipped with an antioxidant protective mechanism compared with the ITA. These findings could partially explain the differential clinical performance of these conduits in CABG. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17604222&query_hl=1 ER - TY - JFULL T1 - Heparin-bonded circuits versus nonheparin-bonded circuits: an evaluation of their effect on clinical outcomes. A1 - Mangoush, O A1 - Purkayastha, S A1 - Haj-Yahia, S A1 - Kinross, J A1 - Hayward, M A1 - Bartolozzi, F A1 - Darzi, A A1 - Athanasiou, T J1 - Eur J Cardiothorac Surg Y1 - 2007/06// VL - 31 SN - 1010-7940 SP - 1058 EP - 1069 N2 - Heparinization of the blood contact surface in cardiopulmonary bypass circuits has been promoted as an important step in the development of open heart surgery. As it decreases the inflammatory response resulting from the extracorporeal circulation, it may have a positive effect on clinical outcomes. This meta-analysis was carried out to examine if heparin-bonded circuits (HBCs) reduce the need for blood products and improve overall clinical outcome. A systematic literature search was performed to identify randomized controlled trials reporting outcomes of HBCs compared with non-HBCs. Primary outcomes assessed were postoperative blood/blood-product transfusion and blood loss. Secondary outcomes included all-cause mortality, acute postoperative myocardial infarction, stroke, re-sternotomy for postoperative bleeding, wound infection, atrial fibrillation, duration of ventilation, intensive care unit (ICU) and hospital-length of stay (LOS). Random effects meta-analytical techniques were applied to identify differences in outcomes between the two groups. Quality of the included studies and heterogeneity were assessed. From an initial review of 762-published studies, 41-randomized trials fulfilled the inclusion criteria, leaving 3434-patients' data for analysis. HBCs significantly decreased the incidence of blood transfusion required (OR=0.8; 95% CI=0.6:0.9, P=0.004). It also significantly decreased re-sternotomy (OR=0.6; 95% CI=0.4:0.8, P=0.002), duration of ventilation (WMD= -1.3h; 95% CI= -1.9:-0.6, P<0.001), ICU-LOS (WMD= -9.3h; 95% CI=-14.7:-3.9, P<0.001) and hospital-LOS (WMD= -0.5 day; 95% CI= -0.9:-0.1, P=0.02). HBCs had no effect on other adverse events evaluated. Although HBCs showed a positive effect on some of the clinical outcomes, we identified only marginal differences for other outcomes. Further evaluation of the cost-effectiveness of this technology is required. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17306555&query_hl=1 ER - TY - JFULL T1 - A pervasive body sensor network for measuring postoperative recovery at home. A1 - Aziz, O A1 - Atallah, L A1 - Lo, B A1 - Elhelw, M A1 - Wang, L A1 - Yang, GZ A1 - Darzi, A J1 - Surg Innov Y1 - 2007/06// VL - 14 SN - 1553-3506 SP - 83 EP - 90 N2 - Patients going home following major surgery are susceptible to complications such as wound infection, abscess formation, malnutrition, poor analgesia, and depression, all of which can develop after the fifth postoperative day and slow recovery. Although current hospital recovery monitoring systems are effective during perioperative and early postoperative periods, they cannot be used when the patient is at home. Measuring and quantifying home recovery is currently a subjective and labor-intensive process. This case report highlights the development and piloting of a wireless body sensor network to monitor postoperative recovery at home in patients undergoing abdominal surgery. The device consists of wearable sensors (vital signs, motion) combined with miniaturized computers wirelessly linked to each other, thus allowing continuous monitoring of patients in a pervasive (unobtrusive) manner in any environment. Initial pilot work with results in both the simulated (with volunteers) and the real home environment (with patients) is presented. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17558012&query_hl=1 ER - TY - JFULL T1 - Perioperative synbiotic treatment to prevent postoperative infectious complications in biliary cancer surgery: a randomized control trial. A1 - Kinross, J A1 - Warren, O A1 - Silk, D A1 - Darzi, A J1 - Ann Surg Y1 - 2007/06// VL - 245 SN - 0003-4932 SP - 1000 EP - 1000 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17522529&query_hl=1 ER - TY - JFULL T1 - Mental training in surgical education: a randomized controlled trial. A1 - Aggarwal, R A1 - Warren, O A1 - Darzi, A J1 - Ann Surg Y1 - 2007/06// VL - 245 SN - 0003-4932 SP - 1002 EP - 1002 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17522530&query_hl=1 ER - TY - JFULL T1 - An evaluation of the feasibility, validity, and reliability of laparoscopic skills assessment in the operating room. A1 - Aggarwal, R A1 - Grantcharov, T A1 - Moorthy, K A1 - Milland, T A1 - Papasavas, P A1 - Dosis, A A1 - Bello, F A1 - Darzi, A J1 - Ann Surg Y1 - 2007/06// VL - 245 SN - 0003-4932 SP - 992 EP - 999 N2 - OBJECTIVE: To assess the use of a synchronized video-based motion tracking device for objective, instant, and automated assessment of laparoscopic skill in the operating room. SUMMARY BACKGROUND DATA: The assessment of technical skills is fundamental to recognition of proficient surgical practice. It is necessary to demonstrate the validity, reliability, and feasibility of any tool to be applied for objective measurement of performance. METHODS: Nineteen subjects, divided into 13 experienced (performed >100 laparoscopic cholecystectomies) and 6 inexperienced (performed <10 LCs) surgeons completed LCs on 53 patients who all had a diagnosis of biliary colic. Each procedure was recorded with the ROVIMAS video-based motion tracking device to provide an objective measure of the surgeon's dexterity. Each video was also rated by 2 experienced observers on a previously validated operative assessment scale. RESULTS: There were significant differences for motion tracking parameters between the 2 groups of surgeons for the Calot triangle dissection part of procedure for time taken (P = 0.002), total path length (P = 0.026), and number of movements (P = 0.005). Both motion tracking and video-based assessment displayed intertest reliability, and there were good correlations between the 2 modes of assessment (r = 0.4 to 0.7, P < 0.01). CONCLUSIONS: An instant, objective, valid, and reliable mode of assessment of laparoscopic performance in the operating room has been defined. This may serve to reduce the time taken for technical skills assessment, and subsequently lead to accurate and efficient audit and credentialing of surgeons for independent practice. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17522527&query_hl=1 ER - TY - JFULL T1 - Curriculum-based solo virtual reality training for laparoscopic intracorporeal knot tying: objective assessment of the transfer of skill from virtual reality to reality A1 - Munz, Y A1 - Almoudaris, AM A1 - Moorthy, K A1 - Dosis, A A1 - Liddle, AD A1 - Darzi, AW J1 - AM J SURG Y1 - 2007/06// VL - 193 SN - 0002-9610 SP - 774 EP - 783 N2 - Background: Very few studies have addressed the transferability of skills from virtual reality (VR) to real life. The aim of this study was to assess the feasibility and effectiveness of teaching intracorporeal knot tying (ICKT) by VR simulation only.Methods: Twenty novices underwent structured training of basic skills training on the Minimally Invasive Surgical Trainer simulator (Mentice AB, Gothenburg, Sweden) followed by knot tying training on the LapSim simulator (Surgical Science, Gothenburg, Sweden). They were assessed pre- and post-training on a video trainer. Assessment of performance included motion tracking and video-based checklist. Nonparametric statistical analysis was used, and P <.05 was deemed significant.Results: All participants completed a correct knot as compared with only 25% before VR training. Time to completion was 66% faster and knot quality 45% better after VR training. Significant reduction in number of movements (P = .006) and distance trave led (P < .000) by both hands after VR training.Conclusions: Teaching ICKT by VR simulators only is feasible and effective. Furthermore, this study highlights the complementary use of different VR simulators within a structured curriculum. (C) 2007 Published by Excerpta Medica Inc. ER - TY - JFULL T1 - The risk of cancer in patients with Crohn's disease. A1 - von Roon, AC A1 - Reese, G A1 - Teare, J A1 - Constantinides, V A1 - Darzi, AW A1 - Tekkis, PP J1 - Dis Colon Rectum Y1 - 2007/06// VL - 50 SN - 0012-3706 SP - 839 EP - 855 N2 - PURPOSE: The risk of cancer in patients with Crohn's disease is not well defined. Using meta-analytical techniques, the present study was designed to quantify the risk of intestinal, extraintestinal, and hemopoietic malignancies in such patients. METHODS: A literature search identified 34 studies of 60,122 patients with Crohn's disease. The incidence and relative risk of cancer were calculated for patients with Crohn's disease and compared with the baseline population of patients without Crohn's disease. Overall pooled estimates, with 95 percent confidence intervals, were obtained, using a random-effects model. RESULTS: The relative risk of small bowel, colorectal, extraintestinal cancer, and lymphoma compared with the baseline population was 28.4 (95 percent confidence interval, 14.46-55.66), 2.4 (95 percent confidence interval, 1.56-4.36), 1.27 (95 percent confidence interval, 1.1-1.47), and 1.42 (95 percent confidence interval, 1.16-1.73), respectively. On subgroup analysis, patients with Crohn's disease had an increased risk of colon cancer (relative risk, 2.59; 95 percent confidence interval, 1.54-4.36) but not of rectal cancer (relative risk, 1.46; 95 percent confidence interval, 0.8-2.55). There was significant association between the anatomic location of the diseased bowel and the risk of cancer in that segment. The risk of small bowel cancer and colorectal cancer was found to be higher in North America and the United Kingdom than in Scandinavian countries with no evidence of temporal changes in the cancer incidence. CONCLUSIONS: The present meta-analysis demonstrated an increased risk of small bowel, colon, extraintestinal cancers, and lymphoma in patients with Crohn's disease. Patients with extensive colonic disease that has been present from a young age should be candidates for endoscopic surveillance; however, further data are required to evaluate the risk of neoplasia over time. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17308939&query_hl=1 ER - TY - JFULL T1 - A meta-analysis on the influence of inflammatory bowel disease on pregnancy. A1 - Cornish, J A1 - Tan, E A1 - Teare, J A1 - Teoh, TG A1 - Rai, R A1 - Clark, SK A1 - Tekkis, PP J1 - Gut Y1 - 2007/06// VL - 56 SN - 0017-5749 SP - 830 EP - 837 N2 - BACKGROUND: Inflammatory bowel disease (IBD) has a typical onset during the peak reproductive years. Evidence of the risk of adverse pregnancy outcomes in IBD is important for the management of pregnancy to assist in its management. AIM: To provide a clear assessment of risk of adverse outcomes during pregnancy in women with IBD. DESIGN: The Medline literature was searched to identify studies reporting outcomes of pregnancy in patients with IBD. Random-effect meta-analysis was used to compare outcomes between women with IBD and normal controls. Patients and SETTING: A total of 3907 patients with IBD (Crohn's disease 1952 (63%), ulcerative colitis 1113 (36%)) and 320 531 controls were reported in 12 studies that satisfied the inclusion criteria. RESULTS: For women with IBD, there was a 1.87-fold increase in incidence of prematurity (<37 weeks gestation; 95% CI 1.52 to 2.31; p<0.001) compared with controls. The incidence of low birth weight (<2500 g) was over twice that of normal controls (95% CI 1.38 to 3.19; p<0.001). Women with IBD were 1.5 times more likely to undergo caesarean section (95% CI 1.26 to 1.79; p<0.001), and the risk of congenital abnormalities was found to be 2.37-fold increased (95% CI 1.47 to 3.82; p<0.001). CONCLUSION: The study has shown a higher incidence of adverse pregnancy outcomes in patients with IBD. Further studies are required to clarify which women are at higher risk, as this was not determined in the present study. This has an effect on the management of patients with IBD during pregnancy, who should be treated as a potentially high-risk group. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17185356&query_hl=1 ER - TY - JFULL T1 - Diagnostic precision of magnetic resonance imaging for preoperative prediction of the circumferential margin involvement in patients with rectal cancer. A1 - Purkayastha, S A1 - Tekkis, PP A1 - Athanasiou, T A1 - Tilney, HS A1 - Darzi, AW A1 - Heriot, AG J1 - Colorectal Dis Y1 - 2007/06// VL - 9 SN - 1462-8910 SP - 402 EP - 411 N2 - OBJECTIVE: Circumferential margin involvement (CMI) is an important prognostic indicator for patients with rectal cancer. This meta-analysis aims at evaluating the diagnostic precision of magnetic resonance imaging (MRI) for the preoperative evaluation of CMI in patients with rectal cancer. METHOD: Quantitative meta-analysis was performed comparing MRI against histology after total mesorectal excision. Sensitivity, specificity and diagnostic odds ratio (DOR) were calculated for each study. Summary receiver operating characteristic (SROC) curves and subgroup analysis were undertaken. Study quality and heterogeneity were evaluated. Meta-regression meta-analysis was used to evaluate the significance of the difference in relative DORs. RESULTS: Nine studies evaluating 529 patients were included. Pooled results showed an overall sensitivity and specificity for MRI detecting CMI preoperatively of 94% and 85% respectively. The SROC analysis demonstrated an overall weighted area under the curve (AUC) of 0.92 (DOR 57.21, 95% CI 18.21-179.77), without significant heterogeneity between the studies (Q-value 14.66, P = 0.06). Good study quality further increased the sensitivity and specificity of MRI. The use of a 1.5 Tesla coil, a phased array coil and the inclusion of two interpreters also resulted in high preoperative diagnostic precision. Meta-regression meta-analysis showed a significant difference in the DOR for studies published in or since 2003 (P = 0.019). CONCLUSION: Magnetic resonance imaging can accurately predict CMI preoperatively for rectal cancer in single units and this is reproducible across different centres. This strategy has important implications for selection of patients for adjuvant therapy prior to surgery. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17504336&query_hl=1 ER - TY - JFULL T1 - Influence of instrument size on endoscopic task performance in pediatric intracorporeal knot tying : Smaller instruments are better in infants. A1 - Lee, AC A1 - Haddad, MJ A1 - Hanna, GB J1 - Surg Endosc Y1 - 2007/05/22/ SN - 1432-2218 N2 - BACKGROUND: The widespread availability of adult minimal access surgical (MAS) equipment together with resource constraints have led pediatric surgeons to adopt the adult setup. This study examined the influence of instrument size on task outcome and physical impact on the surgeon in pediatric endoscopic intracorporeal knot tying. METHODS: Sixteen surgeons participated in this study in which they had to tie surgeon's knots inside a neonatal simulator box with an endoscopic field of 40 mm. All surgeons tied 20 knots using paired pediatric needle-holders and 20 knots using paired adult needle-holders in a randomized order. Knot quality score (KQS) and wrap length were used as indices of knot quality and wrap tightness. Electromyographic (EMG) recordings of the upper limb muscle groups were used to indicate muscular recruitment. A questionnaire on discomfort and instrument preference was also completed by the surgeons. RESULTS: A total of 640 knots were analyzed. Median time was shorter for pediatric needle-holders than for adult needle-holders (94 s vs. 103 s; p < 0.001); however, KQS (0.271 vs. 0.260; p = 0.509) and the tightness around the tube (86 mm vs. 86 mm; p = 0.255) were not significantly different. The proportion of knots that completely slipped was also similar for both needle-holders (19% vs. 22%; p = 0.322). The normalized EMG values when using adult needle-holders were significantly higher than when using pediatric needle-holders in all upper limb muscle groups with the exception of left forearm extensors (p = 0.460). The surgeons reported less discomfort with the pediatric needle-holders in the right forearm and hand, and 13 surgeons expressed overall preference for the smaller instruments. CONCLUSION: Endoscopic knot tying was performed faster in the neonatal simulator box using pediatric needle-holders while maintaining knot quality. Upper limb muscular recruitment was reduced resulting in less discomfort for the surgeon. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17516118&query_hl=1 ER - TY - JFULL T1 - Outcome of kidney transplantation from nonheart-beating versus heart-beating cadaveric donors. A1 - Kokkinos, C A1 - Antcliffe, D A1 - Nanidis, T A1 - Darzi, AW A1 - Tekkis, P A1 - Papalois, V J1 - Transplantation Y1 - 2007/05/15/ VL - 83 SN - 0041-1337 SP - 1193 EP - 1199 N2 - BACKGROUND: This study aimed to assess outcomes of kidney transplants from nonheart-beating (NHB) compared with heart-beating (HB) cadaveric donors with meta-analytical techniques. METHODS: A literature search was performed for studies comparing kidney transplants from NHB vs. HB cadaveric donors between 1992 and 2005. The following outcomes were evaluated: warm and cold ischemia times, primary nonfunction, delayed graft function, length of hospital stay, acute graft rejection, patient and graft survival, and post-transplant serum creatinine. RESULTS: Eighteen comparative studies of 114,081 patients matched the selection criteria; 1,858 received kidney from NHB and 112,223 from HB donor. Warm ischemia time was significantly longer for the NHB group by 24 min (P<0.001). Cold ischemia time was similar for the two groups (P=0.97). The incidence of primary nonfunction and delayed graft function was 2.4 times (P<0.001) and 3.6 times (P<0.001) greater, respectively, in the NHB group. Length of hospital stay was longer for the NHB group by 4.6 days (P<0.001). The 6-month, 2-year, and 5-year patient survival were similar between the two groups. The incidence of acute rejection was similar between the two groups whereas the initial graft survival advantage in favor of the HB group diminished gradually over the course of time. There was no statistically significant difference between the two groups for the recipient serum creatinine levels at 3 and 12 months after transplantation. CONCLUSION: NHB donors carry the potential of expanding the cadaveric kidney pool. Although, transplants from NHB donors are associated with a greater incidence of early adverse events, long-term outcomes appear comparable with those of transplants from HB donors. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17496535&query_hl=1 ER - TY - JFULL T1 - Meta-analysis of short-term and long-term outcomes of J, W and S ileal reservoirs for restorative proctocolectomy. A1 - Lovegrove, RE A1 - Heriot, AG A1 - Constantinides, V A1 - Tilney, HS A1 - Darzi, AW A1 - Fazio, VW A1 - Nicholls, RJ A1 - Tekkis, PP J1 - Colorectal Dis Y1 - 2007/05// VL - 9 SN - 1462-8910 SP - 310 EP - 320 N2 - OBJECTIVE: The choice of ileal pouch reservoir has been a contentious subject with no consensus as to which technique provides better function. This study aimed to compare short- and long-term outcomes of three ileal reservoir designs. METHOD: Comparative studies published between 1985 and 2000 of J, W and S ileal pouch reservoirs were included. Meta-analytical techniques were employed to compare postoperative complications, pouch failure, and functional and physiological outcomes. Quality of life following surgery was also assessed. RESULTS: Eighteen studies, comprising 1519 patients (689 J pouch, 306 W pouch and 524 S pouch) were included. There was no significant difference in the incidence of early postoperative complications between the three groups. The frequency of defecation over 24 h favoured the use of either a W or S pouch [J vs S: weighted mean difference (WMD) 1.48, P < 0.001; J vs W: WMD 0.97, P = 0.01]. The S pouch was associated with an increased need for pouch intubation (S vs J: OR 6.19, P = 0.04). The use of a J pouch was associated with a significantly higher prevalence of use of anti-diarrhoeal medication (J vs S: OR 2.80, P = 0.01; J vs W: OR 3.55, P < 0.001). CONCLUSION: All three reservoirs had similar perioperative complication rates. The S pouch was associated with the need for anal intubation. There was less frequency and less need for antidiarrhoeal agents with the W rather than the J pouch. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17432982&query_hl=1 ER - TY - JFULL T1 - Comparison of outcomes following ileostomy versus colostomy for defunctioning colorectal anastomoses. A1 - Tilney, HS A1 - Sains, PS A1 - Lovegrove, RE A1 - Reese, GE A1 - Heriot, AG A1 - Tekkis, PP J1 - World J Surg Y1 - 2007/05// VL - 31 SN - 0364-2313 SP - 1142 EP - 1151 N2 - BACKGROUND: The present study evaluated outcomes of patients undergoing proximal diversion using either a loop ileostomy or loop colostomy following distal colorectal resection for malignant and non-malignant disease. METHODS: A literature search of the Medline, Ovid, Embase and Cochrane databases was performed to identify studies published between 1966 and 2006, comparing loop ileostomy and loop colostomy to protect a distal colorectal anastomosis. A random effect meta-analytical technique was used and sensitivity analysis performed on studies published since 2000, higher quality papers, those reporting on 70 or more patients, and those reporting outcomes following colorectal cancer resections. RESULTS: Seven studies, including three randomised controlled trials, satisfied the inclusion criteria. Outcomes of a total of 1,204 patients were analysed, of whom 719 (59.7%) underwent defunctioning loop ileostomy. High stoma output was more common following ileostomy formation (OR = 5.39, 95% CI: 1.11, 26.12, P = 0.04), but wound infections following their reversal were significantly fewer (OR = 0.21, 95% CI: 0.07, 0.62, P = 0.004). Overall complications were less frequent for ileostomy patients in the subgroup of high quality studies (OR = 0.22, 95% CI: 0.08, 0.59, P = 0.003). CONCLUSION: The results of this meta-analysis suggest that ileostomy may be preferable to colostomy when used to defunction a distal colorectal anastomosis. Wound infections following stoma reversal were reduced, as were overall stoma-related complications and incisional hernia following stoma reversal for ileostomy patients in high quality studies. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17354030&query_hl=1 ER - TY - JFULL T1 - Comparison of short-term outcomes of laparoscopic vs open approaches to ileal pouch surgery. A1 - Tilney, HS A1 - Lovegrove, RE A1 - Heriot, AG A1 - Purkayastha, S A1 - Constantinides, V A1 - Nicholls, RJ A1 - Tekkis, PP J1 - Int J Colorectal Dis Y1 - 2007/05// VL - 22 SN - 0179-1958 SP - 531 EP - 542 N2 - AIMS: The present meta-analysis compared short-term outcomes between patients undergoing laparoscopic and open restorative proctocolectomy. METHODS: A literature search of Medical Literature Analysis and Retrieval System Online, Ovid, Excerpta Medica and Cochrane databases was performed to identify studies published between 1990 and 2006 comparing laparoscopic and open restorative proctocolectomy. A random-effect meta-analytical technique was used, and sensitivity analysis was performed on studies published since 2001, higher-quality papers, those reporting on more than 30 patients and those with matching of patient characteristics. RESULTS: Ten studies satisfied the selection criteria, including outcomes on 329 patients, 168 (51.1%) of whom underwent laparoscopic resection. Operative time was significantly longer in the laparoscopic group by 86 min (p<0.001) and throughout the subgroup analysis, but this finding was associated with significant heterogeneity. Operative blood loss was less in the laparoscopic group by 84 ml. There was no significant difference in post-operative adverse events between the groups. A statistically significant reduction in length of post-operative stay was observed for laparoscopic patients in high-quality studies and those reporting on more than 30 patients by 1.1 days (p=0.02 in both subgroups) and studies published in or since 2001 by 3.0 days (p=0.004) but not overall. CONCLUSION: Laparoscopic ileal pouch surgery was associated with longer operative time, lower blood loss, shorter length of hospital stay and similar short-term adverse events compared with open surgery. Comparative data on quality of life and long-term outcomes are currently unavailable. The potential advantage of laparoscopic ileal pouch surgery remains to be established. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16900339&query_hl=1 ER - TY - JFULL T1 - Intraperitoneal chemotherapy as first-line treatment in the management of epithelial ovarian cancer. A1 - Rekhraj, S A1 - Kinross, J A1 - Prabhudesai, S A1 - Darzi, A A1 - Ziprin, P J1 - Mini Rev Med Chem Y1 - 2007/05// VL - 7 SN - 1389-5575 SP - 509 EP - 517 N2 - Recent evidence has suggested improved outcomes following incorporation of intraperitoneal chemotherapy administration with intravenous systemic chemotherapy as first-line treatment of small volume residual epithelial ovarian cancer. This review focuses on the mechanism of actions of the chemotherapeutic drugs and reviews the possible reasons for the superior outcomes of intraperitoneal chemotherapy. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17504186&query_hl=1 ER - TY - JFULL T1 - Identification of skills common to renal and iliac endovascular procedures performed on a virtual reality simulator. A1 - Neequaye, SK A1 - Aggarwal, R A1 - Brightwell, R A1 - Van Herzeele, I A1 - Darzi, A A1 - Cheshire, NJ J1 - Eur J Vasc Endovasc Surg Y1 - 2007/05// VL - 33 SN - 1078-5884 SP - 525 EP - 532 N2 - INTRODUCTION: There is a learning curve in the acquisition of endovascular skills for the treatment of vascular disease. Integration of Virtual reality (VR) simulator based training into the educational training curriculum offers a potential solution to overcome this learning curve. However evidence-based training curricula that define which tasks, how often and in which order they should be performed have yet to be developed. The aim of this study was to determine the nature of skills acquisition on the renal and iliac modules of a commercially-available VR simulator. METHOD: 20 surgical trainees without endovascular experience were randomised to complete eight sessions on a VR iliac (group A) or renal (group B) training module. To determine skills transferability across the two procedures, all subjects performed two further VR cases of the other procedure. Performance was recorded by the simulator for parameters such as time taken, contrast fluid usage and stent placement accuracy. RESULTS: During training, both groups demonstrated statistically significant VR learning curves: group A for procedure time (p<0.001) and stent placement accuracy (p=0.013) group B for procedure time (p<0.001), fluoroscopy time (p=0.003) and volume of contrast fluid used (p<0.001). At crossover, subjects in group B (renal trained) performed to the same level of skill on the simulated iliac task as group A. However, those in group A (iliac trained) had a significantly higher fluoroscopy time (median 118 vs 72 secs, p=0.020) when performing their first simulated renal task than for group B. CONCLUSION: Novice endovascular surgeons can significantly improve their performance of simulated procedures through repeated practice on VR simulators. Skills transfer between tasks was demonstrated but complex task training, such as selective arterial cannulation in simulators and possibly in the real world appears to involve a separate skill. It is thus suggested that a stepwise and hierarchical training curriculum is developed for acquisition of endovascular skill using VR simulation to supplement training on patients. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17291792&query_hl=1 ER - TY - JFULL T1 - Comparison of mortality prediction models after open abdominal aortic aneurysm repair. A1 - Hadjianastassiou, VG A1 - Tekkis, PP A1 - Athanasiou, T A1 - Muktadir, A A1 - Young, JD A1 - Hands, LJ J1 - Eur J Vasc Endovasc Surg Y1 - 2007/05// VL - 33 SN - 1078-5884 SP - 536 EP - 543 N2 - OBJECTIVES: Comparison of the accuracy of prediction of contemporary mortality prediction models after open Abdominal Aortic Aneurysm (AAA) surgery. METHODS: Post-operative data were collected from AAA patients from 2 UK Intensive Care Units (ICU). POSSUM and VBHOM based models were compared to the APACHE-AAA model which was able to adjust for the hospital-related effect on outcome. Model performance was assessed using measures of calibration, discrimination and subgroup analysis. RESULTS: 541 patients were studied. The in-hospital mortality rate for elective AAA repair (325 patients) was: 6.2% (95% confidence interval (c.i.) 3.5 to 8.8) and for emergency repair (216 patients) was: 28.7% (95% c.i. 22.5-34.9). The APACHE-based model had the best overall fit to the whole population of AAA patients, and also separately in elective and emergency patients. The V-POSSUM physiology-only (p<0.001) and VBHOM (p=0.011) models had a poor fit in elective patients. The RAAA-POSSUM physiology-only (p<0.001) and VBHOM models (p=0.010) had a poor fit in emergency patients. CONCLUSIONS: The APACHE-AAA model with its ability to adjust for both the hospital-related "effect" as well as the patient case-mix, was a more accurate risk stratification model than other contemporary models, in the post-operative AAA patient managed in ICU. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17196847&query_hl=1 ER - TY - JFULL T1 - Diffuse optical imaging of the healthy and diseased breast: A systematic review. A1 - Leff, DR A1 - Warren, OJ A1 - Enfield, LC A1 - Gibson, A A1 - Athanasiou, T A1 - Patten, DK A1 - Hebden, J A1 - Yang, GZ A1 - Darzi, A J1 - Breast Cancer Res Treat Y1 - 2007/04/28/ SN - 0167-6806 N2 - Screening X-ray mammography is limited by false positives and negatives leading to unnecessary physical and psychological morbidity. Diffuse Optical Imaging using harmless near infra red light, provides lesion detection based on functional abnormalities and represents a novel diagnostic arm that could complement traditional mammography. Reviews of optical breast imaging have not been systematic, are focused mainly on technological developments, and have become superseded by rapid technological advancement. The aim of this study is to review clinically orientated studies involving approximately 2,000 women in whom optical mammography has been used to evaluate the healthy or diseased breast. The results suggest that approximately 85% of breast lesions are detectable on optical mammography. Spectroscopic resolution of tissue haemoglobin composition and oxygen saturation may improve the detectability of breast diseases. Results suggest that breast lesions contain approximately twice the haemoglobin concentration of background tissue. Current evidence suggests that it is not possible to distinguish benign from malignant disease using optical imaging techniques in isolation. Methods to improve the performance of Diffuse Optical Imaging, such as better spectral coverage with additional wavelengths, improved modelling of light transport in tissues and the use of extrinsic dyes may augment lesion detection and characterisation. Future research should involve large clinical trials to determine the overall sensitivity and specificity of optical imaging techniques as well as to establish patient satisfaction and economic viability. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17468951&query_hl=1 ER - TY - JFULL T1 - Safe liver resection following chemotherapy for colorectal metastases is a matter of timing. A1 - Welsh, FK A1 - Tilney, HS A1 - Tekkis, PP A1 - John, TG A1 - Rees, M J1 - Br J Cancer Y1 - 2007/04/10/ VL - 96 SN - 0007-0920 SP - 1037 EP - 1042 N2 - Neoadjuvant chemotherapy (NC) can improve the resectability of hepatic colorectal metastases (CRM). However, there is concern regarding its impact on operative risk. We reviewed 750 consecutive liver resections performed for CRM in a single unit (1996-2005) to evaluate whether NC affected morbidity and mortality. Redo hepatic resections or patients receiving adjuvant chemotherapy following primary resection were excluded. A total of 245 resections were performed in patients not requiring NC (control group) (mean age 63, 67% male) and 252 in patients who had NC (mean age 62, 67% male). The mean (s.d.) duration of surgery was less in the control group (241(64) vs 255(64)min, P=0.014) as was the mean blood loss (390(264) vs 449(424)ml, P=0.069). Postoperative mortality (2 vs 2%) and morbidity (27 vs 29%, P=0.34) was similar between groups. More NC patients developed septic (2.4%) or respiratory (10.3%) complications compared to controls (0 and 5.3%, P<0.03), with significantly more surgical complications if the interval between stopping NC and undergoing surgery was 40% to 50% after consideration of long-term implications. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17197971&query_hl=1 ER - TY - JFULL T1 - Reply to 'Lack of support for an association between CLEC4M homozugosity and protection against SARS coronavirus infection' A1 - Kelvin YK Chan A1 - Vera SF Chan A1 - Yongxiong Chen A1 - Shea-Ping Yip A1 - CL Lin (corressponding author) A1 - US Khoo J1 - Nat Genet Y1 - 2007/// VL - 39 SP - 694 EP - 696 ER - TY - JFULL T1 - Postoperative calculation of acetabular cup position using 2-D–3-D registration A1 - G.P. Penney A1 - P.J. Edwards A1 - J.H. Hipwell A1 - M. Slomczykowski A1 - I. Revie A1 - D.J. Hawkes J1 - IEEE Trans Biomed Eng Y1 - 2007/// IS - 7 VL - 54 PB - IEEE SN - 0018-9294 SP - 1342 EP - 1348 UR - http://ieeexplore.ieee.org/xpl/RecentIssue.jsp?punumber=10 ER - TY - JFULL T1 - Chemokine expression is associated with the accumulation of tumour associated macrophages (TAMs) and progression in human colorectal cancer. A1 - Bailey, C A1 - Negus, R A1 - Morris, A A1 - Ziprin, P A1 - Goldin, R A1 - Allavena, P A1 - Peck, D A1 - Darzi, A J1 - Clin Exp Metastasis Y1 - 2007/// VL - 24 SN - 0262-0898 SP - 121 EP - 130 N2 - Chemokines promote tumour progression by enhancing proliferation and modifying the immune response. The purpose of this study was to test the hypothesis that CCL2 monocyte chemotactic protein-1 (MCP-1) contributes to the progression of colorectal cancer by influencing the number and distribution of tumour associated macrophages (TAMs). Chemokine expression was assessed in human colorectal adenocarcinomas by ribonuclease protection assay (RPA). Colonic adenocarcinoma cell lines were used to assess chemokine production by enzyme linked immunosorbant assay (ELISA), and Boyden microchemotaxis assays were performed to determine cell line supernatant monocyte chemotactic activity. CCL2 production was assessed in paraffin embedded tumour samples by immunohistochemistry. Finally, the number of macrophages and their distribution was determined in the same colorectal adenocarcinomas and compared with CCL2 expression and tumour stage. Results showed that CCL2 produced by cell lines induced monocyte chemoattraction, the expression of this chemokine in solid cancers increased with tumour stage (P < 0.05) and immunohistochemistry localized production to tumour cells. Analysis of the macrophage infiltrate showed that the accumulation was significantly greater in tumours than controls (P < 0.005) and within tumours it was greatest in necrotic regions (median 44,600 per mm(3)). Macrophage accumulation increased with tumour stage and correlated with CCL2 expression (r(s) = 0.8). CXCL8 interleukin 8 (IL-8), a potent angiogenic factor and growth factor, was expressed in all tumours and cell lines. It is concluded that CCL2 induces the accumulation of tumour promoting TAMs in human colorectal cancer and represents a therapeutic target to modify the macrophage response and direct immune mediated therapy. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17390111&query_hl=1 ER - TY - JFULL T1 - Factors affecting circumferential resection margin involvement after rectal cancer excision. A1 - Tilney, HS A1 - Tekkis, PP A1 - Sains, PS A1 - Constantinides, VA A1 - Heriot, AG A1 - Association of Coloproctology of Great Britain and Ireland J1 - Dis Colon Rectum Y1 - 2007/01// VL - 50 SN - 0012-3706 SP - 29 EP - 36 N2 - PURPOSE: This study was designed to assess factors affecting rates of circumferential resection margin involvement after rectal cancer excision, the association between circumferential resection margin involvement rates for patients undergoing anterior resection and abdominoperineal excision within the same unit, and trends in outcomes between units. METHODS: Data about patients undergoing rectal cancer excision between 2000 and 2003 were extracted from the Association of Coloproctology of Great Britain and Ireland database. Multivariate logistic regression analysis was used to identify independent predictors of circumferential resection margin involvement. Pearson correlation coefficient was used to evaluate the association between circumferential resection margin involvement for anterior resection and abdominoperineal excision. RESULTS: A total of 1,430 patients satisfied the inclusion criteria. The circumferential resection margin involvement rate for anterior resection (n=794) was 6.7 percent, between hospital variability was 0 to 40 percent, and for abdominoperineal excision (n=521) was 17.6 percent, between hospital variability 0 to 100 percent. Independent predictors of circumferential resection margin involvement were T stage (P<0.001), nodal involvement (P=0.007), and operative procedure (P<0.001). Units with a high circumferential resection margin involvement rate for anterior resection also had a high circumferential resection margin involvement rate for abdominoperineal excision (Pearson correlation=0.349; P=0.01). CONCLUSIONS: Circumferential resection margin involvement is more common in lymph-node-positive tumors and is more common after abdominoperineal excision compared with anterior resection. This relationship was consistent across units irrespective of their individual circumferential resection margin involvement rates. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17115338&query_hl=1 ER - TY - JFULL T1 - A crucial Role for DC IL-10 in inhibiting successful DC-based immunotherapy - superior anti-tumour immunity against hepatocellular carcinoma evoked by dendritic cells devoid of interleukin-10 A1 - Chen, YX A1 - Man, K A1 - Ling , GS A1 - Chen, Y A1 - Sun, BS A1 - Cheng, Q A1 - Wong, OH A1 - Lo, CK A1 - Ng, IOL A1 - Chan, LC A1 - Lau, GK A1 - Lin , CLS A1 - Huang, FL A1 - Huang, FP J1 - J Immunol Y1 - 2007/// ER - TY - JFULL T1 - A novel subset of putative stem/progenitor cells are the major target for SARS coronavirus in human lung A1 - Chen, YX A1 - Chan, VSF A1 - Zheng B A1 - Chan KYK A1 - TO, LYF A1 - Xu, X A1 - Khoo, US A1 - Lin, CL J1 - J Exp Med 2007 Y1 - 2007/// ER - TY - JFULL T1 - Communication skills for mobile remote presence technology in clinical interactions. A1 - Nestel, D A1 - Sains, P A1 - Wetzel, CM A1 - Nolan, C A1 - Tay, A A1 - Kneebone, RL A1 - Darzi, AW J1 - J Telemed Telecare Y1 - 2007/// VL - 13 SN - 1357-633X SP - 100 EP - 104 N2 - The use of mobile robotic units for teleconsultation means that the clinician's cognitive and attention skills are divided between tele-operation of the robotic unit and the consultation with the patient. We developed a communication guide based on evidence-based patient-centred interviewing and telephone conferencing skills. The communication guide was tested by five trainee surgeons in a pre- and post-test design. Each surgeon completed three simulated patient consultations. After reading the communication guide, trainees completed three further consultations. The trainees rated authenticity, degree of difficulty, familiarity of clinical presentation and confidence in using telepresence to manage the consultations. Their mean scores were 3.0-4.6, 2.2-4.0, 4.4-4.8 and 3.2-4.2 respectively (maximum possible score 5). The simulated patients rated their satisfaction with communication. Their ratings suggested that there were areas for communication skills development with mean scores ranging from 8.2 to 11.4 (maximum possible score = 15). Although we do not yet know enough about communicating with real patients using mobile robotic units, the communication guide appeared to be useful in our simulated interactions. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17359575&query_hl=1 ER - TY - JFULL T1 - Robotic control in knee joint replacement surgery. A1 - Davies, BL A1 - Rodriguez y Baena, FM A1 - Barrett, AR A1 - Gomes, MP A1 - Harris, SJ A1 - Jakopec, M A1 - Cobb, JP J1 - Proc Inst Mech Eng [H] Y1 - 2007/01// VL - 221 SN - 0954-4119 SP - 71 EP - 80 N2 - A brief history of robotic systems in knee arthroplasty is provided. The place of autonomous robots is then discussed and compared to more recent 'hands-on' robotic systems that can be more cost effective. The case is made for robotic systems to have a clear justification, with improved benefits compared to those from cheaper navigation systems. A number of more recent, smaller, robot systems for knee arthroplasty are also described. A specific example is given of an active constraint medical robot, the ACROBOT system, used in a prospective randomized controlled trial of unicondylar robotic knee arthroplasty in which the robot was compared to conventional surgery. The results of the trial are presented together with a discussion of the need for measures of accuracy to be introduced so that the efficacy of the robotic surgery can be immediately identified, rather than have to wait for a number of years before long-term clinical improvements can be demonstrated. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17315770&query_hl=1 ER - TY - JFULL T1 - Novel Applications of Dermabondtrade mark (2-Octyl -Cyanoacrylate) in Cardiothoracic Surgery. A1 - Aziz, O A1 - Rahman, MS A1 - Hadjianastassiou, VG A1 - Kokotsakis, J A1 - Vitali, M A1 - Cherian, A A1 - Darzi, A A1 - Athanasiou, T J1 - Surg Technol Int Y1 - 2007/// VL - 16 SN - 1090-3941 SP - 46 EP - 51 N2 - Dermabondtrade mark (Ethicon Inc., Somerville, NJ, USA) is a cyanoacrylate adhesive normally indicated for skin wound closure. This study describes the emergency use of this adhesive to control bleeding close to coronary anastomoses in exceptional cases. Dermabondtrade mark was used in 17 patients who underwent cardiac surgery during an eight-month period, where other haemostatic interventions were unsuitable. It was applied for haemorrhage in 15 patients and control air leaks in two of the patients. Haemostasis was successful with Dermabondtrade mark alone in 11 patients; the remaining four required additional interventions. It effectively controlled haemorrhage from ventricular pacing wires, vascular sling holes, peri-anastomotic bleeding, and epicardial tears. The adhesive was not placed directly on any graft because of embolic risk. In the two patients with visible air leaks, it was successfully used. No patient events were recorded as a result of haemorrhage and no reported toxicity. Dermabondtrade mark may be indicated in circumstances in which haemostasis with traditional methods has failed or is inappropriate. A need for further high-quality objective research exists on the effectiveness and long-term safety of 2-octyl cyanoacrylate in cardiac surgery. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17429768&query_hl=1 ER - TY - JFULL T1 - Peritoneal metastasis in primary cervical cancer: a case report. A1 - Tseng, MJ A1 - Ho, KC A1 - Lin, G A1 - Yen, TC A1 - Tsai, CS A1 - Lai, CH J1 - Eur J Gynaecol Oncol Y1 - 2007/// VL - 28 SN - 0392-2936 SP - 225 EP - 228 N2 - PURPOSE OF INVESTIGATION: Peritoneal metastasis presenting at initial diagnosis of squamous carcinoma of the uterine cervix is extremely rare. However, one such case was treated successfully with curative treatment. CASE: A 43-year-old woman presented with FIGO Stage IVA cervical carcinoma and underwent concurrent chemoradiation (CCRT) with weekly cisplatin. During CCRT, she suffered from acute lower abdominal pain, high fever, and leukocytosis. Computed tomography (CT) favored a tubo-ovarian abscess, while [18F] fluorodeoxyglucose positron emission tomography (FDG-PET) showed a lesion midway between the umbilicus and symphysis pubis. An exploration by laparoscopy, an omental metastasis adhering to the bladder dome was excised. This patient finished CCRT encompassing the disease extent including the trochar sites and no evidence of disease was noted 50 months after initial diagnosis. CONCLUSION: Though peritoneal metastasis above the pelvis seems ominous, curative treatment may still be viable in selected patients, even in surgical Stage IVB. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17624093&query_hl=1 ER - TY - JFULL T1 - Skills acquisition for laparoscopic gastric bypass in the training laboratory: an innovative approach. A1 - Aggarwal, R A1 - Boza, C A1 - Hance, J A1 - Leong, J A1 - Lacy, A A1 - Darzi, A J1 - Obes Surg Y1 - 2007/01// VL - 17 SN - 0960-8923 SP - 19 EP - 27 N2 - BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a technically demanding procedure, with a long learning curve. The aim of this study was three-fold: to develop a task-based approach to training in LRYGBP, define a tool for objective technical skills assessments, and objectively determine the efficacy of this approach. METHODS: Videos of expert and novice surgeons performing LRYGBP on patients and anesthetised porcine models were analyzed to define an appropriate task for skills assessment. Subsequently, a jejuno-jejunostomy model was developed using cadaveric porcine small bowel, placed into a video-box trainer. 27 surgeons of varying experience levels in advanced laparoscopic procedures performed the task. Assessments of technical skill were by hand motion analysis and video-based scoring. A further 16 surgeons inexperienced in LRYGBP attended a task-based hands-on training course and performed the jejuno-jejunostomy task at start and end of the course. RESULTS: The jejuno-jejunostomy model differentiated between surgeons of varying experience levels for time taken (P<0.001), economy of movement (P=0.001) and video scores (P<0.001). Surgeons attending the training course made significant improvements in time taken (P=0.002) and economy of movement (P=0.006), although not for generic video scores (P=0.243) by the end of course. CONCLUSIONS: The structured, task-based approach for commencement of training in LRYGBP leads to objective improvements in the technical skills of inexperienced surgeons at the end of a short course. The next stage of the curriculum should be to achieve proficiency in the complete procedure on an anesthetised porcine model, prior to preceptorship on human cases. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17355764&query_hl=1 ER - TY - JFULL T1 - Meta-analysis of clinical outcome after first and second liver resection for colorectal metastases. A1 - Antoniou, A A1 - Lovegrove, RE A1 - Tilney, HS A1 - Heriot, AG A1 - John, TG A1 - Rees, M A1 - Tekkis, PP A1 - Welsh, FK J1 - Surgery Y1 - 2007/01// VL - 141 SN - 0039-6060 SP - 9 EP - 18 N2 - BACKGROUND: The perioperative risk and long-term survival benefit of repeat hepatectomy for patients with liver metastases from colorectal cancer, compared with that of a first liver resection, has been reported with varying results in the literature. METHODS: The literature was searched using Medline, Embase, Ovid, and Cochrane databases for all studies published from 1992 to 2006. Two authors independently extracted data using the following outcomes: postoperative complications and mortality; disease recurrence; and long-term survival. Trials were assessed using the modified Newcastle-Ottawa Score. Random-effect meta-analytical techniques were used for analysis. RESULTS: Twenty-one studies met the inclusion criteria, comprising 3,741 patients. The use of adjuvant chemotherapy was similar in both groups (odds ratio [OR] = 0.97; 95% confidence interval [CI] = 0.54, 1.74; P = .92), as was the number of hepatic nodules present at the time of first or second resection (weighted mean difference [WMD] = 0.18; 95% CI = -0.22, 0.57; P = .380). Wedge resection was carried out less often at first hepatectomy (39% vs 46%; OR = 0.66; 95% CI = 0.44, 1.00; P = .05). There was significantly less blood loss in patients undergoing first versus second hepatectomy (WMD = 238 ml; 95% CI = 90, 385; P = .002). There was no difference in perioperative morbidity (OR = 1.01; 95% CI = 0.65, 1.55; P = .98), mortality (OR = 1.01; 95% CI = 0.18, 5.72; P = .99) or long-term survival (HR = 0.90; 95% CI = .66, 1.24; P = .530) between groups. CONCLUSIONS: Repeat hepatectomy for patients with colorectal cancer metastases is safe and provides survival benefit equal to that of a first liver resection. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17188163&query_hl=1 ER - TY - JFULL T1 - Surgical trauma, minimal residual disease and locoregional cancer recurrence. A1 - Ceelen, WP A1 - Morris, S A1 - Paraskeva, P A1 - Pattyn, P J1 - Cancer Treat Res Y1 - 2007/// VL - 134 SN - 0927-3042 SP - 51 EP - 69 N2 - The persistence of residual tumour is associated with the histology and stage of the primary cancer, the completeness and quality of surgery, and postoperative events such as anastomotic leakage or entrapment of cells in exudating wound surfaces. At present, there is no clinical evidence that the use of laparoscopic techniques adversely influences the risk of residual disease. The inflammatory process associated with surgery shares a number of central mediators and pathways with tumour growth and invasiveness. Both cellular components (mainly macrophages and fibroblasts) and humoral factors associated with inflammation have been shown to enhance tumour growth in numerous preclinical studies. Tumour foci at a distance from the main cancer are kept in a dormant state by a range of anti-angiogenic mediators produced by the main cancer. Preclinical studies have shown that removal of the primary cancer reactivates proliferative and metastatic pathways in the residual tumour. Clinically, this phenomenon has been proposed as underlying the observed rapid systemic relapse after surgery in young node positive breast cancer patients. Strategies proposed to prevent residual disease encompass avoidance of tumour spill and minimization of surgical trauma and related inflammation. Efforts to remove or kill free intraperitoneal cells by local antiseptic or cytotoxic regimens have met only limited clinical success. Specific targeted therapy aimed at inhibiting the inflammatory response, tumour cell adhesion, or the metastatic phenotype of dormant cells appears promising in preclinical models and needs to be addressed in future clinical trials. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17633047&query_hl=1 ER - TY - JFULL T1 - Training and assessment of procedural skills in context using an Integrated Procedural Performance Instrument (IPPI). A1 - Kneebone, R A1 - Bello, F A1 - Nestel, D A1 - Yadollahi, F A1 - Darzi, A J1 - Stud Health Technol Inform Y1 - 2007/// VL - 125 SN - 0926-9630 SP - 229 EP - 231 N2 - The use of simulation in the training and assessment of procedural skills is widely acknowledged as a powerful and necessary alternative to the traditional apprenticeship model. However advanced, simulation on its own cannot provide the necessary conditions for holistic practice. The Integrated Procedural Performance Instrument presented in this paper combines simulated patients (SPs) with inanimate models, items of medical equipment or computer generated virtual models to recreate a panel of realistic scenarios, each addressing a combination of technical and non-technical clinical challenges. The result is a safe yet authentic clinical context which can be used for training and assessment. This novel use of simulation provides a patient-centred, learner-focused approach that builds up a composite picture of technical skills, communication skills and professional behaviours across a range of challenging clinical situations. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17377272&query_hl=1 ER - TY - JFULL T1 - Meta-analysis: Alvimopan vs. placebo in the treatment of post-operative ileus. A1 - Tan, EK A1 - Cornish, J A1 - Darzi, AW A1 - Tekkis, PP J1 - Aliment Pharmacol Ther Y1 - 2007/01/01/ VL - 25 SN - 0269-2813 SP - 47 EP - 57 N2 - BACKGROUND: Alvimopan is a selective, competitive mu-opioid receptor antagonist with limited oral bioavailability which may be used to reduce length of post-operative ileus. AIM: The study compared alvimopan with placebo following bowel resection or total abdominal hysterectomy. METHODS: A meta-analysis of randomized-controlled trials published between 2001 and 2006 of alvimopan vs. placebo was performed. The primary efficacy end-points were composite measures of passage of flatus, stool, and tolerance of solid food (GI-3) and passage of stool and tolerance of solid food (GI-2). The incidence of treatment emergent adverse events was assessed. RESULTS: Five trials matched the selection criteria, reporting on 2195 patients. A total of 1521 (69.3%) had alvimopan and 674 (30.7%) placebo. GI-3 significantly improved (hazard ratio 1.30; 95% confidence intervals 1.16, 1.45, P < 0.001), as did GI-2 (hazard ratio 1.61; 95% confidence intervals 1.26, 2.05, P < 0.001) on alvimopan 12 mg. Time to discharge (hazard ratio 1.26; 95% confidence intervals 1.13, 1.40, P < 0.001), time to bowel motion (hazard ratio 1.74; 95% confidence intervals 1.29, 2.35, P < 0.001), and time to solid food (hazard ratio 1.14; 95% confidence intervals 1.01, 1.30, P < 0.04) also improved significantly. No difference was noted in the incidence of treatment emergent adverse events. CONCLUSIONS: Alvimopan showed significant advantages over placebo in restoring gastro-intestinal function, and reduced time to discharge following major abdominal surgery, with acceptable side effects. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17042776&query_hl=1 ER - TY - JFULL T1 - Development and evaluation of a virtual intensive therapy unit - VITU. A1 - Theodoropoulos, A A1 - Kneebone, R A1 - Dornan, B A1 - Leonard, R A1 - Bello, F J1 - Stud Health Technol Inform Y1 - 2007/// VL - 125 SN - 0926-9630 SP - 467 EP - 469 N2 - Complex and safety critical healthcare environments like the Intensive Therapy Unit demand highly skilled professionals efficiently interacting with their technologically advanced surroundings and with each other. The ITU environment is daunting to newcomers and contains considerable potential for harm by inexpert treatment. In spite of this, current training is largely workplace based and depends upon observation and supervised practice with real patients. We propose the development of a distributed collaborative environment that recreates key elements of critical care. Centred on a 'virtual bedspace', team members will care for the patient in a way that accurately reflects actual practice and therefore minimises any learning gap. Graded exposure to increasing levels of complexity will ensure that collaborative learning takes place alongside each participant's clinical experience and complements it appropriately. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17377328&query_hl=1 ER - TY - JFULL T1 - Risk of dysplasia and adenocarcinoma following restorative proctocolectomy for ulcerative colitis. A1 - Das, P A1 - Johnson, MW A1 - Tekkis, PP A1 - Nicholls, RJ J1 - Colorectal Dis Y1 - 2007/01// VL - 9 SN - 1462-8910 SP - 15 EP - 27 N2 - OBJECTIVE: Restorative proctocolectomy (RPC) with or without mucosectomy is the treatment of choice for most patients with ulcerative colitis (UC) requiring surgery. The ileal mucosa in the reservoir and the anorectal columnar epithelium below the ileo-anal anastomosis are at risk of neoplastic transformation. METHOD: The literature has been reviewed to identify patients developing this complication and an attempt has been made to develop a rational follow-up policy based on the data available. RESULTS: Dysplasia in the ileal reservoir is rare. It is associated with histological type C changes, sclerosing cholangitis and unremitting pouchitis in the ileal mucosa and to the presence of sclerosing cholangitis. Nine patients who have developed adenocarcinoma in the residual anorectal mucosa and seven in the reservoir have been reported in the literature. A further hitherto unreported patient treated by the authors brings the total to 17 patients. Twelve of these had histopathological data on either dysplasia or carcinoma in the original operative specimen. The time intervals from the onset of UC and from the RPC to the development of cancer were 120-528 (median 246) and 16-216 (median 60) months respectively. Cancer appeared to be related to the duration of disease rather than to the interval from RPC. In all the reported patients the interval from the onset of UC was 10 years. CONCLUSION: Based on these data a surveillance programme should begin at 10 years from the onset of disease. Patients with dysplasia or carcinoma in the original specimen, those with type C ileal mucosal changes and patients with sclerosing cholangitis should be selected for surveillance. This will involve multiple biopsies of the ileal reservoir and the anorectal mucosa below the ileo-anal anastomosis. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17181842&query_hl=1 ER - TY - JFULL T1 - Association of ICAM3 genetic variant with severe acute respiratory syndrome A1 - Chan KY A1 - Ching JC A1 - Xu MS A1 - Cheung AN A1 - Yip SP A1 - Yam LY A1 - Lai ST A1 - Chu CM A1 - Wong AT A1 - Song YQ A1 - Huang FP A1 - Liu W A1 - Chung PH A1 - Leung GM A1 - Chow EY A1 - Chan EY A1 - Chan JC A1 - Ngan HY A1 - Tam P A1 - Chan LC A1 - Sham P A1 - Chan VS A1 - Peiris M A1 - Lin CL A1 - Khoo US J1 - Journal Infectious Disease Y1 - 2007/// VL - 196 SP - 271 EP - 280 ER - TY - JFULL T1 - Laparoscopic versus open colposuspension for urodynamic stress incontinence. A1 - Tan, E A1 - Tekkis, PP A1 - Cornish, J A1 - Teoh, TG A1 - Darzi, AW A1 - Khullar, V J1 - Neurourol Urodyn Y1 - 2007/// VL - 26 SN - 0733-2467 SP - 158 EP - 169 N2 - AIMS: Laparoscopic colposuspension aims to alleviate urodynamic stress incontinence whilst minimizing operative morbidity and mortality.The present study compared laparoscopic to open surgery with regards to short-term outcomes. METHODS: Meta-analysis of comparative studies published between 1995 and 2006 of laparoscopic versus open colposuspension was performed. End points evaluated were operative outcomes and subjective/objective cure. A random-effect model was used and sensitivity analysis performed to account for bias in patient selection. RESULTS: Sixteen studies matched the selection criteria, reporting on 1,807 patients, of whom 861 (47.6%) underwent laparoscopic and 946 (52.4%) underwent open colposuspension length of hospital stay (WMD = -1.52 days, CI = -2.08, -0.96 days) and return to normal life (WMD = -1.51 weeks, CI = -3.02, 0.01 weeks) were significantly reduced following laparoscopic surgery. These findings remained consistent on sensitivity analysis. Bladder injuries occurred more often in the laparoscopic group (OR = 2.23, CI = 1.11, 4.50), but only with marginal statistical significance. Comparable bladder injury rates were found when studies were matched for quality, year, and randomized trials. Cure rates were similar between the two procedures at 2 years follow-up. CONCLUSION: Laparoscopic colposuspension results in a significant reduction in hospital stay and earlier return to work, with a possible increased risk of bladder injury. When performed by appropriately experienced surgeons it may be a safe option with advantages for the patient, but further randomized controlled trials should be undertaken to evaluate continence in the longer term at 5 years. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17252603&query_hl=1 ER - TY - JFULL T1 - Multi-detector computed tomography in coronary artery bypass graft assessment: a meta-analysis. A1 - Jones, CM A1 - Athanasiou, T A1 - Dunne, N A1 - Kirby, J A1 - Aziz, O A1 - Haq, A A1 - Rao, C A1 - Constantinides, V A1 - Purkayastha, S A1 - Darzi, A J1 - Ann Thorac Surg Y1 - 2007/01// VL - 83 SN - 1552-6259 SP - 341 EP - 348 N2 - Multi-detector computed tomography (MDCT) has become an alternative to coronary angiography in diagnosis of graft occlusion and stenosis after coronary artery bypass. A literature search was performed for studies comparing angiography to 8-slice, 16-slice, and 64-slice MDCT in the assessment of coronary grafts. In assessing occlusion, 14 studies produced pooled sensitivity of 97.6%, specificity of 98.5%, diagnostic odds ratio of 934.2, area under the curve of 0.996, and Q* of 0.977. Ninety-six percent of all grafts were visualized for occlusion assessment. Beta blockers, symptomatic status, and postoperative period did not significantly affect diagnostic performance. Stenosis assessment produced sensitivity of 88.7% and specificity of 97.4%. Eighty-eight percent of patent grafts could be assessed for stenosis. The diagnostic accuracy of MDCT approaches angiography for diagnosing graft occlusion and stenosis in patients with venous and arterial coronary bypass grafts. Our findings show that cardiac surgeons will need to interpret MDCT images of both native and grafted vessels soon in preparation for primary or re-do coronary bypass grafting procedures. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17184705&query_hl=1 ER - TY - JFULL T1 - Skeletonization of radial and gastroepiploic conduits in coronary artery bypass surgery. A1 - Massey, RM A1 - Warren, OJ A1 - Szczeklik, M A1 - Wallace, S A1 - Leff, DR A1 - Kokotsakis, J A1 - Darzi, A A1 - Athanasiou, T J1 - J Cardiothorac Surg Y1 - 2007/// VL - 2 SN - 1749-8090 SP - 26 EP - 26 N2 - The use of a skeletonized internal thoracic artery in coronary artery bypass graft surgery has been shown to confer certain advantages over a traditional pedicled technique, particularly in certain patient groups. Recent reports indicate that radial and gastroepiploic arteries can also be harvested using a skeletonized technique. The aim of this study is to systematically review the available evidence regarding the use of skeletonized radial and gastroepiploic arteries within coronary artery bypass surgery, focusing specifically on it's effect on conduit length and flow, levels of endothelial damage, graft patency and clinical outcome. Four electronic databases were systematically searched for studies reporting the utilisation of the skeletonization technique within coronary revascularisation surgery in humans. Reference lists of all identified studies were checked for any missing publications. There appears to be some evidence that skeletonization may improve angiographic patency, when compared with pedicled vessels in the short to mid-term. We have found no suggestion of increased complication rates or increased operating time. Skeletonization may increase the length of the conduit, and the number of sequential graft sites, but no clear clinical benefits are apparent. Our study suggests that there is not enough high quality or consistent evidence to currently advocate the application of this technique to radial or gastroepiploic conduits ahead of a traditional pedicled technique. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17550580&query_hl=1 ER - TY - JFULL T1 - Technical-skills training in the 21st century A1 - Aggarwal, R A1 - Darzi, A J1 - NEW ENGL J MED Y1 - 2006/12/21/ VL - 355 SN - 0028-4793 SP - 2695 EP - 2696 ER - TY - JFULL T1 - Effective probiotic treatment is rarely cheap. A1 - McLaughlin, SD A1 - Clark, SK A1 - Nicholls, RJ A1 - Tekkis, PP A1 - Ciclitira, PJ J1 - BMJ Y1 - 2006/12/16/ VL - 333 SN - 1468-5833 SP - 1272 EP - 1272 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17170428&query_hl=1 ER - TY - JFULL T1 - Early outcomes in the elderly: a meta-analysis of 4921 patients undergoing coronary artery bypass grafting--comparison between off-pump and on-pump techniques. A1 - Panesar, SS A1 - Athanasiou, T A1 - Nair, S A1 - Rao, C A1 - Jones, C A1 - Nicolaou, M A1 - Darzi, A J1 - Heart Y1 - 2006/12// VL - 92 SN - 1468-201X SP - 1808 EP - 1816 N2 - OBJECTIVE: To assess early outcomes in the elderly population undergoing coronary revascularisation with and without cardiopulmonary bypass (CPB). METHODS: Meta-analysis of all retrospective, non-randomised studies comparing off-pump coronary artery bypass (OPCAB) versus CPB techniques in the elderly (> 70 years) between 1999 and 2005. Age-related early outcomes of interest were death, stroke, atrial fibrillation (AF), renal failure and length of stay in hospital. The random effects model was used. Sensitivity and heterogeneity were analysed. RESULTS: Analysis of 14 non-randomised studies comprising 4921 patients (OPCAB, 1533 (31.1%) and CPB, 3388 (68.9%)) showed a significantly lower incidence of death in the OPCAB group (odds ratio (OR) 0.48, 95% CI 0.28 to 0.84). This effect was greater in OPCAB octogenarians (OR 0.26, 95% CI 0.12 to 0.57). The pattern of incidence of stroke among the OPCAB octogenarians (OR 0.19, 95% CI 0.07 to 0.56) was similar. The incidence of AF was lower in the OPCAB group (OR 0.77, 95% CI 0.61 to 0.97). The incidence of renal failure did not differ. Length of hospital stay was shorter in the OPCAB group, although with significant heterogeneity. CONCLUSIONS: OPCAB may be associated with lower incidence of death, stroke and AF in the elderly, which may result in shorter length of hospital stay. A large randomised trial would confirm whether the elderly would benefit more from OPCAB surgery. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16775087&query_hl=1 ER - TY - JFULL T1 - Fast-track failure after cardiac surgery: development of a prediction model. A1 - Constantinides, VA A1 - Tekkis, PP A1 - Fazil, A A1 - Kaur, K A1 - Leonard, R A1 - Platt, M A1 - Casula, R A1 - Stanbridge, R A1 - Darzi, A A1 - Athanasiou, T J1 - Crit Care Med Y1 - 2006/12// VL - 34 SN - 0090-3493 SP - 2875 EP - 2882 N2 - OBJECTIVE: Risk factors for unsuccessful fast-tracking of cardiac surgery patients have not been collectively defined in the literature. The aim of this study was to determine risk factors for fast-track failure and incorporate them into a predictive fast-track failure score. DESIGN: Prospective observational study. SETTING: Cardiothoracic Department of St Mary's Hospital, London. PATIENTS: Data were collected from April 2003 to April 2005 including 1,084 patients undergoing heart surgery who were admitted into the fast-track unit. INTERVENTIONS: Multifactorial logistic regression was used to develop a propensity score for estimating the likelihood of fast-track failure. MEASUREMENTS AND MAIN RESULTS: One hundred and sixty-nine patients failed fast-track management (15.6%). Independent predictors for fast-track failure were impaired left ventricular function with or without recent acute coronary syndrome (odds ratios 2.89 and 1.65 respectively), re-do operation (one, two, or more vs. none, odds ratio 1.75, 7.98), extracardiac arteriopathy (odds ratio 2.63), preoperative intra-aortic balloon pump (odds ratio 3.09), raised serum creatinine in micromol/L (120-150, >150 vs. <120, odds ratio 1.57, 11.24), and nonelective (odds ratio 3.43) and complex surgery (odds ratio 2.70). Model validation showed very good discrimination (area under the curve = 0.815) and calibration (ĉ statistic = 8.527, p = .129). CONCLUSIONS: The fast-track failure score incorporates several preoperative factors and has been successfully internally validated; after undergoing external validation and possible recalibration it may be used as a tool to facilitate planning and flow of cardiac surgery patients, based on the predicted probability of failure. Application of this score may limit fast-track failure rates and help to reduce morbidity and cost. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17075376&query_hl=1 ER - TY - JFULL T1 - Prospective multicentre evaluation of adverse outcomes following treatment for complicated diverticular disease. A1 - Constantinides, VA A1 - Tekkis, PP A1 - Senapati, A A1 - Association of Coloproctology of Great Britain Ireland J1 - Br J Surg Y1 - 2006/12// VL - 93 SN - 0007-1323 SP - 1503 EP - 1513 N2 - BACKGROUND: The choice of operation for complicated diverticular disease is contentious. The aim of this study was to investigate adverse events following restorative (primary resection and anastomosis, PRA) and non-restorative (Hartmann's procedure, HP) surgery for complicated diverticular disease. METHODS: Five hundred and thirty-nine patients who presented with complicated diverticular disease in 42 centres over a 12-month period from January 2003 were considered for the study. Data were collected prospectively from 248 patients (46.0 per cent) who underwent PRA and 167 (31.0 per cent) who had HP. A propensity score was developed for case-mix adjustment. Multifactorial logistic regression was used to evaluate differences in operative outcomes. RESULTS: Mortality, surgical and medical complication rates were 4.0, 31.0 and 13.7 per cent respectively after PRA, and 23.4, 53.3 and 40.7 per cent for HP (all P < 0.001). After adjusting for the propensity score, the HP group had a 2.1- and 1.9-fold increase in medical and surgical complications respectively compared with those who had PRA, whereas the operative mortality rate was not significantly different. Non-colorectal surgeons performed a significantly higher proportion of HPs in the non-elective setting than colorectal surgeons (80.6 versus 60.4 per cent; chi(2) = 8.31, 1 d.f., P = 0.004). CONCLUSION: PRA with or without a proximal diversion is more often performed non-electively by specialist colorectal surgeons. It may be a safe procedure for complicated diverticular disease in selected patients as it may be associated with fewer postoperative adverse events. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17048279&query_hl=1 ER - TY - JFULL T1 - ATLS versus ETC: time for a decision? A1 - Kinross, J A1 - Warren, O A1 - Darzi, A J1 - Ann Emerg Med Y1 - 2006/12// VL - 48 SN - 1097-6760 SP - 761 EP - 762 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17112943&query_hl=1 ER - TY - JFULL T1 - Robotic prostatectomy: the first UK experience. A1 - Mayer, EK A1 - Winkler, MH A1 - Aggarwal, R A1 - Karim, O A1 - Ogden, C A1 - Hrouda, D A1 - Darzi, AW A1 - Vale, JA J1 - Int J Med Robot Y1 - 2006/12// VL - 2 SN - 1478-596X SP - 321 EP - 328 N2 - BACKGROUND: We describe a teamwork approach to setting up the UK's first clinical programme for robotically assisted laparoscopic radical prostatectomy. METHODS: On 22 November 2004 the Imperial Robotic Urological Surgery Group performed their first robotically assisted prostatectomy. Robotically assisted prostatectomy lends itself to division into eight definable stages. A team of four consultant urological surgeons utilized a structured rotating system, using these stages, for time at the console and tableside assisting. Fluidity of surgery was maintained by a surgeon acting as the tableside assistant for the stage prior to moving to the console. Data was collected prospectively for the first 50 cases and parameters associated with the learning curve compared to other reported series. RESULTS: Median operative time of 369.5 mins, median blood loss of 700 ml, with 12% of patients requiring a blood transfusion. Four patients required conversion to an open procedure; one resulting from equipment failure and three due to failure of progression. Four patients had an anastomotic leak with resulting ileus and two patients sustained rectal injuries, which were repaired intraoperatively using the robot. Median hospital stay was 4 days with a 22% positive surgical margin rate. CONCLUSION: Parameters indicative of the learning curve are comparable to existing published initial series of other robotic centres. The use of teamwork has enabled us to provide safe and time-efficient training for four surgeons simultaneously. The structured approach used in this setting demonstrates that urological surgeons of varying laparoscopic experience can acquire the skills necessary to competently perform laparoscopic radical prostatectomy. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17520650&query_hl=1 ER - TY - JFULL T1 - Virtual reality simulation training can improve technical skills during laparoscopic salpingectomy for ectopic pregnancy. A1 - Aggarwal, R A1 - Tully, A A1 - Grantcharov, T A1 - Larsen, CR A1 - Miskry, T A1 - Farthing, A A1 - Darzi, A J1 - BJOG Y1 - 2006/12// VL - 113 SN - 1470-0328 SP - 1382 EP - 1387 N2 - OBJECTIVES: To assess the first commercially available virtual reality (VR) simulator to incorporate procedural modules for training of inexperienced gynaecological surgeons to perform laparoscopic salpingectomy for ectopic pregnancy. DESIGN: Prospective cohort study. SETTING: Departments of surgery and gynaecology in central London teaching hospitals. SAMPLE: Thirty gynaecological surgeons were recruited to the study, and were divided into novice (<10 laparoscopic procedures), intermediate (20-50) and experienced (>100) groups. METHODS: All subjects were orientated to the VR simulator with a basic skills task, followed by performing ten repetitions of the virtual ectopic pregnancy module, in a distributed manner. MAIN OUTCOME MEASURES: Operative performance was assessed by the time taken to perform surgery, blood loss and total instrument path length. RESULTS: There were significant differences between the groups at the second repetition of the ectopic module for time taken (median 551.1 versus 401.2 versus 249.2 seconds, P = 0.001), total blood loss (median 304.2 versus 187.4 versus 123.3 ml, P = 0.031) and total instrument path length (median 17.8 versus 8.3 versus 6.8 m, P = 0.023). The learning curves of the experienced operators plateaued at the second session, although greater numbers of sessions were necessary for intermediate (seven) and novice (nine) surgeons to achieve similar levels of skill. CONCLUSIONS: Gynaecological surgeons with minimal laparoscopic experience can improve their skills during short-phase training on a VR procedural module. In contrast, experienced operators showed nonsignificant improvements. Thus, VR simulation may be useful for the early part of the learning curve for surgeons who wish to learn to perform laparoscopic salpingectomy for ectopic pregnancy. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17081183&query_hl=1 ER - TY - JFULL T1 - A national study on lymph node retrieval in resectional surgery for colorectal cancer. A1 - Tekkis, PP A1 - Smith, JJ A1 - Heriot, AG A1 - Darzi, AW A1 - Thompson, MR A1 - Stamatakis, JD A1 - Association of Coloproctology of Great Britain and Ireland J1 - Dis Colon Rectum Y1 - 2006/11// VL - 49 SN - 0012-3706 SP - 1673 EP - 1683 N2 - PURPOSE: This study was designed to develop a mathematical model for predicting the number of lymph nodes harvested in bowel cancer resection specimens based on the current clinical practice in the United Kingdom. METHODS: Prospective clinical data were collected from 8,409 newly diagnosed bowel cancer patients presenting to 79 hospitals in Great Britain and Ireland during a variable 12-month period from 2000 to 2002. A two-level hierarchical regression model was used to identify predictors for lymph node harvest. The model was internally validated by comparing observed and model predicted lymph node harvest for patient subgroups. RESULTS: Inclusion criteria were satisfied by 5,164 patients. The average lymph node harvest was 11.7 nodes with significant between-center variability in lymph node harvest (range, 5.5-21.3 nodes). Increasing age, American Society of Anesthesiology grade, and preoperative radiotherapy were associated with a reduction of lymph node harvest (P < 0.001). Abdominoperineal resection of the rectum and transverse colectomy were the lowest yield procedures for lymph node harvest. Independent predictors of lymph node harvest were age, American Society of Anesthesiology grade, Dukes stage, operative urgency, type of resection, and preoperative radiotherapy. When tested, the model was found to accurately predict lymph node harvest for group statistics (comparison of observed and model predicted lymph node harvest F(1,5154) = 0.63; P = 0.427). CONCLUSIONS: The results of the study suggest that the minimum number of lymph nodes harvested in colorectal cancer surgery cannot be set at a fixed value. The lymph node harvest model provides a simple tool to the frontline clinician for comparing standards between multidisciplinary bowel cancer teams. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17019656&query_hl=1 ER - TY - JFULL T1 - Pouch-anal anastomosis vs straight ileoanal anastomosis in pediatric patients: a meta-analysis. A1 - Tilney, HS A1 - Constantinides, V A1 - Ioannides, AS A1 - Tekkis, PP A1 - Darzi, AW A1 - Haddad, MJ J1 - J Pediatr Surg Y1 - 2006/11// VL - 41 SN - 1531-5037 SP - 1799 EP - 1808 N2 - BACKGROUND: Restorative proctocolectomy is the treatment of choice for pediatric patients with refractory colitis, inherited polyposis syndromes, and some with colonic aganglionosis. Evidence concerning the optimal method of reconstruction is, however, sparse. METHODS: Studies comparing outcomes from ileal pouch-anal anastomosis (IPAA) and straight ileoanal anastomosis (SIAA) were identified by searching Medline, Ovid, and Embase. Suitable studies were selected and data extracted for meta-analysis. RESULTS: Of 13 studies identified by literature search, 5 satisfied the inclusion criteria, comprising a total of 306 patients, 86 of whom (28.1%) underwent SIAA, and the remainder, IPAA. Pouch failure was more common in the SIAA group (odds ratio, 3.21; confidence interval, 1.24-8.34), as were abdominal salvage procedures (odds ratio, 9.5; confidence interval, 3.14-28.77). Short-term adverse events were similar between the 2 groups, with the exception of perianal sepsis, the higher frequency of which, in SIAA, just reached statistical significance. Bowel frequency was lower in the IPAA patients, although few studies presented functional data in a comparable form. CONCLUSIONS: There are few good-quality studies that compare the outcomes from SIAA and IPAA, meaning that caution should be exercised in the generalization of the results of this meta-analysis, which suggests pouch procedures to be favorable in terms of reconstruction survival and functional outcome. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17101347&query_hl=1 ER - TY - JFULL T1 - Surgery for local recurrence of rectal cancer. A1 - Heriot, AG A1 - Tekkis, PP A1 - Darzi, A A1 - Mackay, J J1 - Colorectal Dis Y1 - 2006/11// VL - 8 SN - 1462-8910 SP - 733 EP - 747 N2 - OBJECTIVE: Despite improvement in management of primary rectal cancer, 2.6-32% of patients develop local recurrence. A proportion of these patients can be amenable to salvage surgery. The present article reviews the evidence for and against the surgical management for local recurrence of rectal cancer, the role of adjuvant and intraoperative radiotherapy (IORT), and evaluates short and long-term outcomes. METHOD: A literature search was performed using Medline, Embase, Ovid and Cochrane database for studies between 1980 and 2005 assessing surgical management of local recurrence of rectal cancer and the evidence was critically evaluated. RESULTS: Nearly 50% of rectal cancer recurrences are local and are therefore potentially amenable to curative resection. Preoperative imaging is important for appropriate selection of patients for surgery and preoperative adjuvant therapy is essential. Five-year survival following resection ranges from 18% to 58% with 5-year survival following complete resection of over 35% though morbidity ranges from 21% to 82%. Neoadjuvant radiotherapy is beneficial and IORT may have a contributory role in treatment. Aggressive surgical treatment favourably affects quality of life and is cost effective. Surgery for local recurrence can result in significant long-term survival with acceptable morbidity and improved quality of life in appropriately selected patients. Assessment in a specialist centre familiar with these techniques is essential. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17032318&query_hl=1 ER - TY - JFULL T1 - Outcomes following laparoscopic versus open repair of incisional hernia. A1 - Sains, PS A1 - Tilney, HS A1 - Purkayastha, S A1 - Darzi, AW A1 - Athanasiou, T A1 - Tekkis, PP A1 - Heriot, AG J1 - World J Surg Y1 - 2006/11// VL - 30 SN - 0364-2313 SP - 2056 EP - 2064 N2 - AIM: The purpose of this study was to compare short- and long-term outcomes for patients undergoing laparoscopic or open surgery for incisional hernia repair using meta-analytical techniques. METHODS: A literature search was performed to identify comparative studies reporting outcomes on laparoscopic versus open surgery for incisional hernia repair. A random-effect meta-analytical model was used and subgroup analysis performed on high-quality studies, those reporting on more than 30 patients, and those published since 2000. RESULTS: Five studies, with a total of 351 patients, satisfied the inclusion criteria. Laparoscopic surgery was attempted in 148 (42.2%) patients. Overall, in the laparoscopic group, operative time was significantly longer--by 12.0 minutes (P = 0.03) and length of stay reduced by 3.3 days (P < 0.003) although this finding was associated with significant heterogeneity between studies (P < 0.001). There was no difference in the short-term adverse events between the groups, but there were fewer wound infections for laparoscopic patients in high-quality studies [odds ratio (OR) = 0.22, 95% confidence interval (CI): 0.05, 0.85, P = 0.03] and those reporting on more than 30 patients (OR = 0.19, 95% CI: 0.04, 0.84, P = 0.03). No difference in hernia recurrence was shown in the overall or subgroup analysis. CONCLUSIONS: Laparoscopic incisional hernia repair was associated with a reduced length of stay and lower wound infection rate. The impact on post-operative quality of life and financial implications needs further prospective, validated evaluation. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17058029&query_hl=1 ER - TY - JFULL T1 - Conceptual framework for laparoscopic VR simulators. A1 - Lamata, P A1 - Gómez, EJ A1 - Bello, F A1 - Kneebone, RL A1 - Aggarwal, R A1 - Lamata, F J1 - IEEE Comput Graph Appl Y1 - 2006/11// VL - 26 SN - 0272-1716 SP - 69 EP - 79 N2 - Availability of YR laparoscopic simulation for surgical training has increased significantly. Nevertheless, few studies have explored such simulators' requirements and the degree of fidelity necessary to provide effective educational tools. The authors aim to identify which didactic resources available in YR simulation technologies are most important for laparoscopic training. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17120915&query_hl=1 ER - TY - JFULL T1 - Assessing procedural skills in context: Exploring the feasibility of an Integrated Procedural Performance Instrument (IPPI). A1 - Kneebone, R A1 - Nestel, D A1 - Yadollahi, F A1 - Brown, R A1 - Nolan, C A1 - Durack, J A1 - Brenton, H A1 - Moulton, C A1 - Archer, J A1 - Darzi, A J1 - Med Educ Y1 - 2006/11// VL - 40 SN - 0308-0110 SP - 1105 EP - 1114 N2 - BACKGROUND: The assessment of clinical procedural skills has traditionally focused on technical elements alone. However, in real practice, clinicians are expected to be able to integrate technical with communication and other professional skills. We describe an integrated procedural performance instrument (IPPI), where clinicians are assessed on 12 clinical procedures in a simulated clinical setting which combines simulated patients (SPs) with inanimate models or items of medical equipment. Candidates are observed remotely by assessors whose data are fed back to the clinician within 24 hours of the assessment. This paper describes the feasibility of IPPI. RESULTS: A full-scale IPPI and 2 pilot studies with trainee and qualified health care professionals has yielded an extensive data set including 585 scenario evaluations from candidates, 60 from clinical assessors and 31 from simulated patients (SPs). Interview and questionnaire data showed that for the majority of candidates IPPI provided a powerful and valuable learning experience. Realism was rated highly. Remote and real-time assessment worked effectively, although for some procedures limited camera resolution affected observation of fine details. DISCUSSION: IPPI offers an innovative approach to assessing clinical procedural skills. Although resource-intensive, it has the potential to provide insight into individual's performance over a spectrum of clinical scenarios and at no risk to the safety of patients. Additional benefits of IPPI include assessment in real time from experts (allowing remote rating by external examiners) as well as provision of feedback from simulated patients. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17054620&query_hl=1 ER - TY - JFULL T1 - Very low-dose computed tomography for planning and outcome measurement in knee replacement - The imperial knee protocol A1 - Henckel, J A1 - Richards, R A1 - Lozhkin, K A1 - Harris, S A1 - Baena, FMRY A1 - Barrett, ARW A1 - Cobb, JP J1 - J BONE JOINT SURG BR Y1 - 2006/11// VL - 88B SN - 0301-620X SP - 1513 EP - 1518 N2 - Surgeons need to be able to measure angles and distances in three dimensions in the planning and assessment of knee replacement. Computed tomography (CT) offers the accuracy needed but involves greater radiation exposure to patients than traditional long-leg standing radiographs, which give very little information outside the plane of the image.There is considerable variation in CT radiation doses between research centres, scanning protocols and individual scanners, and ethics committees are rightly demanding more consistency in this area.By refining the CT scanning protocol we have reduced the effective radiation dose received by the patient down to the equivalent of one long-leg standing radiograph. Because of this, it will be more acceptable to obtain the three-dimensional data set produced by CT scanning. Surgeons will be able to document the impact of implant position on outcome with greater precision. ER - TY - JFULL T1 - Carotid artery stenting performed on a virtual reality simulator differentiates level of procedural experience and technical skill A1 - Van Herzeele, I A1 - Aggarwal, R A1 - Choong, A A1 - Neequaye, S A1 - Brightwell, R A1 - Darzi, A A1 - Cheshire, N J1 - AM J CARDIOL Y1 - 2006/10/22/ VL - 98 SN - 0002-9149 SP - 242M EP - 242M ER - TY - JFULL T1 - MRI in predicting curative resection of rectal cancer - New dilemma in multidisciplinary team management A1 - Heald, RJ A1 - O'Neill, BDP A1 - Moran, B A1 - Brown, G A1 - Darzi, AW A1 - Wotherspoon, AC A1 - Cunningham, D A1 - Tait, DM J1 - BRIT MED J Y1 - 2006/10/14/ VL - 333 SN - 0959-8146 SP - 808 EP - 808 ER - TY - JFULL T1 - A comparison of segmental vs subtotal/total colectomy for colonic Crohn's disease: a meta-analysis. A1 - Purkayastha, S A1 - Tekkis, PP A1 - Lanitis, S A1 - Athanasiou, T A1 - Heriot, AG A1 - Darzi, AW A1 - Orchard, TR A1 - Nicholls, RJ J1 - Colorectal Dis Y1 - 2006/10// VL - 8 SN - 1462-8910 SP - 723 EP - 724 N2 - Purpose: To evaluate differences in short- and long-term outcomes of patients with colonic Crohn's disease (CD) undergoing either subtotal/total colectomy with ileorectal anastomosis (IRA) or segmental colectomy(SC). Method: Comparative studies from 1988 to 2002, of subtotal/total colectomy and IRA vs SC, were used. The study end points included surgical and overall recurrence, time to recurrence, postoperative morbidity and incidence of permanent stoma. Meta-analytical tools were used to evaluate the study outcomes. Results: Six studies, consisting of a total of 488 patients (223-IRA and 265-SC) were included. Meta-analysis suggested no significant difference between IRA and SC in recurrence of CD. Time to recurrence was longer in the IRA group by 4.4 years (95%CI, 3.1-5.8), P < 0.001. There was no difference in postoperative complications (OR = 1.4, 95%CI, 0.16-12.74) or the need for a permanent stoma between the two groups (OR = 2.75, 95%CI, 0.78-9.71). Patients with two or more colonic segments involved were associated with lower re-operation rate in the IRA group, a difference which did not reach statistical significance (P = 0.177). Conclusions: Both procedures were equally effective as treatment options for colonic CD, however, patients in the SC group exhibited recurrence earlier than those in the IRA group. The choice of operation is dependent on the extent of colonic disease, with a trend towards better outcomes with IRA for two or more colonic segments involved. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16970591&query_hl=1 ER - TY - JFULL T1 - Preoperative planning and intraoperative guidance for accurate computer-assisted minimally invasive hip resurfacing surgery A1 - Barrett, ARW A1 - Davies, BL A1 - Gomes, MPSF A1 - Harris, SJ A1 - Henckel, J A1 - Jakopec, M A1 - Baena, FMRY A1 - Cobb, JP J1 - P I MECH ENG H Y1 - 2006/10// VL - 220 SN - 0954-4119 SP - 759 EP - 773 N2 - Hip resurfacing is an alternative to total hip replacement (THR) and is particularly suitable for the younger, more active patient. However, it is a more demanding procedure. This paper describes a system that enables the surgeon to plan the surgery preoperatively with optimally sized and placed components, and then transfer this plan to an intraoperative system that registers computer models to the real patient and tracks surgical tools, allowing the surgeon to ensure that the bone is resected correctly and that the components are fitted in accordance with the plan. The paper describes a series of instruments used with the system which are locked to the bone. These instruments serve the dual purpose of soft tissue retraction and bone immobilization. The system will shortly be the subject of laboratory and clinical evaluation. Registration, a cornerstone of the tracked instrument system, has been tested, and accuracy measures are provided. Experimental results for the remainder of the system will be provided after clinical trials. ER - TY - JFULL T1 - Diagnostic precision of anti-Saccharomyces cerevisiae antibodies and perinuclear antineutrophil cytoplasmic antibodies in inflammatory bowel disease. A1 - Reese, GE A1 - Constantinides, VA A1 - Simillis, C A1 - Darzi, AW A1 - Orchard, TR A1 - Fazio, VW A1 - Tekkis, PP J1 - Am J Gastroenterol Y1 - 2006/10// VL - 101 SN - 0002-9270 SP - 2410 EP - 2422 N2 - AIMS: The aim of this study was to assess the diagnostic precision of antiSaccharomyces cerevisiae (ASCA) and perinuclear antineutrophil cytoplasmic antibodies (pANCA) in inflammatory bowel disease (IBD) and evaluate their discriminative ability between ulcerative colitis (UC) and Crohn's disease (CD). METHODS: Meta-analysis of studies reporting on ASCA and pANCA in IBD was performed. Sensitivity, specificity, and likelihood ratios (LR+, LR-) were calculated for different test combinations for CD, UC, and for IBD compared with controls. Meta-regression was used to analyze the effect of age, DNAse, colonic CD, and assay type. RESULTS: Sixty studies comprising 3,841 UC and 4,019 CD patients were included. The ASCA+ with pANCA- test offered the best sensitivity for CD (54.6%) with 92.8% specificity and an area under the ROC (receiver operating characteristic) curve (AUC) of 0.85 (LR+ = 6.5, LR- = 0.5). Sensitivity and specificity of pANCA+ tests for UC were 55.3% and 88.5%, respectively (AUC of 0.82; LR+ = 4.5, LR- = 0.5). Sensitivity and specificity were improved to 70.3% and 93.4% in a pediatric subgroup when combined with an ASCA- test. Meta-regression analysis showed decreased diagnostic precision of ASCA for isolated colonic CD (RDOR = 0.3). CONCLUSIONS: ASCA and pANCA testing are specific but not sensitive for CD and UC. It may be particularly useful for differentiating between CD and UC in the pediatric population. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16952282&query_hl=1 ER - TY - JFULL T1 - The human face of simulation: patient-focused simulation training. A1 - Kneebone, R A1 - Nestel, D A1 - Wetzel, C A1 - Black, S A1 - Jacklin, R A1 - Aggarwal, R A1 - Yadollahi, F A1 - Wolfe, J A1 - Vincent, C A1 - Darzi, A J1 - Acad Med Y1 - 2006/10// VL - 81 SN - 1040-2446 SP - 919 EP - 924 N2 - Simulation is firmly established within health care training but often focuses on training for technical tasks and can overlook crucial skills such as professionalism and physician-patient communication. The authors locate this paper within current developments in health care and relate it to the literature on simulation. They make the case for placing real human "patients" (played by actors) within simulation environments, thereby ensuring that the training experience remains rooted in actual practice. By practicing repeatedly within a safe environment, technical skills, communication with patients and team members, decision making, and clinical judgment may all be practiced and mastered while preserving patient safety. In elaborating this concept of patient-focused simulation (PFS), the authors draw on work already published by their group and several recent studies that are in review. These explore PFS in low, medium, and high complexity settings. Important or rare situations can be recreated and practiced, as well as key procedures required across a range of experience levels and clinical specialties. Finally, the case is made for curriculum redesign to ensure that simulator-based technical skills training and assessment take place within an authentic context that reflects the wider elements of clinical practice. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16985358&query_hl=1 ER - TY - JFULL T1 - Innovative training for new surgical roles--the place of evaluation. A1 - Kneebone, RL A1 - Nestel, D A1 - Chrzanowska, J A1 - Barnet, AE A1 - Darzi, A J1 - Med Educ Y1 - 2006/10// VL - 40 SN - 0308-0110 SP - 987 EP - 994 N2 - BACKGROUND: This paper describes the central role of 'external' evaluation, provided by an independent researcher, in developing an innovative curriculum for new professional roles with surgery. Workforce changes affecting the National Health Service provided an opportunity to develop 2 new roles and design training programmes to support them. The perioperative specialist practitioner (PSP) role was designed from scratch, while surgical care practitioner (SCP) training built on existing practice. Training programmes combined formal modules at Imperial College London (approximately 48 days over 10 months) with supervised clinical practice in each participant's base hospital. Programmes balanced factual knowledge, clinical and communication skills, professional issues and personal development and used a range of innovative techniques. EVALUATION METHODS: A qualitative approach based on a utilisation-focused model monitored the development and implementation of 4 pilot PSP and SCP training programmes. A total of 124 individual and 48 group interviews were conducted at intervals over 3 years, sampling course participants, the project team clinical supervisors and administrators. An independent researcher collected, analysed and presented data at key stages, feeding back findings to the project team as the programmes evolved. DISCUSSION: Effective training programmes for new roles can be developed, but the process is time-consuming and requires sensitivity. An independent evaluator offers great benefits, modulating the collaborative partnership between participants and project team. Positive responses (relating to content and teaching methods) from our study enabled us to refine a learner-centred programme. Negative responses often demanded immediate action to address important concerns, and evaluation provided early warning. External evaluation provides a vital perspective in the development of curricula supporting new roles. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16987189&query_hl=1 ER - TY - JFULL T1 - Long-term, health-related, quality of life comparison in patients undergoing single stage vs staged resection for complicated diverticular disease. A1 - Constantinides, VA A1 - Aydin, HN A1 - Tekkis, PP A1 - Fazio, VW A1 - Heriot, AG A1 - Remzi, FH J1 - Colorectal Dis Y1 - 2006/10// VL - 8 SN - 1462-8910 SP - 663 EP - 671 N2 - OBJECTIVE: To evaluate long-term health-related quality of life, for single-staged and staged resections following reversal, for complicated diverticular disease. PATIENTS AND METHODS: Between 1981 and 2003, 188 patients undergoing single stage (n = 158) or staged resection (n = 30) completed the SF-36 questionnaire. Health-related quality of life (HRQL) was compared between the two groups and the US normal population based on the eight domains of the SF-36. HRQL analysis was also performed at various time intervals. The effect of age and postoperative complications on HRQL was also determined. Functional and postoperative outcomes were also assessed. RESULTS: The single and staged resection groups differed in the presence of comorbidity, degree of peritoneal contamination and operative urgency. No difference in functional outcomes or HRQL was found, even after analysing time-interval subgroups. Social functioning and general health was substantially worse in both groups when compared to US norms. Ageing was found to significantly reduce physical functioning (P < 0.001) and physical and emotional role limitations (P < 0.001 for both). Post-operative complications significantly reduced scores when compared to patients without complications, for physical functioning (63.57 vs 78.7, respectively; P < 0.001), physical role limitation (80.65 vs 86.9, respectively; P < 0.001) and bodily pain (66.67 vs 74.81, respectively; P < 0.01). CONCLUSIONS: No significant difference in long-term HRQL was found in patients undergoing single staged or staged resection for complicated diverticular disease. There was significant impact of ageing and postoperative complications on physical health. Prospective studies that include pre-operative data on HRQL are required to compare the two operative techniques, with emphasis on quality of life of patients left with a permanent stoma. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16970576&query_hl=1 ER - TY - JFULL T1 - Observational assessment of surgical teamwork: a feasibility study. A1 - Undre, S A1 - Healey, AN A1 - Darzi, A A1 - Vincent, CA J1 - World J Surg Y1 - 2006/10// VL - 30 SN - 0364-2313 SP - 1774 EP - 1783 N2 - BACKGROUND: Teamwork is fundamental to effective surgery, yet there are currently no measures of teamwork to guide training, evaluate team interventions or assess the impact of teamwork on outcomes. We report the first steps in the development of an observational assessment of teamwork and preliminary findings. METHOD: We observed 50 operations in general surgery from a single operating theater using a measure of teamwork specifically developed for use in the operating theater. The OTAS (Observational Teamwork Assessment for Surgery) comprises a procedural task checklist centered on the patient, equipment and communications tasks and ratings on team behavior constructs, namely: communication, co-operation, co-ordination, shared-leadership and monitoring. RESULTS: Ratings of overall team performance were reasonably high, though variable, but there was evidence that clinically significant steps were being missed which at the very least eroded safety margins. There was, for instance, a frequent failure to check both surgical and anesthetic equipment and a failure to confirm the procedure verbally, patient notes were missing in about one-eighth of the cases and delays or changes occurred in over two-thirds of the cases. CONCLUSIONS: This study takes an initial step towards developing measures of team performance in surgery that are defined in relation to tasks and behaviors of the team. The observational method of assessment is feasible and can provide a wealth of potentially valuable research data. However, for these measures to be used for formal assessment, more research is needed to make them robust and standardized. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16983480&query_hl=1 ER - TY - JFULL T1 - The perioperative specialist practitioner: developing and evaluating a new surgical role. A1 - Kneebone, R A1 - Nestel, D A1 - Chrzanowska, J A1 - Barnet, AE A1 - Younger, J A1 - Burgess, A A1 - Darzi, A J1 - Qual Saf Health Care Y1 - 2006/10// VL - 15 SN - 1475-3901 SP - 354 EP - 358 N2 - INTRODUCTION: This paper describes the design, implementation and evaluation of a new professional role in surgery. The role of the perioperative specialist practitioner (PSP), conceived as a response to the Working Time Directive, provides integrated preoperative and postoperative care to patients undergoing surgery in hospital. METHODS: A 1-year training programme was designed, dealing with a wide range of knowledge, skills and attitudes. Effective communication was a key component. Nine intensive 5-day modules at Imperial College London (London, UK) alternated with supervised experience of the surgical team at each participant's home trust. Detailed evaluation of the role and the training programme was provided by an independent research team, using an interview-based qualitative approach. Observational data were provided by the project team. Data were analysed using standard qualitative methods. RESULTS: 27 PSPs across 12 National Health Service trusts took part in two PSP training programmes. A total of 124 interviews (94 individual and 30 group) were carried out with PSPs and their colleagues. Overall, the role was seen as successful and positive, with great potential for dealing with reductions in junior medical cover. Each site encountered different opportunities and problems. Lack of mentorship was a key issue, and the role provoked considerable opposition in trusts. The training programme was viewed as highly successful. DISCUSSION: PSPs can provide high levels of expertise, but within clear limits. Our training programme has been effective and is perceived to be of high quality. However, introducing a new role requires time and sensitivity if opposition is to be minimised. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17074873&query_hl=1 ER - TY - JFULL T1 - Acute appendicitis: weighing up risks and benefits of investigations and treatments. A1 - Purkayastha, S A1 - Purkayastha, S A1 - Paraskevas, P J1 - BMJ Y1 - 2006/09/23/ VL - 333 SN - 1468-5833 SP - 652 EP - 653 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16990328&query_hl=1 ER - TY - JFULL T1 - The surgical efficiency score: a feasible, reliable, and valid method of skills assessment. A1 - Datta, V A1 - Bann, S A1 - Mandalia, M A1 - Darzi, A J1 - Am J Surg Y1 - 2006/09// VL - 192 SN - 0002-9610 SP - 372 EP - 378 N2 - BACKGROUND: Technical skills assessments are being increasingly used in surgical residency programs, with the objectivity and validity of several techniques well established. However, many of these methods are labor and time intensive, limiting their feasibility. This study aims to compare more efficient techniques of skills appraisals with an established gold standard. METHODS: Thirty surgeons completed 2 previously validated laboratory-based surgical models: small bowel anastomosis and vein patch insertion. Gold standard evaluation was the Objective Structured Assessment of Technical Skills (OSATS) method. "Efficient" techniques used were (1) quality of final product (FP); (2) snapshot assessment (SS), in which task performance was edited to a 2-minute sound bite and scored with OSATS; and (3) the surgical efficiency score (SES), a combination of final product quality and hand-motion analysis. All human observer evaluations used retrospective video analysis with 3 trained observers. Nonparametric tests were used to analyze the results. RESULTS: With respect to small bowel anastomosis, correlations with OSATS were as follows: FP 0.341 (P=.07), SS 0.577 (P<.001), and SES 0.842 (P<.001). For vein patch insertion, the correlations were as follows: FP 0.545 (P=.001), SS 0.609 (P<.001), and SES 0.700 (P<.001). Interobserver concordance was high for both models with respect to FP (Cronbach's alpha 0.80 for small bowel anastomosis and 0.84 for vein patch insertion). With respect to SS, interobserver reliability was high for vein patch insertion (Cronbach's alpha 0.80) but only moderate for small bowel anastomosis (0.59). CONCLUSIONS: The surgical efficiency score and snap shot assessments both show significant correlations with the traditional OSATS appraisals and suggest that skills assessment can be made more feasible. Correlations were closer with the former and interobserver concordance more variable with the latter, suggesting the surgical efficiency score as the most reliable of the methods evaluated. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16920433&query_hl=1 ER - TY - JFULL T1 - A comparison of adverse events and functional outcomes after restorative proctocolectomy for familial adenomatous polyposis and ulcerative colitis. A1 - Lovegrove, RE A1 - Tilney, HS A1 - Heriot, AG A1 - von Roon, AC A1 - Athanasiou, T A1 - Church, J A1 - Fazio, VW A1 - Tekkis, PP J1 - Dis Colon Rectum Y1 - 2006/09// VL - 49 SN - 0012-3706 SP - 1293 EP - 1306 N2 - PURPOSE: Restorative proctocolectomy is the procedure of choice for patients undergoing proctocolectomy for familial adenomatous polyposis or ulcerative colitis. This meta-analysis was designed to identify differences in adverse events and functional outcomes between these two groups. METHODS: Studies published between 1986 and 2003 that compared outcomes between patients with familial adenomatous polyposis and ulcerative colitis were included. Meta-analytical techniques using random effect models were used to compare short-term and long-term adverse events as well as functional outcomes between the groups. RESULTS: Nineteen studies comprising 5,199 patients (familial adenomatous polyposis, 782; ulcerative colitis, 4,417) were analyzed. There were no significant differences in immediate postoperative adverse events between the two groups. Pouch-related fistulation was significantly increased in the ulcerative colitis group (10.5 percent vs. familial adenomatous polyposis 4.8 percent; odds ratio 2.31; P < 0.001). There was no significant difference in pouch failure between the two groups (ulcerative colitis 5.8 percent vs. familial adenomatous polyposis 4.5 percent; odds ratio 1.22; P = 0.43). The incidence of pouchitis was significantly greater in the ulcerative colitis group (30.1 vs. 5.5 percent; odds ratio 6.44; P < 0.001). Patients with familial adenomatous polyposis had a significant advantage in stool frequency with one less motion per 24 hours (95 percent confidence interval, 0.21-1.76; P = 0.01). CONCLUSIONS: In contrast to studies reporting similar outcomes for patients undergoing restorative proctocolectomy for familial adenomatous polyposis or ulcerative colitis, the present meta-analysis suggested that patients with ulcerative colitis are at greater risk of pouch-related fistulation and pouchitis. Although there was an increase in the 24-hour stool frequency in the ulcerative colitis group, this may be accounted for by the younger age at surgery in the familial adenomatous polyposis group. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16830218&query_hl=1 ER - TY - JFULL T1 - Comparison of POSSUM scoring systems and the surgical risk scale in patients undergoing surgery for complicated diverticular disease. A1 - Constantinides, VA A1 - Tekkis, PP A1 - Senapati, A A1 - Association of Coloproctology of Great Britain and Ireland J1 - Dis Colon Rectum Y1 - 2006/09// VL - 49 SN - 0012-3706 SP - 1322 EP - 1331 N2 - PURPOSE: This study was designed to evaluate the accuracy of the Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity, Portsmouth-Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity, colorectal-Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity, and the Surgical Risk Scale for the treatment of patients with complicated diverticular disease. METHODS: Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity variables were prospectively recorded for 324 patients undergoing colorectal resections in 42 hospitals in the United Kingdom from January to December 2003. The accuracy of each model was evaluated by measures of discrimination, calibration, and subgroup analysis. RESULTS: The overall operative mortality was 10.8 percent (Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity-estimated mortality rate, 21.9 percent; Portsmouth-Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity-estimated mortality rate, 10.5 percent; colorectal-Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity-estimated mortality rate, 10 percent; Surgical Risk Scale-estimated mortality rate, 38.2 percent). Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity and the Surgical Risk Scale over-predicted mortality in young patients (P < 0.001) and Portsmouth-Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity underpredicted mortality in elderly patients (P < 0.001). Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity and the Surgical Risk Scale overpredicted mortality in patients with generalized peritonitis (Hinchey III and IV). There was no significant difference between the observed and colorectal-Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity predicted mortality across patient subgroups and when the overall sample was considered. CONCLUSIONS: The study suggested a lack of calibration of Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity, Portsmouth-Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity, and the Surgical Risk Scale at the extreme of age and for patients with severe peritoneal contamination. Colorectal-Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity was found to accurately evaluate mortality arising from complicated diverticular disease. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16680607&query_hl=1 ER - TY - JFULL T1 - The developing market for medical robotics A1 - Wang, YL A1 - Butner, SE A1 - Darzi, A J1 - P IEEE Y1 - 2006/09// VL - 94 SN - 0018-9219 SP - 1763 EP - 1771 N2 - This paper discusses the developing market for medical robotics. It first describes some of the dynamics and market drivers in health care, and then provides an outline of the areas of consideration when developing a commercial medical robot. The paper also offers three case studies of robotic systems that have been commercialized. Finally, it summarizes some of the key ingredients to be considered for the commercialization process. ER - TY - JFULL T1 - Patient safety alerts: a balance between evidence and action. A1 - Vincent, CA A1 - Lee, AC A1 - Hanna, GB J1 - Arch Dis Child Fetal Neonatal Ed Y1 - 2006/09// VL - 91 SN - 1359-2998 SP - F314 EP - F315 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16923929&query_hl=1 ER - TY - JFULL T1 - A national perspective on the decline of abdominoperineal resection for rectal cancer A1 - Tilney, HS A1 - Heriot, AG A1 - Purkayastha, S A1 - Antoniou, A A1 - Aylin, P A1 - Tekkis, PP J1 - J AM COLL SURGEONS Y1 - 2006/09// VL - 203 SN - 1072-7515 SP - S70 EP - S71 ER - TY - JFULL T1 - Active-constraint Robotics for Surgery A1 - Brian Davies A1 - Matjaz Jakopec A1 - Simon J Harris A1 - Ferdinando Rodriguez y Baena A1 - Adrian Barrett A1 - Alexander Evangelidis A1 - Paula Gomes A1 - Johann Henckel A1 - Justin Cobb J1 - Proceedings of the IEEE Y1 - 2006/09// IS - 9 VL - 94 PB - Fran Zappulla IEEE SN - 0018-9219 SP - 1969 EP - 1704 ER - TY - JFULL T1 - Comparison of reports of randomized controlled trials and systematic reviews in surgical journals: literature review. A1 - Panesar, SS A1 - Thakrar, R A1 - Athanasiou, T A1 - Sheikh, A J1 - J R Soc Med Y1 - 2006/09// VL - 99 SN - 0141-0768 SP - 470 EP - 472 N2 - OBJECTIVES: Randomized controlled trials and systematic reviews of such trials are the gold standard for assessing the effectiveness of interventions. There have been concerns about the anecdotal evidence underpinning many of the interventions used and introduced into surgical care. The American College of Surgeons has prioritized the need for more trials and systematic reviews of trials. To investigate the assertion that the methodological quality of studies conducted in surgery is in general poor and to assess the possible impact of new policy developments in the US, we sought to compare the number and proportion of published randomized controlled trials and systematic reviews in the leading two US and UK general surgical journals. Two reviewers systematically and independently hand searched all issues of these journals over a 12-month period to identify randomised controlled trials and systematic reviews. DESIGN: Systematic searching and independent abstraction of data from all volumes of the top two general surgical journals published in the USA and the UK in 2004. SETTING: 519 original reports in UK journals and 616 original reports in USA journals. MAIN OUTCOME MEASURES: Number and proportion of randomized controlled trials and systematic reviews. RESULTS: Overall, the proportion of randomized controlled trials in all four journals was 5.6% (95% confidence interval [CI] 4.4-7.0) and 5.2% (95% CI 4.1-6.7) for systematic reviews. For journals published in the UK 29/519 (5.6%) of the publications were reports of randomized controlled trials, and for the USA journals this figure was 34/616 (5.5%); odds ratio [OR]=0.99, 95%CI 0.6-1.6; P=0.96. Systematic reviews were significantly more commonly reported in the UK journals: UK 37/519 (7.1%) versus USA 22/616 (3.6%); OR=0.48, 95%CI 0.3-0.8; P<0.01. CONCLUSIONS: The concerns expressed almost a decade ago remain valid: there are still very few reports of randomized controlled trials and systematic reviews published in leading USA and UK surgical journals, with relatively little difference between these countries in the proportion of reported studies employing these designs. The American College of Surgeons initiative has yet to make an impact. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16946391&query_hl=1 ER - TY - JFULL T1 - Gaze-down three-dimensional 'open-box' training shortens the laparoscopic learning curve A1 - Aggarwal, R A1 - Boshier, P A1 - Hanna, G A1 - Darzi, A J1 - J AM COLL SURGEONS Y1 - 2006/09// VL - 203 SN - 1072-7515 SP - S77 EP - S77 ER - TY - JFULL T1 - Technical skills examination for general surgical trainees. A1 - Datta, V A1 - Bann, S A1 - Aggarwal, R A1 - Mandalia, M A1 - Hance, J A1 - Darzi, A J1 - Br J Surg Y1 - 2006/09// VL - 93 SN - 0007-1323 SP - 1139 EP - 1146 N2 - BACKGROUND: The technical skills of surgical trainees are difficult to assess and compare objectively. This study involved a structured, multistation, technical skills examination that enables the stratification of surgical trainees. METHODS: Twenty-two surgeons (five basic surgical trainees, eight junior specialist trainees, four senior specialist trainees and five consultants) participated in the study. All undertook a five-station technical skills examination consisting of three synthetic simulations (bowel anastomosis, vascular anastomosis, saphenofemoral dissection) and two virtual reality-based (flexible sigmoidoscopy and laparoscopy) assessment stations. Video-based analyses and in-built computer scoring were used to measure each surgeon's performance. The mean rank was determined for each variable, and the sum of the mean ranks produced a total score. RESULTS: There was a significant improvement in overall performance with increasing seniority (P<0.001). Significant differences were observed between basic surgical trainees and junior specialist trainees (P=0.019), and between junior and senior specialist trainees (P=0.048), but not between senior trainees and consultants. CONCLUSION: This examination successfully differentiated surgical skill, both between surgeons with different grades of experience and within the target study group of specialist trainees. The examination is feasible in terms of the timeframe needed to complete tasks, cost, and efficiency in performing video-based assessments. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16838394&query_hl=1 ER - TY - JFULL T1 - Gaze-contingent control for minimally invasive robotic surgery. A1 - Mylonas, GP A1 - Darzi, A A1 - Yang, GZ J1 - Comput Aided Surg Y1 - 2006/09// VL - 11 SN - 1092-9088 SP - 256 EP - 266 N2 - OBJECTIVE: Recovering tissue depth and deformation during robotically assisted minimally invasive procedures is an important step towards motion compensation, stabilization and co-registration with preoperative data. This work demonstrates that eye gaze derived from binocular eye tracking can be effectively used to recover 3D motion and deformation of the soft tissue. METHODS: A binocular eye-tracking device was integrated into the stereoscopic surgical console. After calibration, the 3D fixation point of the participating subjects could be accurately resolved in real time. A CT-scanned phantom heart model was used to demonstrate the accuracy of gaze-contingent depth extraction and motion stabilization of the soft tissue. The dynamic response of the oculomotor system was assessed with the proposed framework by using autoregressive modeling techniques. In vivo data were also used to perform gaze-contingent decoupling of cardiac and respiratory motion. RESULTS: Depth reconstruction, deformation tracking, and motion stabilization of the soft tissue were possible with binocular eye tracking. The dynamic response of the oculomotor system was able to cope with frequencies likely to occur under most routine minimally invasive surgical operations. CONCLUSION: The proposed framework presents a novel approach towards the tight integration of a human and a surgical robot where interaction in response to sensing is required to be under the control of the operating surgeon. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17127651&query_hl=1 ER - TY - JFULL T1 - Multi-slice computed tomography in coronary artery disease. A1 - Jones, CM A1 - Athanasiou, T A1 - Dunne, N A1 - Kirby, J A1 - Attaran, S A1 - Chow, A A1 - Purkayastha, S A1 - Darzi, A J1 - Eur J Cardiothorac Surg Y1 - 2006/09// VL - 30 SN - 1010-7940 SP - 443 EP - 450 N2 - Multi-slice computed tomography technology is emerging as a realistic investigation in patients with suspected disease in native, stented or grafted coronary arteries. A non-invasive diagnostic tool is desirable as these patients are at high risk for complications of invasive angiography. A 64-slice CT may achieve the desired diagnostic accuracy, and overcome the limitations of spatial resolution, respiratory motion, artifacts from calcification and stents, and radiation dose considerations to produce reliable image quality. These advances, as well as the capacity for integrated functional cardiac assessment, may change the referral patterns in patients who have had previous bypass surgery or percutaneous intervention. This review outlines the debated issues about 64-slice cardiac CT in patients before and after coronary artery bypass surgery, as well as coronary stenting and functional assessment. A review of the recent literature on native coronary artery and bypass graft assessment by multi-slice CT is also performed. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16857366&query_hl=1 ER - TY - JFULL T1 - Social deprivation and outcomes in colorectal cancer. A1 - Smith, JJ A1 - Tilney, HS A1 - Heriot, AG A1 - Darzi, AW A1 - Forbes, H A1 - Thompson, MR A1 - Stamatakis, JD A1 - Tekkis, PP A1 - Association of Coloproctology of Great Britain and Ireland J1 - Br J Surg Y1 - 2006/09// VL - 93 SN - 0007-1323 SP - 1123 EP - 1131 N2 - BACKGROUND: The aim of this study was to examine the influence of social deprivation on postoperative mortality and length of stay in patients having surgery for colorectal cancer. METHODS: Data were extracted from the Association of Coloproctology of Great Britain and Ireland database of patients presenting between April 2001 and March 2002. The effect of social deprivation, measured by the Townsend score, on 30-day postoperative mortality and length of stay was evaluated by two-level hierarchical regression analysis. RESULTS: A total of 7290 (86.8 percent) patients underwent surgery. Operative mortality was 6.7 percent and median length of stay 11 days. Deprivation indices were significantly higher in patients with Dukes' 'D' cancers, undergoing emergency surgery and with higher American Society of Anesthesiologists (ASA) grades (P<0.005). Worsening deprivation was associated with higher operative mortality and longer stay (P=0.014). For each unit increase in deprivation, there was 2.9 (95 percent confidence interval 0.5 to 5.2) percent increase in 30-day mortality. On multifactorial analysis, social deprivation was an independent predictor of length of stay, but its effect on operative mortality was explained by differences in ASA grade, operative urgency and Dukes' classification. CONCLUSION: Social deprivation was an independent risk factor of postoperative length of stay and associated with higher postoperative mortality. These results have important implications for risk modelling of postoperative outcomes. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16779877&query_hl=1 ER - TY - JFULL T1 - Does serum procalcitonin have a role in evaluating the severity of acute pancreatitis? A question revisited. A1 - Purkayastha, S A1 - Chow, A A1 - Athanasiou, T A1 - Cambaroudis, A A1 - Panesar, S A1 - Kinross, J A1 - Tekkis, P A1 - Darzi, A J1 - World J Surg Y1 - 2006/09// VL - 30 SN - 0364-2313 SP - 1713 EP - 1721 N2 - PURPOSE: This study was designed to evaluate the diagnostic accuracy of serum procalcitonin (PCT) for the diagnosis of severity in acute pancreatitis (AP), compared with routine clinical, biochemical, radiological, and combination severity scoring systems. METHODS: Quantitative meta-analysis was performed on prospective studies, comparing serum PCT, against validated scoring systems for diagnosing severe AP. The sensitivity, specificity, and diagnostic odds ratio were calculated for each study. Summary receiver operating characteristic (SROC) curves and subgroup analysis were undertaken. Study quality and heterogeneity were evaluated. Meta-regression meta-analysis was used to evaluate the effect of using serum PCT in the diagnostic accuracy severity scoring in AP. RESULTS: Summary receiver operating characteristic analysis of nine studies showed an overall sensitivity and specificity of 74% (range: 66%-81%) and 83% (range: 79%-87%), respectively. Overall unweighted area under the curve (AUC) was 0.91 (DOR = 16.26 95% CI: 5.68-46.60), demonstrating significant heterogeneity (Q-value = 25.32; P = 0.001). When high-quality studies alone were evaluated, there was an increase in the overall sensitivity (89%); however, specificity was similar (82%), with an overall unweighted AUC of 0.94 (DOR 41.46, 95% CI: 17.95-95.80), with no significant heterogeneity. Meta-regression analysis confirmed the significant effect of study quality on the diagnostic accuracy of severity scoring using serum PCT (P = 0.025). CONCLUSIONS: The use of PCT for severity scoring in AP has a moderate sensitivity but higher specificity. However, the overall accuracy for predicting severity in AP is high. The prognosis of severity, especially early on (<48 hours from onset of symptoms), and the evaluation of potential infectious complications of AP may be the most useful factors to assess in subsequent clinical trials to identify its exact application in clinical practice in the management of AP. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16927057&query_hl=1 ER - TY - JFULL T1 - Evaluating surgical dexterity during corneal suturing A1 - Saleh, GM A1 - Voyazis, Y A1 - Hance, J A1 - Ratnasothy, J A1 - Darzi, A J1 - ARCH OPHTHALMOL-CHIC Y1 - 2006/09// VL - 124 SN - 0003-9950 SP - 1263 EP - 1266 N2 - Objective: To evaluate motion tracking as an aid to a more objective assessment of ophthalmic microsurgical skill.Methods: In a cohort study, 3 groups of differing levels of surgical experience were assessed. The groups included novice surgeons ( n= 10) with fewer than 5 previously performed corneal sutures, trainee surgeons ( n= 10) with 5 to 100 previously performed corneal sutures, and expert surgeons ( n= 10) with more than 100 previously performed corneal sutures. The Imperial College Surgical Assessment Device was used for the objective assessment of surgical dexterity during corneal suturing. Each of the subjects used a 10-0 nylon suture in a 3-1-1 pattern on an artificial eye ( Royal College of Ophthalmologists, London, England). The Imperial College Surgical Assessment Device measures 3-dimensional spatial vectors via electromagnetic sensors attached to the surgeon's fingers. The number of movements, path length for the respective movements, and time taken to complete the given task were recorded.Results: Highly statistically significant differences were found between the 3 grades of surgeon experience for time taken ( P < .001), number of hand movements ( P <. 001), and path length of the hand movements ( P=. 002) to complete the given task.Conclusions: Motion analysis measured by this technology may be useful in the formal surgical training of residents and as an objective quantitative measure of dexterity. ER - TY - JFULL T1 - An evidence-based virtual reality training program for novice laparoscopic surgeons. A1 - Aggarwal, R A1 - Grantcharov, TP A1 - Eriksen, JR A1 - Blirup, D A1 - Kristiansen, VB A1 - Funch-Jensen, P A1 - Darzi, A J1 - Ann Surg Y1 - 2006/08// VL - 244 SN - 0003-4932 SP - 310 EP - 314 N2 - OBJECTIVE: To develop an evidence-based virtual reality laparoscopic training curriculum for novice laparoscopic surgeons to achieve a proficient level of skill prior to participating in live cases. SUMMARY BACKGROUND DATA: Technical skills for laparoscopic surgery must be acquired within a competency-based curriculum that begins in the surgical skills laboratory. Implementation of this program necessitates the definition of the validity, learning curves and proficiency criteria on the training tool. METHODS: The study recruited 40 surgeons, classified into experienced (performed >100 laparoscopic cholecystectomies) or novice groups (<10 laparoscopic cholecystectomies). Ten novices and 10 experienced surgeons were tested on basic tasks, and 11 novices and 9 experienced surgeons on a procedural module for dissection of Calot triangle. Performance of the 2 groups was assessed using time, error, and economy of movement parameters. RESULTS: All basic tasks demonstrated construct validity (Mann-Whitney U test, P < 0.05), and learning curves for novices plateaued at a median of 7 repetitions (Friedman's test, P < 0.05). Expert surgeons demonstrated a learning rate at a median of 2 repetitions (P < 0.05). Performance on the dissection module demonstrated significant differences between experts and novices (P < 0.002); learning curves for novice subjects plateaued at the fourth repetition (P < 0.05). Expert benchmark criteria were defined for validated parameters on each task. CONCLUSION: A competency-based training curriculum for novice laparoscopic surgeons has been defined. This can serve to ensure that junior trainees have acquired prerequisite levels of skill prior to entering the operating room, and put them directly into practice. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16858196&query_hl=1 ER - TY - JFULL T1 - Colorectal cancer and rectal bleeding in primary care: urban or rural myth? A1 - Purkayastha, S A1 - Darzi, A J1 - BMJ Y1 - 2006/07/22/ VL - 333 SN - 1468-5833 SP - 201 EP - 202 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16858062&query_hl=1 ER - TY - JFULL T1 - A comparison of hand-sewn versus stapled ileal pouch anal anastomosis (IPAA) following proctocolectomy: a meta-analysis of 4183 patients. A1 - Lovegrove, RE A1 - Constantinides, VA A1 - Heriot, AG A1 - Athanasiou, T A1 - Darzi, A A1 - Remzi, FH A1 - Nicholls, RJ A1 - Fazio, VW A1 - Tekkis, PP J1 - Ann Surg Y1 - 2006/07// VL - 244 SN - 0003-4932 SP - 18 EP - 26 N2 - OBJECTIVE: Using meta-analytical techniques, the study compared postoperative adverse events and functional outcomes of stapled versus hand-sewn ileal pouch-anal anastomosis (IPAA) following restorative proctocolectomy. BACKGROUND: The choice of mucosectomy and hand-sewn versus stapled pouch-anal anastomosis has been a subject of debate with no clear consensus as to which method provides better functional results and long-term outcomes. METHODS: Comparative studies published between 1988 and 2003, of hand-sewn versus stapled IPAA were included. Endpoints were classified into postoperative complications and functional and physiologic outcomes measured at least 3 months following closure of ileostomy or surgery if no proximal diversion was used, quality of life following surgery, and neoplastic transformation within the anal transition zone. RESULTS: Twenty-one studies, consisting of 4183 patients (2699 hand-sewn and 1484 stapled IPAA) were included. There was no significant difference in the incidence of postoperative complications between the 2 groups. The incidence of nocturnal seepage and pad usage favored the stapled IPAA (odds ratio [OR] = 2.78, P < 0.001 and OR = 4.12, P = 0.007, respectively). The frequency of defecation was not significantly different between the 2 groups (P = 0.562), nor was the use of antidiarrheal medication (OR = 1.27, P = 0.422). Anorectal physiologic measurements demonstrated a significant reduction in the resting and squeeze pressure in the hand-sewn IPAA group by 13.4 and 14.4 mm Hg, respectively (P < 0.018). The stapled IPAA group showed a higher incidence of dysplasia in the anal transition zone that did not reach statistical significance (OR = 0.42, P = 0.080). CONCLUSIONS: Both techniques had similar early postoperative outcomes; however, stapled IPAA offered improved nocturnal continence, which was reflected in higher anorectal physiologic measurements. A risk of increased incidence of dysplasia in the ATZ may exist in the stapled group that cannot be quantified by this study. We describe a decision algorithm for the choice of IPAA, based on the relative risk of long-term neoplastic transformation. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16794385&query_hl=1 ER - TY - JFULL T1 - Primary resection with anastomosis vs. Hartmann's procedure in nonelective surgery for acute colonic diverticulitis: a systematic review. A1 - Constantinides, VA A1 - Tekkis, PP A1 - Athanasiou, T A1 - Aziz, O A1 - Purkayastha, S A1 - Remzi, FH A1 - Fazio, VW A1 - Aydin, N A1 - Darzi, A A1 - Senapati, A J1 - Dis Colon Rectum Y1 - 2006/07// VL - 49 SN - 0012-3706 SP - 966 EP - 981 N2 - PURPOSE: This study compares primary resection with anastomosis and Hartmann's procedure in an adult population with acute colonic diverticulitis. METHODS: Comparative studies published between 1984 and 2004 of primary resection with anastomosis vs. Hartmann's procedure were included. The primary end point was postoperative mortality. Secondary end points included surgical and medical morbidity, operative time, and length of postoperative hospitalization. Random effects model was used and sensitivity analysis was performed. RESULTS: Fifteen studies, including 963 patients (57 percent primary resection with anastomoses, 43 percent Hartmann's procedures), were analyzed. Overall mortality was significantly reduced with primary resection and anastomosis (4.9 vs. 15.1 percent; odds ratio = 0.41). Subgroup analysis of trials matched for emergency operations showed significantly decreased mortality with primary resection and anastomosis (7.4 vs. 15.6 percent; odds ratio = 0.44). No significant difference in mortality was observed in trials matched for severity of peritonitis Hinchey > 2 (14.1 vs. 14.4 percent; odds ratio = 0.85). Sensitivity analysis did not reveal significant heterogeneity between the studies for the primary outcome. CONCLUSIONS: Patients selected for primary resection and anastomosis have a lower mortality than those treated by Hartmann's procedure in the emergency setting and comparable mortality under conditions of generalized peritonitis (Hinchey > 2). The retrospective nature of the included studies allows for a considerable degree of selection bias that limits robust and clinically sound conclusions. This analysis highlights the need for high-quality randomized trials comparing the two techniques. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16752192&query_hl=1 ER - TY - JFULL T1 - Comparison of laparoscopic and open ileocecal resection for Crohn's disease: a metaanalysis. A1 - Tilney, HS A1 - Constantinides, VA A1 - Heriot, AG A1 - Nicolaou, M A1 - Athanasiou, T A1 - Ziprin, P A1 - Darzi, AW A1 - Tekkis, PP J1 - Surg Endosc Y1 - 2006/07// VL - 20 SN - 1432-2218 SP - 1036 EP - 1044 N2 - BACKGROUND: The role of laparoscopic surgery for patients with ileocecal Crohn's disease is a contentious issue. This metaanalysis aimed to compare open resection with laparoscopically assisted resection for ileocecal Crohn's disease. METHODS: A literature search of the Medline, Ovid, Embase, and Cochrane databases was performed to identify comparative studies reporting outcomes for both laparoscopic and open ileocecal resection. Metaanalytical techniques were applied to identify differences in outcomes between the two groups. Sensitivity analysis was undertaken to evaluate the heterogeneity of the study. RESULTS: Of 20 studies identified by literature review, 15 satisfied the criteria for inclusion in the study. These included outcomes for 783 patients, 338 (43.2%) of whom had undergone laparoscopic resection, with an overall conversion rate to open surgery of 6.8%. The operative time was significantly longer in the laparoscopic group, by 29.6 min (p = 0.002), although the blood loss and complications in the two groups were similar. In terms of postoperative recovery, the laparoscopic patients had a significantly shorter time for recovery of their enteric function and a shorter hospital stay, by 2.7 days (p < 0.001). CONCLUSIONS: For selected patients with noncomplicated ileocecal Crohn's disease, laparoscopic resection offered substantial advantages in terms of more rapid resolution of postoperative ileus and shortened hospital stay. There was no increase in complications, as compared with open surgery. The contraindications to laparoscopic approaches for Crohn's disease remain undefined. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16715212&query_hl=1 ER - TY - JFULL T1 - Surgical crisis management skills training and assessment: a simulation[corrected]-based approach to enhancing operating room performance. A1 - Moorthy, K A1 - Munz, Y A1 - Forrest, D A1 - Pandey, V A1 - Undre, S A1 - Vincent, C A1 - Darzi, A J1 - Ann Surg Y1 - 2006/07// VL - 244 SN - 0003-4932 SP - 139 EP - 147 N2 - BACKGROUND: Intraoperative surgical crisis management is learned in an unstructured manner. In aviation, simulation training allows aircrews to coordinate and standardize recovery strategies. Our aim was to develop a surgical crisis simulation and evaluate its feasibility, realism, and validity of the measures used to assess performance. METHODS: Surgical trainees were exposed to a bleeding crisis in a simulated operating theater. Assessment of performance consisted of a trainee's technical ability to control the bleeding and of their team/human factors skills. This assessment was performed in a blinded manner by 2 surgeons and one human factors expert. Other measures consisted of time measures such as time to diagnose the bleeding (TD), inform team members (TT), achieve control (TC), and close the laceration (TL). Blood loss was used as a surrogate outcome measures. RESULTS: There were considerable variations within both senior (n = 10) and junior (n = 10) trainees for technical and team skills. However, while the senior trainees scored higher than the juniors for technical skills (P = 0.001), there were no differences in human factors skills. There were also significant differences between the 2 groups for TD (P = 0.01), TC (P = 0.001), and TL (0.001). The blood loss was higher in the junior group. CONCLUSIONS: We have described the development of a novel simulated setting for the training of crisis management skills and the variability in performance both in between and within the 2 groups. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16794399&query_hl=1 ER - TY - JFULL T1 - Outcome of kidney transplantation from non-heart-beating versus heart-beating cadaveric donors A1 - Kokkinos, C A1 - Antcliffe, D A1 - Nanidis, T A1 - Tekkis, P A1 - Athanasiou, T A1 - Darzi, A A1 - Papalois, V J1 - NEPHROL DIAL TRANSPL Y1 - 2006/07// VL - 21 SN - 0931-0509 SP - 522 EP - 523 ER - TY - JFULL T1 - Self-assessment of performance among surgical trainees during simulated procedures in a simulated operating theater. A1 - Moorthy, K A1 - Munz, Y A1 - Adams, S A1 - Pandey, V A1 - Darzi, A A1 - Imperial College--St. Mary's Hospital Simulation Group J1 - Am J Surg Y1 - 2006/07// VL - 192 SN - 0002-9610 SP - 114 EP - 118 N2 - BACKGROUND: The ability of surgeons to assess their own performance is essential for training and self-regulation. The latter is based on the premise that they recognize their weaknesses and seek remedial action accordingly. METHODS: Twenty-seven surgical trainees performed a simulated saphenofemoral high-tie on a synthetic model in a simulated operating theater. The performance assessment consisted of blinded rating of technical skills and a global rating of team skills by a human factors expert and a trained surgical research fellow. Subjects also were asked to assess their own performance using the same methods. Spearman's rho was used for data analysis. RESULTS: There was a strong correlation between the experts rating of technical skills and self-assessment (rho = .64). However, the correlation improved with increasing experience. It was .24 for junior trainees, .43 for those with intermediate experience, and .52 for senior trainees. There was a low correlation between the self-assessment and the expert scores for human factors skills (rho = .31). The correlation was higher for the 2 junior groups compared with the senior trainees. CONCLUSIONS: Unlike other studies on self-assessment, this study found that senior surgical trainees are accurate in their self-assessment of technical skills. However, this was not true in the case of human factors skills. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16769287&query_hl=1 ER - TY - JFULL T1 - Comparison of laparoscopic versus hand-assisted live donor nephrectomy A1 - Kokkinos, C A1 - Nanidis, T A1 - Antcliffe, D A1 - Tekkis, P A1 - Papalois, V J1 - NEPHROL DIAL TRANSPL Y1 - 2006/07// VL - 21 SN - 0931-0509 SP - 526 EP - 526 ER - TY - JFULL T1 - Effect of off-pump coronary artery bypass surgery on clinical, angiographic, neurocognitive, and quality of life outcomes: randomised controlled trial. A1 - Al-Ruzzeh, S A1 - George, S A1 - Bustami, M A1 - Wray, J A1 - Ilsley, C A1 - Athanasiou, T A1 - Amrani, M J1 - BMJ Y1 - 2006/06/10/ VL - 332 SN - 1468-5833 SP - 1365 EP - 1365 N2 - OBJECTIVE: To compare the clinical, angiographic, neurocognitive, and quality of life outcomes of off-pump coronary artery bypass surgery with conventional coronary artery bypass grafting surgery using cardiopulmonary bypass. DESIGN: Randomised controlled clinical trial. SETTING: Tertiary cardiothoracic centre in Middlesex, England. PARTICIPANTS: 168 patients (27 women) requiring primary isolated coronary artery bypass grafting surgery. INTERVENTIONS: Patients were randomised to conventional coronary artery bypass grafting surgery using cardiopulmonary bypass (n = 84) or off-pump coronary artery bypass surgery (n = 84), carried out by one surgeon. Angiographic examination was carried out at three months postoperatively. Neurocognitive tests were carried out at baseline and at six weeks and six months postoperatively. MAIN OUTCOME MEASURES: Clinical outcome, graft patency at three months, neurocognitive function at six weeks and six months, and health related quality of life. RESULTS: Graft patency was evaluated by angiography in 151 (89.9%) patients and was similar between the cardiopulmonary bypass and off-pump groups (risk difference - 1%, 95% confidence interval - 5% to 4%), with the off-pump group considered the treatment group. Patients in the off-pump group required fewer blood transfusions (1.7 units v 1.0 unit, P = 0.02), shorter duration of mechanical ventilation (7.7 hours v 3.9 hours, P = 0.03), and shorter hospital stay (10.8 days v 8.9 days). Scores for neurocognitive function showed a significant difference in three memory subtests at six weeks and two memory subtests at six months in favour of the off-pump group. CONCLUSIONS: Patients who underwent off-pump coronary artery bypass surgery showed similar patency of grafts, better clinical outcome, shorter hospital stay, and better neurocognitive function than patients who underwent conventional coronary artery bypass grafting surgery using cardiopulmonary bypass. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16740529&query_hl=1 ER - TY - JFULL T1 - Mechanical properties of the human abdominal wall measured in vivo during insufflation for laparoscopic surgery. A1 - Song, C A1 - Alijani, A A1 - Frank, T A1 - Hanna, GB A1 - Cuschieri, A J1 - Surg Endosc Y1 - 2006/06// VL - 20 SN - 1432-2218 SP - 987 EP - 990 N2 - BACKGROUND: Carbon dioxide insufflation of the peritoneal cavity for laparoscopic surgery offers a unique opportunity to measure some mechanical properties of the human abdominal wall that hitherto have been difficult to obtain. METHODS: The movement and change of the abdominal wall during insufflation to a pressure of 12 mmHg was studied in 18 patients undergoing laparoscopic surgery using a remote motion analysis system that does not compromise the sterility of the operative filed. These data together with the known abdominal wall thickness of each patient (measured by preoperative ultrasound scanning) enabled estimates of mechanical stiffness. RESULTS: The findings showed that the abdominal wall changes from a cylinder to a dome during inflation, and that its area is increased by 15%. A volume, averaging 1.27 x 10(-3)m(3), results from expansion, reshaping of the abdominal wall, and displacement of the diaphragm. The abdominal wall is stiffer in the transverse plane than in the sagittal plane (Young's modulus, 42.5 +/- 9.0 kPa vs 22.5 +/- 2.6 kPa; p = 0.03; paired t-test). CONCLUSIONS: Measurements of mechanical properties of the abdominal wall in patients undergoing laparoscopic surgery were obtained using a remote motion analysis system. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16738998&query_hl=1 ER - TY - JFULL T1 - Cardiac output monitoring with brachial arterial catheter. A1 - Al-Ruzzeh, S A1 - Modine, T A1 - Athanasiou, T A1 - Fayad, G J1 - J Cardiothorac Vasc Anesth Y1 - 2006/06// VL - 20 SN - 1053-0770 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16750755&query_hl=1 ER - TY - JFULL T1 - Training junior operative residents in laparoscopic suturing skills is feasible and efficacious. A1 - Aggarwal, R A1 - Hance, J A1 - Undre, S A1 - Ratnasothy, J A1 - Moorthy, K A1 - Chang, A A1 - Darzi, A J1 - Surgery Y1 - 2006/06// VL - 139 SN - 0039-6060 SP - 729 EP - 734 N2 - BACKGROUND: Laparoscopic suturing has been regarded as an advanced operative task, and courses to develop this skill are aimed at senior trainees and consultants. This study evaluates the role of laparoscopic suturing courses in the modern operative training curriculum. METHODS: The performance of 9 senior operative trainees (course A) was compared to that of 14 junior operative trainees (course B) at identical, 2-day laparoscopic suturing courses. Pre- and post-course assessments measured time taken, dexterity, and quality for the placement of 1 intracorporeal suture on synthetic bowel. Post-course data was compared to the performance of a group of 6 experts. RESULTS: The median number of laparoscopic procedures carried out unassisted was 130 for surgeons on course A, and 0 for those on course B. At the pre-course assessment, senior trainees (course A) were significantly faster, more dexterous, and had higher checklist scores then those on course B. Both groups had improved significantly by the end of each the course. Post-course comparison between the 2 groups showed equivalent path length and checklist scores, although group A remained faster (P = .003) and made fewer movements (P = .033). Senior trainees had similar performance data to the group of expert surgeons, although this was not the case for junior trainees. CONCLUSIONS: Endoscopic suturing is a task that can be learned by operative trainees during short skills courses, regardless of baseline laparoscopic experience. Skills training in laparoscopic suturing should thus not be reserved only for those contemplating advanced laparoscopic operation. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16782426&query_hl=1 ER - TY - JFULL T1 - Simulated patients and the development of procedural and operative skills. A1 - Nestel, D A1 - Kneebone, R A1 - Black, S J1 - Med Teach Y1 - 2006/06// VL - 28 SN - 1466-187X SP - 390 EP - 391 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16807185&query_hl=1 ER - TY - JFULL T1 - Prediction of postoperative mortality in elderly patients with colorectal cancer. A1 - Heriot, AG A1 - Tekkis, PP A1 - Smith, JJ A1 - Cohen, CR A1 - Montgomery, A A1 - Audisio, RA A1 - Thompson, MR A1 - Stamatakis, JD J1 - Dis Colon Rectum Y1 - 2006/06// VL - 49 SN - 0012-3706 SP - 816 EP - 824 N2 - PURPOSE: This study was designed to develop a model for predicting postoperative mortality in elderly patients undergoing surgery for colorectal cancer. METHODS: This multicenter study was conducted by using routinely collected clinical data, assessing patients older than aged 80 years, with 30-day operative mortality as the primary end point. Data were collected from The Association of Coloproctology of Great Britain and Ireland database, encompassing 8,077 newly diagnosed colorectal cancer patients undergoing resectional surgery in 79 hospitals between April 2000 to March 2002, The Association of Coloproctology Malignant Bowel Obstruction Study, encompassing 1,046 patients with malignant bowel obstruction in 148 hospitals, between April 1998 to March 1999, and The Wales-Trent audit, encompassing 3,522 newly diagnosed colorectal cancer patients, between July 1992 to June 1993. A multilevel logistic regression model was developed to adjust for case-mix and to accommodate the variability of outcomes between the three study populations. The model was internally validated using a Bayesian resampling technique and tested using measures of discrimination, calibration, and subgroup analysis. RESULTS: A total of 2,533 patients satisfied the inclusion criteria, with a 30-day mortality of 15.6 percent. Multivariate analysis identified the following independent risk factors: age (odds ratio for 85-90, 90-95, >95 vs. 80-85 = 1.1, 1.8, 2.9), American Society of Anesthesiology grade (odds ratio for Grade III, IV vs. I-II = 2.7, 6.1), operative urgency (odds ratio for emergency vs. elective = 1.9), no cancer excision vs. resection (odds ratio = 1.2), and metastatic disease (odds ratio for metastases vs. no metastases = 1.9). The model offered adequate discrimination (area under receiver operator curve = 0.732) and excellent agreement between observed and predicted outcomes during eight colorectal procedures (P = 0.885). CONCLUSIONS: The elderly colorectal cancer model can accurately estimate 30-day mortality in patients older than aged 80 years undergoing surgery for colorectal cancer. Because the mortality can be considerable, this may have important implications when determining management for this group of patients. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16741639&query_hl=1 ER - TY - JFULL T1 - Laparoscopic vs open subtotal colectomy for benign and malignant disease. A1 - Tilney, HS A1 - Lovegrove, RE A1 - Purkayastha, S A1 - Heriot, AG A1 - Darzi, AW A1 - Tekkis, PP J1 - Colorectal Dis Y1 - 2006/06// VL - 8 SN - 1462-8910 SP - 441 EP - 450 N2 - AIM: The present meta-analysis aims to compare short-term and long-term outcomes in patients undergoing laparoscopic or open subtotal colectomy for benign and malignant disease. METHODS: A literature search of Medline, Ovid, Embase and Cochrane databases was performed to identify studies published between 1992 and 2005, comparing laparoscopic (LSC) and open (OSC) subtotal colectomy. A random effect meta-analytical technique was used and sensitivity analysis performed on studies published since the beginning of 2000, higher quality papers, those reporting on more than 40 patients, and those studies reporting on adult cases or acute colitis. RESULTS: A total of eight studies satisfied the criteria for inclusion. These included outcomes on 336 patients, 143 (42.6%) of whom had undergone laparoscopic resection, with an overall conversion rate to open surgery of 5% (range 0-11.8%). Operative time was significantly longer in the laparoscopic group by 86.2 min (P < 0.001) and throughout subgroup analysis, although it was only in patients with acute colitis that this finding was without significant heterogeneity. Operative blood loss was less in the laparoscopic group by 57.5 millilitres in high quality and studies published since 2000, and 65.3 millilitres in those reporting on more than 40 patients. There was no significant difference in early or long-term complications between the groups. A statistically significant reduction in length of postoperative stay was observed in the laparoscopic groups by 2.9 days (P < 0.001). CONCLUSION: Laparoscopic subtotal colectomy was associated with longer operating times but a reduced length of stay compared to open surgery. Although short-term outcomes were equivalent in both groups, the suggested benefits in terms of reduced long-term obstructive complications were not supported by this meta-analysis. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16684090&query_hl=1 ER - TY - JFULL T1 - Cadaver validation of intensity-based ultrasound to CT registration A1 - Penney GP A1 - Barratt DC A1 - Chan CSK A1 - Slomczykowski M A1 - Carter TJ A1 - Edwards PJ A1 - Hawkes DJ J1 - Medical Image Analysis Y1 - 2006/06// IS - 3 VL - 10 SN - 1361-8415 SP - 385 EP - 395 ER - TY - JFULL T1 - Mechanical properties of the human abdominal wall measured in vivo during insufflation for laparoscopic surgery. A1 - Song, C A1 - Alijani, A A1 - Frank, T A1 - Hanna, GB A1 - Cuschieri, A J1 - Surg Endosc Y1 - 2006/05/12/ SN - 1432-2218 N2 - BACKGROUND: Carbon dioxide insufflation of the peritoneal cavity for laparoscopic surgery offers a unique opportunity to measure some mechanical properties of the human abdominal wall that hitherto have been difficult to obtain. METHODS: The movement and change of the abdominal wall during insufflation to a pressure of 12 mmHg was studied in 18 patients undergoing laparoscopic surgery using a remote motion analysis system that does not compromise the sterility of the operative filed. These data together with the known abdominal wall thickness of each patient (measured by preoperative ultrasound scanning) enabled estimates of mechanical stiffness. RESULTS: The findings showed that the abdominal wall changes from a cylinder to a dome during inflation, and that its area is increased by 15%. A volume, averaging 1.27 x 10(-3)m(3), results from expansion, reshaping of the abdominal wall, and displacement of the diaphragm. The abdominal wall is stiffer in the transverse plane than in the sagittal plane (Young's modulus, 42.5 +/- 9.0 kPa vs 22.5 +/- 2.6 kPa; p = 0.03; paired t-test). CONCLUSIONS: Measurements of mechanical properties of the abdominal wall in patients undergoing laparoscopic surgery were obtained using a remote motion analysis system. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16699888&query_hl=1 ER - TY - JFULL T1 - Prediction of Postoperative Mortality in Elderly Patients With Colorectal Cancer. A1 - Heriot, AG A1 - Tekkis, PP A1 - Smith, JJ A1 - Cohen, CR A1 - Montgomery, A A1 - Audisio, RA A1 - Thompson, MR A1 - Stamatakis, JD J1 - Dis Colon Rectum Y1 - 2006/05/11/ SN - 0012-3706 N2 - PURPOSE: This study was designed to develop a model for predicting postoperative mortality in elderly patients undergoing surgery for colorectal cancer. METHODS: This multicenter study was conducted by using routinely collected clinical data, assessing patients older than aged 80 years, with 30-day operative mortality as the primary end point. Data were collected from The Association of Coloproctology of Great Britain and Ireland database, encompassing 8,077 newly diagnosed colorectal cancer patients undergoing resectional surgery in 79 hospitals between April 2000 to March 2002, The Association of Coloproctology Malignant Bowel Obstruction Study, encompassing 1,046 patients with malignant bowel obstruction in 148 hospitals, between April 1998 to March 1999, and The Wales-Trent audit, encompassing 3,522 newly diagnosed colorectal cancer patients, between July 1992 to June 1993. A multilevel logistic regression model was developed to adjust for case-mix and to accommodate the variability of outcomes between the three study populations. The model was internally validated using a Bayesian resampling technique and tested using measures of discrimination, calibration, and subgroup analysis. RESULTS: A total of 2,533 patients satisfied the inclusion criteria, with a 30-day mortality of 15.6 percent. Multivariate analysis identified the following independent risk factors: age (odds ratio for 85-90, 90-95, >95 vs. 80-85 = 1.1, 1.8, 2.9), American Society of Anesthesiology grade (odds ratio for Grade III, IV vs. I-II = 2.7, 6.1), operative urgency (odds ratio for emergency vs. elective = 1.9), no cancer excision vs. resection (odds ratio = 1.2), and metastatic disease (odds ratio for metastases vs. no metastases = 1.9). The model offered adequate discrimination (area under receiver operator curve = 0.732) and excellent agreement between observed and predicted outcomes during eight colorectal procedures (P = 0.885). CONCLUSIONS: The elderly colorectal cancer model can accurately estimate 30-day mortality in patients older than aged 80 years undergoing surgery for colorectal cancer. Because the mortality can be considerable, this may have important implications when determining management for this group of patients. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16680501&query_hl=1 ER - TY - JFULL T1 - On a new vision for academia. A1 - Darzi, A J1 - Health Serv J Y1 - 2006/05/11/ VL - 116 SN - 0952-2271 SP - 33 EP - 33 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16749404&query_hl=1 ER - TY - JFULL T1 - Homograft implantation techniques in the aortic position: to preserve or replace the aortic root? A1 - Athanasiou, T A1 - Jones, C A1 - Jin, R A1 - Grunkemeier, GL A1 - Ross, DN J1 - Ann Thorac Surg Y1 - 2006/05// VL - 81 SN - 1552-6259 SP - 1578 EP - 1585 N2 - BACKGROUND: One determinant of durability of the homograft in the aortic position is the implantation technique. This study uses meta-analytical techniques to evaluate the differences in early and long-term outcomes of patients undergoing aortic homograft implantation with either a root replacement or a root preserving technique. METHODS: A systematic review of the literature (1965-2005) reporting results after homograft implantation in the aortic position with emphasis in the implantation technique was performed. Random and fixed-effects models were used. Cumulative and influential meta-analysis, graphic exploration, and sensitivity analysis were carried out to explain the heterogeneity between studies and to investigate potential publication bias. RESULTS: Eleven studies were included. None of the studies was randomized. There was no significant difference in early mortality between root replacement and root preserving groups (odds ratio = 2.57 with 95% confidence interval [CI] 0.68-9.72 in random-effects model) and the root replacement group had a significantly lower rate of reoperation during long-term follow-up (hazard ratio = 0.55 with 95% CI 0.38-0.80 in random-effects model). Subgroup analysis focusing on patients having the subcoronary technique for homograft implantation showed similar results. Significant heterogeneity between studies can be detected. No publication bias was found. CONCLUSIONS: There was no significant difference in early mortality between root replacement and root preserving groups. However, the root replacement technique group had a significantly lower rate of reoperation during long-term follow-up. Excluding outliers identified in a funnel plot reduced the heterogeneity and reached a similar conclusion. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16631637&query_hl=1 ER - TY - JFULL T1 - Outcome following extended resection for T4 rectal cancer A1 - Heriot, A A1 - Woods, R A1 - Ngan, S A1 - Tekkis, PP A1 - Mackay, J J1 - DIS COLON RECTUM Y1 - 2006/05// VL - 49 SN - 0012-3706 SP - 775 EP - 775 ER - TY - JFULL T1 - Optimising preoperative diagnosis in phyllodes tumour of the breast. A1 - Jacklin, RK A1 - Ridgway, PF A1 - Ziprin, P A1 - Healy, V A1 - Hadjiminas, D A1 - Darzi, A J1 - J Clin Pathol Y1 - 2006/05// VL - 59 SN - 0021-9746 SP - 454 EP - 459 N2 - The role of the pathologist in the preoperative diagnosis of phyllodes tumours of the breast is critical to appropriate surgical planning. However, reliable differentiation of phyllodes tumour from cellular fibroadenoma remains difficult. Preoperative diagnostic accuracy allows correct surgical treatment, avoiding the pitfalls of reoperation because of inadequate excision, or surgical overtreatment. Specific clinical indices may arouse diagnostic suspicion but are unreliable for confirmation, as with current imaging modes. Fine needle aspiration cytology has a high false negative rate. Few studies have evaluated the role of core needle biopsy, but it may prove a useful adjunct. Both diagnostic and prognostic information may in future be gained from application of immunohistochemical and other techniques assessing the expression of proliferative markers including p53, Ki-67, and others. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16461806&query_hl=1 ER - TY - JFULL T1 - A predictive model for the length of postoperative stay following colorectal cancer surgery A1 - Tilney, HS A1 - Tekkis, PP A1 - Lovegrove, RE A1 - Smith, JJ A1 - Thompson, MR A1 - Stamatakis, JD A1 - Heriot, AG J1 - DIS COLON RECTUM Y1 - 2006/05// VL - 49 SN - 0012-3706 SP - 784 EP - 784 ER - TY - JFULL T1 - Gastrointestinal: gastric wall hematoma. A1 - Ng, SC A1 - Shariff, M A1 - Datta, D A1 - Hanna, G A1 - Holdstock, G J1 - J Gastroenterol Hepatol Y1 - 2006/05// VL - 21 SN - 0815-9319 SP - 915 EP - 915 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16704546&query_hl=1 ER - TY - JFULL T1 - Microvessel and carbonic anhydrase 9 (CA-9) expression, angiogenesis and prognosis in patients with rectal cancer A1 - Rasheed, S A1 - Harris, AL A1 - Tekkis, PP A1 - Turley, H A1 - Silver, A A1 - Johnson, V A1 - McDonald, PJ A1 - Talbot, IC A1 - Glynne-Jones, R A1 - Northover, JM A1 - Guenther, T J1 - DIS COLON RECTUM Y1 - 2006/05// VL - 49 SN - 0012-3706 SP - 711 EP - 711 ER - TY - JFULL T1 - Hypoxia-inducible factor 1-alpha (HIF-1 alpha) and hypoxia-inducible factor 2-alpha (HIF-2 alpha) expression, angiogenesis and relationship to prognosis in rectal cancer patients A1 - Rasheed, S A1 - Harris, AL A1 - Tekkis, PP A1 - Turley, H A1 - Silver, A A1 - Johnson, V A1 - McDonald, PJ A1 - Talbot, IC A1 - Glynne-Jones, R A1 - Northover, JM A1 - Guenther, T J1 - DIS COLON RECTUM Y1 - 2006/05// VL - 49 SN - 0012-3706 SP - 719 EP - 720 ER - TY - JFULL T1 - An inexpensive 3-D model for teaching local flap design on the face and head. A1 - Nicolaou, M A1 - Yang, GZ A1 - Darzi, A A1 - Butler, PE J1 - Ann R Coll Surg Engl Y1 - 2006/05// VL - 88 SN - 1478-7083 SP - 320 EP - 320 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17390517&query_hl=1 ER - TY - JFULL T1 - Operative strategies for diverticular peritonitis - A decision analysis between primary resection and anastomosis versus Hartmann's procedures A1 - Constantinides, VA A1 - Tekkis, PP A1 - Heriot, A A1 - Remzi, F A1 - Darzi, A A1 - Senapati, A J1 - DIS COLON RECTUM Y1 - 2006/05// VL - 49 SN - 0012-3706 SP - 774 EP - 774 ER - TY - JFULL T1 - Evaluation of the risk of a nonrestorative resection for the treatment of diverticular disease: the Cleveland Clinic diverticular disease propensity score. A1 - Aydin, HN A1 - Tekkis, PP A1 - Remzi, FH A1 - Constantinides, V A1 - Fazio, VW J1 - Dis Colon Rectum Y1 - 2006/05// VL - 49 SN - 0012-3706 SP - 629 EP - 639 N2 - PURPOSE: The choice of operation for diverticular disease is a contentious issue, particularly in patients with acute symptoms. This study compares early outcomes between primary resection and anastomosis and Hartmann's resection and describes a propensity score for the selection of patients for nonrestorative procedures. METHODS: Data were collected from 731 patients undergoing primary resection and anastomosis (Group 1) and 123 patients undergoing primary Hartmann's resection (Group 2) for diverticular disease in a single tertiary referral center from January 1981 to May 2003. Multifactorial logistic regression was used to develop a propensity score for estimating the likelihood of performing a nonrestorative procedure. RESULTS: Operative 30-day mortality and surgical or medical complications were 0.7 percent, 26.0 percent, and 4.8 percent for primary resection and anastomosis and 12 percent, 43.9 percent, and 14.6 percent for Hartmann's resection, respectively (P < 0.001). There was no difference in the readmission rates between primary resection and anastomosis and Hartmann's resection (7.6 percent vs. 9.9 percent, P = 0.428). Laparoscopy was used for 32.7 percent of primary resection and anastomosis vs. 1.6 percent for Hartmann's resection (P < 0.001). Independent predictors in favor for Hartmann's resection were body mass index > or = 30 kg/m2 (odd's ratio = 2.32), Mannheim peritonitis index >10 (odd's ratio = 6.75), operative urgency (emergency, urgent vs. elective surgery, odd's ratio = 16.08 vs. 13.32), and Hinchey stage > II (odd's ratio = 27.82). The area under the receiver operating characteristic curve for the choice of operative procedure was 93.9 percent. CONCLUSIONS: Although Hartmann's resection was associated with a higher incidence of postoperative adverse events, the choice of operation was dependent on the patient presentation and intra-abdominal contamination, which can be quantified in the preoperative setting by the Cleveland Clinic diverticulitis propensity score. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16598405&query_hl=1 ER - TY - JFULL T1 - To divert or not to divert: A propensity model for omission of ileostomy in ileal pouch surgery A1 - Tekkis, PP A1 - Lovegrove, RE A1 - Remzi, FH A1 - Heriot, AG A1 - Tilney, HS A1 - Hull, TL A1 - Strong, SA A1 - Church, JM A1 - Nicholls, RJ A1 - Fazio, VW J1 - DIS COLON RECTUM Y1 - 2006/05// VL - 49 SN - 0012-3706 SP - 738 EP - 739 ER - TY - JFULL T1 - A mixed-valent ruthenium-oxo oxalato cluster Na7[Ru4(mu3-O)4(C2O4)6] with potent anti-HIV activities. A1 - Wong, EL A1 - Sun, RW A1 - Chung, NP A1 - Lin, CL A1 - Zhu, N A1 - Che, CM J1 - J Am Chem Soc Y1 - 2006/04/19/ VL - 128 SN - 0002-7863 SP - 4938 EP - 4939 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16608312&query_hl=1 ER - TY - JFULL T1 - Reply. A1 - Weerasinghe, A A1 - Athanasiou, T A1 - Tekkis, PP J1 - Ann Thorac Surg Y1 - 2006/04// VL - 81 SN - 1552-6259 SP - 1549 EP - 1550 N2 - L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16564327&query_hl=1 ER - TY - JFULL T1 - Does clopidogrel affect outcome after coronary artery bypass grafting? A meta-analysis. A1 - Purkayastha, S A1 - Athanasiou, T A1 - Malinovski, V A1 - Tekkis, P A1 - Foale, R A1 - Casula, R A1 - Glenville, B A1 - Darzi, A J1 - Heart Y1 - 2006/04// VL - 92 SN - 1468-201X SP - 531 EP - 532 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16537769&query_hl=1 ER - TY - JFULL T1 - Recent advances in adult cardiac surgery. A1 - Chikwe, J A1 - Athanasiou, T A1 - Casula, R J1 - Br J Hosp Med (Lond) Y1 - 2006/04// VL - 67 SN - 1750-8460 SP - 200 EP - 205 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16681316&query_hl=1 ER - TY - JFULL T1 - Postoperative renal dysfunction after on-pump versus off-pump coronary revascularization: Role of on-pump hemodilution and transfusions - Reply A1 - Weerasinghe, A A1 - Athanasiou, T A1 - Tekkis, PP J1 - ANN THORAC SURG Y1 - 2006/04// VL - 81 SN - 0003-4975 SP - 1549 EP - 1550 ER - TY - JFULL T1 - Teamwork in the operating theatre: cohesion or confusion? A1 - Undre, S A1 - Sevdalis, N A1 - Healey, AN A1 - Darzi, SA A1 - Vincent, CA J1 - J Eval Clin Pract Y1 - 2006/04// VL - 12 SN - 1356-1294 SP - 182 EP - 189 N2 - RATIONALE: The aim of the research that we report here was to empirically assess the cohesiveness of the multidisciplinary operating theatre (OT) team. METHOD: We used concepts from the team performance and team mental models literature to assess OT professionals' perceptions of their teamwork, the structure of their teams and their respective roles within them and their teams' performance. RESULTS: Team structure: OT professionals would welcome a change from the current structure of the team, although there was no agreement on what that structure is. Nurses perceived the team as unitary, surgeons and anaesthetists perceived it as comprising multiple subteams. Team roles: OT professionals tended to overrate their own understanding of their colleagues' role in the OT relative to the role understanding that the colleagues attributed to them. This tendency was especially marked for the surgeons. Team communication and team performance: OT professionals agreed on the relative importance of the various communicating pairs in the OT. Moreover, they were satisfied with the quality of communication among them, except for the communication between the surgeon and the anaesthetist, which received lower ratings. Finally, the quality of the teamwork in the OT was deemed acceptable, although there is room for improvement. CONCLUSIONS: The OT environment need not be as cohesive as previously assumed--a finding that carries implications for the effectiveness of team training interventions. Further research is needed in order to fully comprehend the dynamics of the OT as a working environment and, most importantly, their relation to patient safety. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16579827&query_hl=1 ER - TY - JFULL T1 - Optimal prediction of mortality after abdominal aortic aneurysm repair with statistical models (vol 43, pg 467, 2006) A1 - Hadjianastassiou, VG A1 - Franco, L A1 - Jerez, JM A1 - Evangelou, IE A1 - Goldhill, DR A1 - Tekkis, PP A1 - Hands, LJ J1 - J VASC SURG Y1 - 2006/04// VL - 43 SN - 0741-5214 SP - 877 EP - 877 ER - TY - JFULL T1 - Meta-analysis of observational studies of ileorectal versus ileal pouch-anal anastomosis for familial adenomatous polyposis. A1 - Aziz, O A1 - Athanasiou, T A1 - Fazio, VW A1 - Nicholls, RJ A1 - Darzi, AW A1 - Church, J A1 - Phillips, RK A1 - Tekkis, PP J1 - Br J Surg Y1 - 2006/04// VL - 93 SN - 0007-1323 SP - 407 EP - 417 N2 - BACKGROUND: Surgery for familial adenomatous polyposis (FAP) aims to minimize cancer risk while providing good functional outcome. Colectomy with ileorectal anastomosis and proctocolectomy with ileal pouch-anal anastomosis both offer this, but there is no clear consensus about which is better. METHODS: This is a meta-analysis of comparative studies published between 1991 and 2003 reporting early and late postoperative adverse events, functional outcomes and quality of life. RESULTS: Twelve studies containing 1002 patients (53.4 per cent ileal pouch, 46.6 per cent ileorectal anastomosis) were identified. Bowel frequency (weighted mean difference 1.62 (95 per cent confidence interval (c.i.) 1.05 to 2.20)), night defaecation (odds ratio (OR) 6.64 (95 per cent c.i. 2.99 to 14.74)) and use of incontinence pads (OR 2.72 (95 per cent c.i. 1.02 to 7.23)) were significantly less in the ileorectal group, although faecal urgency was reduced with the ileal pouch (odds ratio 0.43 (95 per cent c.i. 0.23 to 0.80)). Reoperation within 30 days was more common after ileal pouch construction (23.4 versus 11.6 per cent; OR 2.11 (95 per cent c.i. 1.21 to 3.70)). There was no significant difference between the techniques in terms of sexual dysfunction, dietary restriction, or postoperative complications. Rectal cancer was a diagnosis only in the ileorectal group (5.5 per cent). CONCLUSION: Ileal pouch and ileorectal anastomoses have individual merits. Further research is needed to determine which most benefits patients with FAP. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16511903&query_hl=1 ER - TY - JFULL T1 - Self-appraisal hierarchical task analysis of laparoscopic surgery performed by expert surgeons. A1 - Sarker, SK A1 - Hutchinson, R A1 - Chang, A A1 - Vincent, C A1 - Darzi, AW J1 - Surg Endosc Y1 - 2006/04// VL - 20 SN - 1432-2218 SP - 636 EP - 640 N2 - BACKGROUND: Evaluation of technical skill is notoriously difficult because of the subjectivity and time-consuming expert analysis. No ongoing evaluation scheme exists to assess the continuing competency of surgeons. This study examined whether surgeons' self-assessment accurately reflects their actual surgical technique. METHODS: Hierarchical task analysis (HTA) of laparoscopic cholecystectomy was constructed. Ten expert surgeons were asked to modify the HTA for their own technique. The HTAs of these surgeons then were compared with their actual operations, which had been recorded and assessed by two observers. RESULTS: A total of 40 operations were assessed. All the gallbladders subjected to surgery were classified as grades 1 to 3. The mean interrater reliability for the two observers had a k value of 0.84 (p < 0.05), and the mean intrarater reliability between surgeons and observers had a k value of 0.79 (p < 0.05). CONCLUSIONS: Surgeons' self-evaluation is accurate for technical skills aspects of their operations. This study demonstrates that self-appraisal using HTA is feasible, accurate, and practical. The authors aim to increase the numbers in their study and also to recruit residents. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16446987&query_hl=1 ER - TY - JFULL T1 - Competence assessment of laparoscopic operative and cognitive skills: Objective Structured Clinical Examination (OSCE) or Observational Clinical Human Reliability Assessment (OCHRA). A1 - Tang, B A1 - Hanna, GB A1 - Carter, F A1 - Adamson, GD A1 - Martindale, JP A1 - Cuschieri, A J1 - World J Surg Y1 - 2006/04// VL - 30 SN - 0364-2313 SP - 527 EP - 534 N2 - BACKGROUND: There is no agreed system that is acknowledged as the ideal assessment of laparoscopic operative and cognitive skills. A new approach that combines Objective Structured Clinical Examination (OSCE) and Observational Clinical Human Reliability Assessment (OCHRA) was developed and used to assess trainees' operative and cognitive skills during laparoscopic training courses. METHODS: Performance of 60 trainees participating in 3-day essential laparoscopic skills training (cognitive and psychomotor) courses were assessed and scored using both OSCE and OCHRA. RESULTS: The study showed significant inverse correlations between the number of technical errors identified by OCHRA and the scores obtained by OSCE for individual tasks performed either by electro-surgical hook or laparoscopic scissors (r = -0.864 and r = -0.808, respectively). Significant differences between trainees were observed in relation to both overall OSCE scores and OCHRA parameters: execution time, total errors, and consequential errors (P < 0.001). CONCLUSIONS: OCHRA provides a discriminative feedback assessment of laparoscopic operative skills. OCHRA and OSCE are best regarded as complementary assessment tools for operative and cognitive skills. The present study has documented significant variance between surgical trainees in the acquisition of both cognitive and operative skills. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16547622&query_hl=1 ER - TY - JFULL T1 - Laparoscopic vs. open surgery for diverticular disease: a meta-analysis of nonrandomized studies. A1 - Purkayastha, S A1 - Constantinides, VA A1 - Tekkis, PP A1 - Athanasiou, T A1 - Aziz, O A1 - Tilney, H A1 - Darzi, AW A1 - Heriot, AG J1 - Dis Colon Rectum Y1 - 2006/04// VL - 49 SN - 0012-3706 SP - 446 EP - 463 N2 - PURPOSE: This study was designed to compare outcomes between laparoscopic and open surgery for patients with diverticular disease by using meta-analytic techniques. METHODS: Comparative studies published between 1996 and 2004 of open vs. laparoscopic surgery for diverticular disease were included. The end points that were evaluated are operative and functional outcomes and adverse events. A random effects model was used during analysis of these outcomes; heterogeneity was assessed and sensitivity analysis was performed to account for bias in patient selection. RESULTS: Twelve nonrandomized studies, incorporating 19,608 patients, were included in the analysis. One study with 18,444 patients accounted for 94.5 percent of the total sample. Laparoscopic surgery resulted in reduced infective (odds ratio, 0.61; P = 0.01), pulmonary (odds ratio, 0.4; P < 0.001), gastrointestinal tract (odds ratio, 0.75; P = 0.03), and cardiovascular complications (odds ratio, 0.28; P = 0.0008) with no significant heterogeneity. Operative time was longer with laparoscopic surgery (weighted mean difference, 67.59; P = 0.04), and length of stay was significantly shorter (weighted mean difference, -3.81; P < 0.0001); however, these outcomes demonstrated significant heterogeneity. These results remained significant throughout all the sensitivity analyses except when evaluating high-quality studies (when the study with 18,444 patients was excluded), in which only blood loss and length of stay were significantly in favor of the laparoscopic group. CONCLUSIONS: The results for patients selected for laparoscopic surgery compared with open surgery for diverticular disease are equivalent with a potential reduction in complications and hospital stay. Laparoscopic surgery for diverticular disease performed by appropriately experienced surgeons in the elective setting may be safe and feasible; because of the potential of significant bias arising from the included studies, a randomized, controlled trial is recommended. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16534656&query_hl=1 ER - TY - JFULL T1 - Treatment of poisoning induced cardiac impairment using cardiopulmonary bypass: a review. A1 - Purkayastha, S A1 - Bhangoo, P A1 - Athanasiou, T A1 - Casula, R A1 - Glenville, B A1 - Darzi, AW A1 - Henry, JA J1 - Emerg Med J Y1 - 2006/04// VL - 23 SN - 1472-0213 SP - 246 EP - 250 N2 - Severe poisoning can cause potentially fatal cardiac depression. Cardiopulmonary bypass (CPB) can support the depressed myocardium, but there are no clear indications or guidelines available on its use in severe poisoning. A review was conducted of relevant papers in the available literature (seven single case reports of both deliberate and accidental ingestion of cardiotoxic drugs and two animal studies). Although CPB is rarely used in the management of poisoning, it may have potential benefits for haemodynamic instability not responding to conventional measures. At present there is insufficient evidence concerning the use of CPB as a treatment for severe cardiac impairment due to poisoning (grade C). This review suggests that in patients with severe and potentially prolonged reversible cardiotoxicity there is potential for full survival with CPB, provided that the patient has not already sustained hypoxic cerebral damage due to resistant hypotension prior to its use. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16549566&query_hl=1 ER - TY - JFULL T1 - Training in the operating theatre: is it safe? A1 - Aggarwal, R A1 - Darzi, A J1 - Thorax Y1 - 2006/04// VL - 61 SN - 0040-6376 SP - 278 EP - 279 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16565265&query_hl=1 ER - TY - JFULL T1 - Laparoscopic versus open surgery for rectal cancer: a meta-analysis. A1 - Aziz, O A1 - Constantinides, V A1 - Tekkis, PP A1 - Athanasiou, T A1 - Purkayastha, S A1 - Paraskeva, P A1 - Darzi, AW A1 - Heriot, AG J1 - Ann Surg Oncol Y1 - 2006/03// VL - 13 SN - 1068-9265 SP - 413 EP - 424 N2 - BACKGROUND: Laparoscopic rectal cancer surgery aims to provide patients with curative resection while minimizing postoperative morbidity and mortality. This study used meta-analytical techniques to compare laparoscopic and open surgery as the primary treatment for patients with rectal cancer with regard to short-term and long-term outcomes. METHODS: A literature search was performed on all studies between 1993 and 2004 comparing laparoscopic and open surgery for rectal cancer. Subgroup analysis was performed on patients undergoing abdominoperineal excision of the rectum. The following end points were evaluated: operative outcomes, postoperative recovery, and early and late adverse events. RESULTS: Twenty studies matched the selection criteria and reported on 2071 subjects, of whom 909 (44%) underwent laparoscopic and 1162 (56%) underwent open surgery for rectal cancer. Time to stomal function (weighted mean difference [WMD], -1.52; 95% confidence interval [95% CI], -2.20, -1.01), first bowel movement (WMD, -.72; 95% CI, -1.21, -.22), feeding solids (WMD, -.92; 95% CI, -1.35, -.50), and length of hospital stay (WMD, -2.67; 95% CI, -3.81, -1.54) were all significantly reduced after laparoscopic surgery. In patients who underwent abdominoperineal excision of the rectum, wound infection (odds ratio, .15; 95% CI, .03, .73) and requirement for postoperative parenteral analgesia (WMD, -.63; 95% CI, -1.22, -.04) were also significantly reduced. There was no difference between groups in the extent of oncological clearance. CONCLUSIONS: Laparoscopic rectal cancer surgery results in an earlier postoperative recovery and a resected specimen that is oncologically comparable to open surgery. Results from randomized trials reporting long-term outcomes such as cancer recurrence (local and metastatic) and 5-year survival are eagerly awaited. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16450220&query_hl=1 ER - TY - JFULL T1 - Cardiac robotics: a review and St. Mary's experience. A1 - Deeba, S A1 - Aggarwal, R A1 - Sains, P A1 - Martin, S A1 - Athanasiou, T A1 - Casula, R A1 - Darzi, A J1 - Int J Med Robot Y1 - 2006/03// VL - 2 SN - 1478-596X SP - 16 EP - 20 N2 - BACKGROUND: The introduction of the laparoscope led to the progress of surgery to a new era, where surgeries that were deemed major are now being performed through keyhole incisions with comparable outcomes to open surgery. However, with this new technique rose several problems like inaccurate depth perception, diminished tactile feedback, need for experienced assistance, and reduction in degrees of motion of the surgeons hands all of which inspired surgeons and engineers to look for mechanical tools to help in reducing these problems. Henceforth; came the application of robotics in surgery. METHODS: A PubMed and Medline search was performed on cardiac robotic surgery and its applications in mitral valve repair and coronary artery surgery. A total of twenty one articles were picked that allude to the subject. A history of robotic surgery was outlined followed by applications of robotic manipulation in cardiac surgery was narrated. A quick overview of this technology in telemedicine was then outlined followed by future prospects of this technology in surgery was contemplated. RESULTS: The experience of the group from St. Mary's Hospital, London in this field was outlined. During the period of 4 years a total of 102 cases of robotic cardiac surgery were performed. The mean length of hospital stay was 3.1 days with a standard deviation of 1.4 days and the morbidity of the series explained. There was no mortality. CONCLUSION: Early studies have shown that minimally invasive cardiac surgery is feasible and yields results similar to conventional cardiac surgery, yet it is more technically demanding on the surgeon. As advantageous as this new modality is, further multicenter studies are needed to prove its efficacy. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17520609&query_hl=1 ER - TY - JFULL T1 - Informed prognosis [corrected] after abdominal aortic aneurysm repair using predictive modeling techniques [corrected] A1 - Hadjianastassiou, VG A1 - Franco, L A1 - Jerez, JM A1 - Evangelou, IE A1 - Goldhill, DR A1 - Tekkis, PP A1 - Hands, LJ J1 - J Vasc Surg Y1 - 2006/03// VL - 43 SN - 0741-5214 SP - 467 EP - 473 N2 - OBJECTIVE: To identify the best method for the prediction of postoperative mortality in individual abdominal aortic aneurysm surgery (AAA) patients by comparing statistical modelling with artificial neural networks' (ANN) and clinicians' estimates. METHODS: An observational multicenter study was conducted of prospectively collected postoperative Acute Physiology and Chronic Health Evaluation II data for a 9-year period from 24 intensive care units (ICU) in the Thames region of the United Kingdom. The study cohort consisted of 1205 elective and 546 emergency AAA patients. Four independent physiologic variables-age, acute physiology score, emergency operation, and chronic health evaluation-were used to develop multiple regression and ANN models to predict in-hospital mortality. The models were developed on 75% of the patient population and their validity tested on the remaining 25%. The results from these two models were compared with the observed outcome and clinicians' estimates by using measures of calibration, discrimination, and subgroup analysis. RESULTS: Observed in-hospital mortality for elective surgery was 9.3% (95% confidence interval [CI], 7.7% to 11.1%) and for emergency surgery, 46.7% (95% CI, 42.5 to 51.0%). The ANN and the statistical models were both more accurate than the clinicians' predictions. Only the statistical model was internally valid, however, when applied to the validation set of observations, as evidenced by calibration (Hosmer-Lemeshow C statistic, 14.97; P = .060), discrimination properties (area under receiver operating characteristic curve, 0.869; 95% CI, 0.824 to 0.913), and subgroup analysis. CONCLUSIONS: The prediction of in-hospital mortality in AAA patients by multiple regression is more accurate than clinicians' estimates or ANN modelling. Clinicians can use this statistical model as an objective adjunct to generate informed prognosis. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16520157&query_hl=1 ER - TY - JFULL T1 - Technical skills continue to improve beyond surgical training. A1 - Pandey, V A1 - Wolfe, JH A1 - Moorthy, K A1 - Munz, Y A1 - Jackson, MJ A1 - Darzi, AW J1 - J Vasc Surg Y1 - 2006/03// VL - 43 SN - 0741-5214 SP - 539 EP - 545 N2 - BACKGROUND: There is growing focus on surgical technical competence and the means by which we are able to measure it. Ongoing studies have shown a plateau effect with increasing experience of the operator. The aim of this study was to assess the technical competence of five groups of surgeons with increasing experience and validate a new rating tool for use in surgical assessment. METHODS: Fifty surgeons performed a saphenofemoral junction ligation on a synthetic groin model. The procedure was videotaped, blinded, and reviewed independently by three assessors. Performance was assessed using a previously validated global rating scale of generic surgical skill. In addition, each procedure was rated with the procedure-specific Imperial College Evaluation of Procedure-Specific Skill (ICEPS) rating scale to establish the construct validity (ability to differentiate on the basis of skill) and inter-observer reliability. RESULTS: Both rating scales showed improved scores with ascending grades (P < .001) and demonstrated a high inter-observer reliability both for generic and procedure-specific skill (alpha = 0.97 and alpha = 0.96, respectively). Total operative scores demonstrated significant differences between surgeons in postgraduate years 1 and 2 and surgeons in years 3 and 4 and also between newly appointed and experienced consultants (P < .041). Procedure-specific performance showed a plateau effect at the registrar level. Generic skill continued to improve, and significant differences were seen between newly appointed and senior consultants (P < .026). CONCLUSION: This study shows that surgical performance continues to improve significantly beyond consultancy, and the data suggest that generic and procedural performance continue to improve, with significant improvement in the former with increasing experience. The ICEPS rating scale demonstrates construct validity and a high inter-observer reliability supporting its use in formative and summative assessment. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16520169&query_hl=1 ER - TY - JFULL T1 - Long-term outcome and quality of life after continent ileostomy. A1 - Nessar, G A1 - Fazio, VW A1 - Tekkis, P A1 - Connor, J A1 - Wu, J A1 - Bast, J A1 - Borkowski, A A1 - Delaney, CP A1 - Remzi, FH J1 - Dis Colon Rectum Y1 - 2006/03// VL - 49 SN - 0012-3706 SP - 336 EP - 344 N2 - INTRODUCTION: This study was designed to evaluate long-term outcomes for patients undergoing Kock continent ileostomy, identify factors associated with adverse outcomes, and compare changes in quality of life after removal of the reservoir. METHODS: The records of all patients (n = 330) undergoing continent ileostomy at the Cleveland Clinic Foundation between 1974 and 2001 were reviewed. Patient-related, intraoperative, and postoperative factors were evaluated as predictor variables of long-term pouch survival. Quality of life was evaluated using the continent ileostomy surgery follow-up questionnaire and the Cleveland Global Quality of Life scale (n = 216). These were compared between patients with continent ileostomy (n = 181) and patients who underwent removal of the continent ileostomy and conversion to an end stoma (n = 35). RESULTS: The median patient follow-up was 11 (range, 1-27) years. The median revision-free pouch interval was 14 (95 percent confidence interval, 11-17) months. The 10-year and 20-year pouch survival was 87 and 77 percent, respectively. Patients had an average of 3.7(range, 1-28) complications and 2.9 (range, 1-27) pouch revisions during follow-up. On multivariate analysis, Crohn's disease (hazard ratio = 4.5), female gender (hazard ratio = 2.4), fistula development (hazard ratio = 3), and body mass index (hazard ratio = 2.4 per 5 unit increase) were independent predictors of pouch failure. Quality of life measurements for patients with a continent ileostomy were higher on all scales in comparison with patients who had the Kock reservoir and then reverted to a Brooke ileostomy. CONCLUSIONS: Despite the associated morbidity with continent ileostomy surgery, long-term results and quality of life were encouraging. Continent ileostomy may be offered as an attractive long-term option to select patients whose only alternative is an end ileostomy. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16450211&query_hl=1 ER - TY - JFULL T1 - Platelet-monocyte pro-coagulant interactions in on-pump coronary surgery. A1 - Weerasinghe, A A1 - Athanasiou, T A1 - Philippidis, P A1 - Day, J A1 - Mandal, K A1 - Warren, O A1 - Anderson, J A1 - Taylor, K J1 - Eur J Cardiothorac Surg Y1 - 2006/03// VL - 29 SN - 1010-7940 SP - 312 EP - 318 N2 - OBJECTIVE: Platelets and monocytes possess haemostatic properties, but the clinical effect of platelet-monocyte interactions on haemostasis following coronary surgery is not known. The study characterises the platelet and monocyte responses in cardiac surgery and its impact on haemostasis. METHODS: In 1342 patients, changes in white blood cell counts (WBC), monocyte counts and platelet counts were measured. PMC formation was analysed by flow-cytometry using monoclonal antibodies against pan-leucocyte marker CD45, monocyte marker CD14 and platelet marker CD42. TF expression was determined using monoclonal antibodies against, CD45, CD14 and human-TF. Continuous variables were expressed as mean+/-SD. Changes in monocyte and platelet counts over time were considered as repeated measures data, and analysed using Generalised Estimating Equations (GEE). Multivariate regression analysis was used to evaluate the effect of several factors on blood loss. RESULTS: A monocytosis occurs with on-pump coronary surgery, but is less pronounced than with off-pump surgery. No difference was seen in patients having redo-surgery or more complex cardiac surgery. Factors associated with monocytosis on multivariate analysis were higher body mass index (p=0.02), diabetes (p=0.035) and smoking (p=0.01). Older patients manifested a lower response (p<0.001). Cross-clamp fibrillation was associated with a lower (p=0.048) monocytic response than was cardioplegia. PMC formation dropped following administration of heparin, peaked at 5 min of CPB, and declined by 2h of CPB (p=0.04). A return towards preoperative levels was found during postoperative days 1-5. No significant change in monocyte TF expression occurred. The mean postoperative blood loss was 581.2+/-292.8 ml, and inversely related to increasing preoperative platelet counts (p<0.001), and to higher monocyte % counts (p=0.012). Patients, who were female (p<0.001), had higher body mass indices (p<0.001), and higher core body temperatures during surgery (p=0.013), as well as patients having perioperative aprotinin (p<0.001) related to less blood loss. CONCLUSIONS: A higher postoperative platelet count as well as monocyte% significantly and independently decreases postoperative blood loss following cardiac surgery. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16423536&query_hl=1 ER - TY - JFULL T1 - Minimally invasive conduit harvesting: a systematic review. A1 - Aziz, O A1 - Athanasiou, T A1 - Darzi, A J1 - Eur J Cardiothorac Surg Y1 - 2006/03// VL - 29 SN - 1010-7940 SP - 324 EP - 333 N2 - Minimally invasive conduit harvesting techniques for coronary artery bypass grafting have developed over the past decade, aiming to reduce the morbidity and recovery time associated with the procedure, whilst preserving the quality of the conduit. Two types of commonly harvested free conduits include the great saphenous vein and the radial artery. Although much research has focussed on comparing less invasive and conventional harvest techniques, there is at present no consensus on the areas where one technique is superior to the other. Aspects of conduits that deserve appreciation when comparing minimally invasive and open harvesting techniques include wound healing at the harvest site, the macroscopic, histological and functional quality of the conduit, but perhaps most importantly its long-term angiographic patency. This paper aims to review the literature comparing minimally invasive and conventional conduit harvesting techniques for coronary artery bypass grafting, with regard to the previously mentioned factors. A literature search of Medline, Ovid, Embase and Cochrane databases was used to identify comparative studies published between 1997 and 2005. Outcomes of interest included: wound infection, non-infective healing disturbances, post-operative pain, neurological disturbance, mobility, patient satisfaction, conduit quality (macroscopic, histological and functional) and long-term conduit patency. A scoring system was applied and used to grade the quality of the evidence, based on which a recommendation of it being 'good' (Grade A), 'fair' (Grade B), or 'insufficient' (Grade C) was made. Results showed that there was 'good' evidence to suggest that wound infection and non-infective complications are reduced with minimally invasive harvest as compared to conventional vein harvest. The evidence suggesting that post-operative pain and mobilisation is reduced after minimally invasive vein harvest and that once harvested, the conduits are macroscopically comparable to conventional ones, is only 'fair'. Finally, although initial reports are encouraging, there is at present insufficient evidence to comment on whether minimally invasive radial artery harvesting is better than that of conventional open surgery. Wounds from minimally invasively harvested venous conduits appear to be less prone to complications although more comparative evidence on conduit quality and long-term patency is eagerly awaited. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16387505&query_hl=1 ER - TY - JFULL T1 - Acquisition of endovascular skills by consultant vascular surgeons: effect of repetition in a virtual reality training model A1 - Aggarwal, R A1 - Black, SA A1 - Hance, JR A1 - Darzi, AW A1 - Cheshire, NJW J1 - BRIT J SURG Y1 - 2006/03// VL - 93 SN - 0007-1323 SP - 381 EP - 382 ER - TY - JFULL T1 - Objective assessment of small bowel anastomosis skill in trainee general surgeons and urologists. A1 - Shah, J A1 - Munz, Y A1 - Manson, J A1 - Moorthy, K A1 - Darzi, A J1 - World J Surg Y1 - 2006/02// VL - 30 SN - 0364-2313 SP - 248 EP - 251 N2 - INTRODUCTION: The object of this study was to compare the technical ability of general surgery and urology trainees to perform a small bowel anastomosis using a life-like bench model. METHODS: Forty subjects were divided into two groups based on the stage of their training. Specialist registrars (SpRs) trained for 1 to 3 years were defined as junior SpRs, and those with 4 to 6 years of training were defined as senior SpRs. They were asked to perform a small bowel anastomosis on a standard latex model using the same equipment, suture material, and standardized instructions. Trainees were assessed by three trained observers based on a global rating scale. RESULTS: Interrater reliability was 0.83 for the general surgical group and 0.88 for the urology group. The median scores obtained by the junior SpRs were lower than those achieved by the senior SpRs, and general surgical trainees consistently performed better than their matched urology group. This difference reached statistical significance for the senior group. CONCLUSIONS: Global rating scores provide a reliable, valid method for assessing technical skills between specialties when performing a small bowel anastomosis. We provide reasons why general surgeons may be more proficient at this task than urologists. These findings have possible application to identifying trainees who need additional training and may also provide a mechanism to ensure competence in this task. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16425076&query_hl=1 ER - TY - JFULL T1 - A comparison of segmental vs subtotal/total colectomy for colonic Crohn's disease: a meta-analysis. A1 - Tekkis, PP A1 - Purkayastha, S A1 - Lanitis, S A1 - Athanasiou, T A1 - Heriot, AG A1 - Orchard, TR A1 - Nicholls, RJ A1 - Darzi, AW J1 - Colorectal Dis Y1 - 2006/02// VL - 8 SN - 1462-8910 SP - 82 EP - 90 N2 - OBJECTIVE: Using meta-analytical techniques the present study evaluated differences in short-term and long-term outcomes of adult patients with colonic Crohn's disease who underwent either colectomy with ileorectal anastomosis (IRA) or segmental colectomy (SC). METHODS: Comparative studies published between 1988 and 2002, of subtotal/total colectomy and ileorectal anastomosis vs segmental colectomy, were used. The study end points included were surgical and overall recurrence, time to recurrence, postoperative morbidity and incidence of permanent stoma. Random and fixed-effect meta-analytical models were used to evaluate the study outcomes. Sensitivity analysis, funnel plot and meta-regressive techniques were carried out to explain the heterogeneity and selection bias between the studies. RESULTS: Six studies, consisting of a total of 488 patients (223 IRA and 265 SC) were included. Analysis of the data suggested that there was no significant difference between IRA and SC in recurrence of Crohn's disease. Time to recurrence was longer in the IRA group by 4.4 years (95% CI: 3.1-5.8), P < 0.001. There was no difference between the incidence of postoperative complications (OR = 1.4., 95% CI 0.16-12.74) or the need for a permanent stoma between the two groups (OR = 2.75, 95% CI 0.78-9.71). Patients with two or more colonic segments involved were associated with lower re-operation rate in the IRA group, a difference which did not reach statistical significance (P = 0.177). CONCLUSIONS: Both procedures were equally effective as treatment options for colonic Crohn's disease however, patients in the SC group exhibited recurrence earlier than those in the IRA group. The choice of operation is dependent on the extent of colonic disease, with a trend towards better outcomes with IRA for two or more colonic segments involved. Since no prospective randomised study has been undertaken, a clear view about which approach is more suitable for localised colonic Crohn's disease cannot be obtained. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16412066&query_hl=1 ER - TY - JFULL T1 - Long-term results of abdominal salvage surgery following restorative proctocolectomy. A1 - Tekkis, PP A1 - Heriot, AG A1 - Smith, JJ A1 - Das, P A1 - Canero, A A1 - Nicholls, RJ J1 - Br J Surg Y1 - 2006/02// VL - 93 SN - 0007-1323 SP - 231 EP - 237 N2 - BACKGROUND: This study evaluated outcomes of patients who underwent abdominal salvage ileal pouch redo surgery and identified factors associated with pouch failure following restorative proctocolectomy. METHODS: Data on patients who underwent abdominal salvage surgery in a tertiary referral centre between 1985 and 2003 were collected. Outcomes studied included failure of salvage and bowel function of patients with an intact intestine. RESULTS: One hundred and twelve patients underwent 117 pouch salvage procedures for ulcerative colitis (86), indeterminate colitis/ulcerative colitis (eight), indeterminate colitis/Crohn's disease (three), familial adenomatous polyposis (ten) and other conditions (five). The most common indications for pouch salvage were intra-abdominal sepsis (45 patients), anastomotic stricture (13) and retained rectal stump (35). Median follow-up was 46 (range 1-147) months. Twenty-four patients (21.4 per cent) experienced pouch failure, the incidence of which increased with time. The pouch failed in all patients with Crohn's disease. Successful salvage at 5 years was significantly associated with non-septic (85 per cent) rather than septic (61 per cent) indications (P = 0.016). Frequency of night-time defaecation and faecal urgency improved after salvage surgery (P = 0.036 and P = 0.016 respectively at 5-year follow-up; n = 32). CONCLUSION: Abdominal salvage surgery was associated with a failure rate of 21.4 per cent. A successful outcome was less likely when the procedure was carried out for septic compared with non-septic indications. The rate of pouch failure increased with length of follow-up. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16432813&query_hl=1 ER - TY - JFULL T1 - Hands-on robotic unicompartmental knee replacement - A prospective, randomised controlled study A1 - Cobb J A1 - Henckel J A1 - Gomes, P A1 - Harris S A1 - Jakopec, M A1 - Rodriguez, F A1 - Barrett, A A1 - Davies, B J1 - Journal of Bone and Joint Surgery Y1 - 2006/02// IS - 2 VL - 88-B SN - 0301-620X SP - 188 EP - 197 UR - http://PMID: 16434522 ER - TY - JFULL T1 - Development of assessing generic and specific technical skills in laparoscopic surgery. A1 - Sarker, SK A1 - Chang, A A1 - Vincent, C A1 - Darzi, SA J1 - Am J Surg Y1 - 2006/02// VL - 191 SN - 0002-9610 SP - 238 EP - 244 N2 - BACKGROUND: Assessing live laparoscopic surgery using structured methodology is still in its infancy; however, it removes bias and subjectivity. We critique a new assessment tool for technical skills in laparoscopic surgery. METHODS: A hierarchical task analysis was done for laparoscopic cholecystectomy (LC), and a global assessment for generic and specific technical skills for LC was developed. Two experienced surgeons with >12 years of postgraduate experience assessed 50 full-length LC operations blindly and independently. RESULTS: Five consultant/attending and 4 registrar/resident surgeons were recruited. Interrater reliability was k = 0.86 and k = 0.84 (P < .05) for generic and specific technical skills, respectively. Mean time for consultants was 32 minutes (range 15 to 70) and for registrars was 53 minutes (range 20 to 90). Parametric Student t test analysis was significant for time between the 2 groups, P < .05. Nonparametric analysis of variance between the 2 groups for generic and specific technical skills was significant at P < .05. CONCLUSIONS: This assessment tool for live laparoscopic surgery may have face, content, concurrent, construct, and predictive validities for generic and specific technical skills. We aim to continue the study and expand assessment to other surgical techniques. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16442953&query_hl=1 ER - TY - JFULL T1 - The effects of stress on surgical performance. A1 - Wetzel, CM A1 - Kneebone, RL A1 - Woloshynowych, M A1 - Nestel, D A1 - Moorthy, K A1 - Kidd, J A1 - Darzi, A J1 - Am J Surg Y1 - 2006/01// VL - 191 SN - 0002-9610 SP - 5 EP - 10 N2 - BACKGROUND: Although the general literature on stress and performance is extensive, little is known about specific effects of stress in surgical practice. This qualitative study explored key surgical stressors, their impact on performance, and coping strategies used by surgeons. METHODS: Individual in-depth semistructured interviews with surgeons were analyzed by 2 researchers independently. Key themes were discussed within the research team. RESULTS: Sixteen interviews were performed, including interviews with consultants (n = 9) and surgeons in training (n = 7). A wide range of intraoperative stressors was identified. Although stress had both positive and negative effects, undue levels of stress impaired judgment, decision making, and communication. Although junior surgeons showed uncertainty about their ability to cope, senior surgeons had developed sophisticated strategies for controlling each situation. CONCLUSIONS: Although stress poses significant risks, coping strategies are not taught explicitly during surgical training. This article presents a framework for categorizing surgical stress and suggests key elements for effective coping strategies. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16399098&query_hl=1 ER - TY - JFULL T1 - Emergency laparoscopy--current best practice. A1 - Warren, O A1 - Kinross, J A1 - Paraskeva, P A1 - Darzi, A J1 - World J Emerg Surg Y1 - 2006/// VL - 1 SN - 1749-7922 SP - 24 EP - 24 N2 - Emergency laparoscopic surgery allows both the evaluation of acute abdominal pain and the treatment of many common acute abdominal disorders. This review critically evaluates the current evidence base for the use of laparoscopy, both diagnostic and interventional, in the emergency abdomen, and provides guidance for surgeons as to current best practise. Laparoscopic surgery is firmly established as the best intervention in acute appendicitis, acute cholecystitis and most gynaecological emergencies but requires further randomised controlled trials to definitively establish its role in other conditions. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16945124&query_hl=1 ER - TY - JFULL T1 - A surgically induced hypoxic environment causes changes in the metastatic behaviour of tumours in vitro. A1 - Paraskeva, PA A1 - Ridgway, PF A1 - Olsen, S A1 - Isacke, C A1 - Peck, DH A1 - Darzi, AW J1 - Clin Exp Metastasis Y1 - 2006/// VL - 23 SN - 0262-0898 SP - 149 EP - 157 N2 - The use of laparoscopic techniques for curative resections of malignant tumours has been under scrutiny. The potential benefits to the patient in the form of earlier recovery and less immune paresis are countered by the reports of increased tumour recurrence. The biological sequelae of the hypoxic laparoscopic environment on tumour cells is unknown. Components of the metastatic cascade were evaluated under in vitro laparoscopic conditions using a human colonic adenocarcinoma cell line (SW1222). Exposure to the laparoscopic gases carbon dioxide and helium for 4 h, comparable to the duration of a laparoscopic colorectal resection, had no effect on cell viability. A cellular hypoxic insult was demonstrated by the induction of hypoxia inducible factor 1alpha (HIF-1alpha). Exposure also resulted in significant reduction in homotypic adhesion as well as to a variety of extracellular matrix components. These effects were recoverable under re-oxygenation. The changes were reflected at the molecular level by significant down regulation of adhesion molecules known to be involved in tumour progression (E-cadherin, CD44 and beta1 sub-unit). Modulation of adherence has significant implications for laparoscopic oncological surgery, demonstrating that tumours become potentially more friable and easier to disseminate in surgeons who are less experienced or where instrumentation is sub-optimal. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16912913&query_hl=1 ER - TY - JFULL T1 - Large annular subvalvular left ventricular aneurysm: diagnostic evaluation using computed tomographic angiography. A1 - Warren, O A1 - Athanasiou, T A1 - Massey, R A1 - Hamady, M A1 - Stanbridge, R J1 - Tex Heart Inst J Y1 - 2006/// VL - 33 SN - 0730-2347 SP - 529 EP - 531 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17215989&query_hl=1 ER - TY - JFULL T1 - Diagnostic precision of nanoparticle-enhanced MRI for lymph-node metastases: a meta-analysis. A1 - Will, O A1 - Purkayastha, S A1 - Chan, C A1 - Athanasiou, T A1 - Darzi, AW A1 - Gedroyc, W A1 - Tekkis, PP J1 - Lancet Oncol Y1 - 2006/01// VL - 7 SN - 1470-2045 SP - 52 EP - 60 N2 - BACKGROUND: At present, there is no accepted, ideal imaging modality or technique for diagnosis of lymph-node metastases. We aimed to assess the diagnostic precision of MRI with ferumoxtran-10-an ultrasmall superparamagnetic iron-oxide nanoparticle used as a contrast agent for diagnosis of lymph-node metastases, compared with that of unenhanced MRI and final histological diagnosis. METHODS: We did a meta-analysis of prospective studies that compared MRI, with and without ferumoxtran-10, with histological diagnosis after surgery or biopsy. Sensitivity, specificity, and diagnostic odds ratio (DOR) were calculated for every study; summary receiver operating characteristic (ROC) and subgroup analyses were done; and study quality and heterogeneity were assessed. Metaregression analysis was used to analyse the effect of ferumoxtran-10 in diagnostic precision of MRI. FINDINGS: Summary ROC curve analysis for per-lymph-node data showed an overall sensitivity of 0.88 (95% CI 0.85-0.91) and overall specificity of 0.96 (0.95-0.97) for ferumoxtran-10-enhanced MRI. Overall weighted area under the curve for ferumoxtran-10-enhanced MRI was 0.96 (SE 0.01), DOR 123.05 (95% CI 5.93-256.93). Unenhanced MRI had less overall sensitivity (0.63 [0.57-0.69]) and specificity (0.93 [0.91-0.94]), with an overall weighted area under the ROC curve of 0.84 (SE 0.11) and DOR of 26.75 (95% CI 8.48-84.42). Significant heterogeneity was noted for studies reporting enhanced MRI and unenhanced MRI. Metaregression analysis confirmed the significant effect of ferumoxtran-10 in the diagnostic precision of MRI (p=0.001). INTERPRETATION: Ferumoxtran-10-enhanced MRI is sensitive and specific in detection of lymph-node metastases for various tumours. It offers higher diagnostic precision than does unenhanced MRI for detection of lymph-node metastases, and allows functional and anatomical definition when used as an imaging modality. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16389184&query_hl=1 ER - TY - JFULL T1 - A competency-based virtual reality training curriculum for the acquisition of laparoscopic psychomotor skill. A1 - Aggarwal, R A1 - Grantcharov, T A1 - Moorthy, K A1 - Hance, J A1 - Darzi, A J1 - Am J Surg Y1 - 2006/01// VL - 191 SN - 0002-9610 SP - 128 EP - 133 N2 - BACKGROUND: Studies have demonstrated the beneficial effect of training novice laparoscopic surgeons using virtual reality (VR) simulators, although there is still no consensus regarding an optimal VR training curriculum. This study aims to establish and validate a structured VR curriculum to provide an evidence-based approach for laparoscopic training programmes. METHODS: The minimally invasive VR simulator (MIST-VR) has 12 abstract laparoscopic tasks, each at 3 graduated levels of difficulty (easy, medium, and hard). Twenty medical students completed 2 sessions of all tasks at the easy level, 10 sessions at the medium level, and finally 5 sessions of the 2 most complex tasks at the hard level. At the medium level, subjects were randomized into 2 equal groups performing either all 12 tasks (group A) or the 2 most complex tasks (group B). Performance was measured by time taken, path length, and errors for each hand. The results were compared between groups, and to those of 10 experienced laparoscopic surgeons. RESULTS: Baseline performance of both groups was similar at the easy level. At the medium level, learning curves for all 3 parameters reached plateau at the second (group A, P < .05) and sixth (group B, P < .05) repetitions. Performance at the hard level was similar between the 2 groups, and all achieved the pre-set expert criteria. CONCLUSION: A graduated laparoscopic training curriculum enables trainees to familiarise, train and be assessed on laparoscopic VR simulators. This study can aid the incorporation of VR simulation into established surgical training programmes. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16399123&query_hl=1 ER - TY - JFULL T1 - Pancreatic and periampullary cancers: treatment and outcome A1 - Spalding, DRC J1 - BRIT J HOSP MED Y1 - 2006/01// VL - 67 SP - 14 EP - 20 N2 - Periampullary cancers arise within 2 cm of the major duodenal papilla and include cancers of the head of pancreas, distal common bile duct, ampulla of Voter and duodenum. Their anatomical locations and clinical features are similar, as are the therapeutic approaches; however, their long-term outcomes vary. ER - TY - JFULL T1 - Novel use of a magnetic coupling device to repair damage of the internal thoracic artery. A1 - Charitou, A A1 - Panesar, SS A1 - DeL Stanbridge, R A1 - Athanasiou, T J1 - J Card Surg Y1 - 2006/01// VL - 21 SN - 0886-0440 SP - 89 EP - 91 N2 - At present, there is limited reported literature on the use of the magnetic anastomotic device Ventrica MVP in the coronary artery bypass surgery setting. The device has been primarily used to perform distal coronary anastomoses. We report for the first time the novel use of this magnetic coupling device as a technique to repair iatrogenic injury of the left internal thoracic artery conduit. Technical issues, advantages, disadvantages, and the use of computer tomography angiogram for assessment of the anastomosis are discussed. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16426358&query_hl=1 ER - TY - JFULL T1 - The effect of depth perception on visual-motor compensation in minimal invasive surgery A1 - Nicolaou, M A1 - Atallah, L A1 - James, A A1 - Leong, J A1 - Darzi, A A1 - Yang, GZ J1 - LECT NOTES COMPUT SC Y1 - 2006/// VL - 4091 SN - 0302-9743 SP - 156 EP - 163 N2 - Despite technological advances in minimally invasive surgery (MIS) in recent years, 3D visualization of the operative field still remains one of greatest challenges. In this paper, the effect of three visualization techniques including conventional 2D, 2D with enhanced depth cue based on shadow, and active 3D displays for novices with no prior adaptation to laparoscopic visualization techniques has been analyzed. A wavelet based paradigm is proposed which offer important insights into the effect of depth perception and visual-motor compensation when performing MIS instrument maneuvers. The proposed method has shown to be advantageous over conventional end-point methods of laparoscopic performance assessment as important supplementary information can be derived from the same trajectories where conventional measures fail to show significant differences. ER - TY - JFULL T1 - Simulating tele-manipulator controlled tool-tissue interactions using a nonlinear FEM deformable model. A1 - Wang, DA A1 - Faraci, A A1 - Bello, F A1 - Darzi, A J1 - Stud Health Technol Inform Y1 - 2006/// VL - 119 SN - 0926-9630 SP - 565 EP - 567 N2 - Enhanced visualization of an operating scene presented by a robotically assisted tele-manipulator system such as the da Vinci(TM) can be provided through the use of augmented reality facilities. Generating overlays from 3D models and the intra-operative video allows the surgeon to acquire greater information about the surgical scene. Tool-tissue interactions must be tracked to ensure the overlays are updated regularly and accurately. The work presented here describes how these interactions may be modelled by integrating a nonlinear finite element model with the 3D reconstruction and using the tool kinematic data as input to the deformation. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16404122&query_hl=1 ER - TY - JFULL T1 - The Acrobot® System for Robotic MIS Total Knee and Uni-Condylar Arthroplasty A1 - Brian Davies A1 - Ferdinando Rodriguez A1 - Matja Jakopec A1 - Simon J Harris A1 - Adrian Barrett A1 - Paula Gomes A1 - Johan Henckel A1 - Jusitn P Cobb J1 - International Journal of Humanoid Robotics Y1 - 2006/// IS - 4 VL - 3 PB - World Scientific Publishing Co. SP - 415 EP - 428 ER - TY - JFULL T1 - Optical mapping of the frontal cortex during a surgical knot-tying task, a feasibility study A1 - Leff, D A1 - Koh, PH A1 - Aggarwal, R A1 - Leong, J A1 - Deligianni, F A1 - Elwell, C A1 - Delpy, DT A1 - Darzi, A A1 - Yang, GZ J1 - LECT NOTES COMPUT SC Y1 - 2006/// VL - 4091 SN - 0302-9743 SP - 140 EP - 147 N2 - Functional neuroimaging technologies have transformed cognitive neuroscience by enhancing our understanding of the functional subclassification of brain regions. Whilst a number of studies have explored brain activation associated with complex motor skills, few of the tasks investigated have had direct occupational relevance. To date there have been no functional studies involving surgeons or motor paradigms with relevance to surgery. This study reports on the feasibility of Near Infrared Spectroscopy (NIRS) for studying subjects performing realistic surgical tasks in a laboratory setting. We observed a recognisable haemodynamic response to brain activation, which was reliable and repeatable in subjects despite days without practice on the task. A wide range of prefrontal activation was observed, thought to reflect considerable variation in the cognitive resources allocated to complete a highly attention demanding surgical task. ER - TY - JFULL T1 - Laparoscopic versus open appendectomy in children: a meta-analysis. A1 - Aziz, O A1 - Athanasiou, T A1 - Tekkis, PP A1 - Purkayastha, S A1 - Haddow, J A1 - Malinovski, V A1 - Paraskeva, P A1 - Darzi, A J1 - Ann Surg Y1 - 2006/01// VL - 243 SN - 0003-4932 SP - 17 EP - 27 N2 - OBJECTIVE: This study aims to use meta-analysis to compare laparoscopic and open appendectomy in a pediatric population. SUMMARY BACKGROUND DATA: Meta-analysis is a statistical tool that can be used to evaluate the literature in both qualitative and quantitative ways, accounting for variations in characteristics that can influence overall estimate of outcomes of interest. Meta-analysis of laparoscopic versus open appendectomy in a pediatric population has not previously been performed. METHODS: Comparative studies published between 1992 and 2004 of laparoscopic versus open appendectomy in children were included. Endpoints were postoperative pyrexia, ileus, wound infection, intra-abdominal abscess formation, operative time, and postoperative hospital stay. RESULTS: Twenty-three studies including 6477 children (43% laparoscopic, 57% open) were included. Wound infection was significantly reduced with laparoscopic versus open appendectomy (1.5% versus 5%; odds ratio [OR] = 0.45, 95% confidence interval [CI], 0.27-0.75), as was ileus (1.3% versus 2.8%; OR = 0.5, 95% CI, 0.29-0.86). Intra-abdominal abscess formation was more common following laparoscopic surgery, although this was not statistically significant. Subgroup analysis of randomized trials did not reveal significant difference between the 2 techniques in any of the 4 complications. Operative time was not significantly longer in the laparoscopic group, and postoperative stay was significantly shorter (weighted mean difference, -0.48; 95% CI, -0.65 to -0.31). Sensitivity analysis identified lowest heterogeneity when only randomized studies were considered, followed by prospective, recent, and finally large studies. CONCLUSIONS: The results of this meta-analysis suggest that laparoscopic appendectomy in children reduces complications. However, we also see the need for further high-quality randomized trials comparing the 2 techniques, matched not only for age and sex but also for obesity and severity of appendicitis. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16371732&query_hl=1 ER - TY - JFULL T1 - Self-calibrating 3D-ultrasound-based bone registration for minimally invasive orthopedic surgery A1 - Barratt DC A1 - Penney GP A1 - Chan CSK A1 - Slomczykowski M A1 - Carter TJ A1 - Edwards PJ A1 - Hawkes DJ J1 - IEEE Trans Med Imaging Y1 - 2006/// IS - 3 VL - 25 SN - 0278-0062 SP - 312 EP - 323 ER - TY - JFULL T1 - Elasticity of the living abdominal wall in laparoscopic surgery. A1 - Song, C A1 - Alijani, A A1 - Frank, T A1 - Hanna, G A1 - Cuschieri, A J1 - J Biomech Y1 - 2006/// VL - 39 SN - 0021-9290 SP - 587 EP - 591 N2 - Laparoscopic surgery requires inflation of the abdominal cavity and this offers a unique opportunity to measure the mechanical properties of the living abdominal wall. We used a motion analysis system to study the abdominal wall motion of 18 patients undergoing laparoscopic surgery, and found that the mean Young's modulus was 27.7+/-4.5 and 21.0+/-3.7 kPa for male and female, respectively. During inflation, the abdominal wall changed from a cylinder to a dome shape. The average expansion in the abdominal wall surface was 20%, and a working space of 1.27 x 10(-3)m(3) was created by expansion, reshaping of the abdominal wall and diaphragmatic movement. For the first time, the elasticity of human abdominal wall was obtained from the patients undergoing laparoscopic surgery, and a 3D simulation model of human abdominal wall has been developed to analyse the motion pattern in laparoscopic surgery. Based on this study, a mechanical abdominal wall lift and a surgical simulator for safe/ergonomic port placements are under development. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16389099&query_hl=1 ER - TY - JFULL T1 - Clampless arterial coronary artery bypass grafting with the use of magnetic coupling devices. A1 - Athanasiou, T A1 - Asrafian, H A1 - Krasopoulos, G A1 - Purkayastha, S A1 - Malinowski, V A1 - Al-Ruzzeh, S A1 - Glenville, B A1 - De La Stanbridge, R A1 - Casula, R J1 - J Card Surg Y1 - 2006/01// VL - 21 SN - 0886-0440 N2 - BACKGROUND: The aim of our study was to evaluate the feasibility of using the Ventrica MVP device to perform proximal anastomoses as part of the clampless off-pump coronary artery bypass (OPCAB) arterial revascularization procedure. METHODS: We present our preliminary experience of these first nine coronary artery cases performed in the UK from April 2003 to December 2004. RESULTS: The device was used in eight patients for the proximal anastomosis of a radial artery (n = 8) or right internal thoracic artery (n = 1) graft as a Y-graft from the left internal thoracic artery to the circumflex territories. One patient died in this series although the autopsy showed that the device was intact and free of clots and the reported cause of death was an acute cardiac event due to myocardial ischemia. Anastomotic patency was confirmed in five patients with the use of multidetector row computed tomography coronary angiogram. The anastomosis time in our series was 6.3 +/- 2.1 minutes and the blood loss 814 +/- 245 mL. The mean length of stay was 5.2 +/- 1.2 days. No other significant major morbidity events were observed postoperatively (neurological complications, renal failure, and reopening for bleeding). The assessment of quality of life at 6 months postoperatively using SF-36 questionnaires revealed improvement. CONCLUSION: The versatile use of Ventrica MVP distal anastomotic device is feasible in clinical practice allowing surgeons to perform proximal anastomoses and arterial OPCAB surgery with short learning curve and without compromising the clinical outcome and quality of life. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16426353&query_hl=1 ER - TY - JFULL T1 - Meta-analysis of colonic reservoirs versus straight coloanal anastomosis after anterior resection. A1 - Heriot, AG A1 - Tekkis, PP A1 - Constantinides, V A1 - Paraskevas, P A1 - Nicholls, RJ A1 - Darzi, A A1 - Fazio, VW J1 - Br J Surg Y1 - 2006/01// VL - 93 SN - 0007-1323 SP - 19 EP - 32 N2 - BACKGROUND AND METHODS: The comparative benefits and drawbacks of straight coloanal anastomosis (CAA), colonic J-pouch and coloplasty anastomosis after anterior resection are uncertain. Studies published between 1986 and 2005 of colonic J-pouch versus transverse coloplasty or straight CAA were analysed. Endpoints included postoperative complications, and functional and physiological outcomes measured within 6 months, 1 year and 2 years or more after the procedure. A random-effect model was used to aggregate the study endpoints and assess heterogeneity. RESULTS: Thirty-five studies containing 2240 patients (1066 straight CAA, 1050 J-pouch and 124 coloplasty) were included. There was no significant difference in postoperative complications between the three groups. There was a significant reduction in the frequency of defaecation per day by 1.88, 1.35 and 0.74 motions at the three time intervals in the J-pouch group compared with the straight CAA group. Faecal urgency was less prevalent in patients with a J-pouch than those with a straight CAA (odds ratio 0.27 at 6 months or less and 0.21 at 1 year). There was no difference in functional outcome between J-pouch and coloplasty anastomosis. CONCLUSIONS: The colonic J-pouch provided functional benefits over straight anastomosis with no increase in postoperative complications. Coloplasty appeared to have similar benefits but further studies are required for validation. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16273532&query_hl=1 ER - TY - JFULL T1 - Reduction in adhesive small-bowel obstruction by Seprafilm adhesion barrier after intestinal resection. A1 - Fazio, VW A1 - Cohen, Z A1 - Fleshman, JW A1 - van Goor, H A1 - Bauer, JJ A1 - Wolff, BG A1 - Corman, M A1 - Beart, RW A1 - Wexner, SD A1 - Becker, JM A1 - Monson, JR A1 - Kaufman, HS A1 - Beck, DE A1 - Bailey, HR A1 - Ludwig, KA A1 - Stamos, MJ A1 - Darzi, A A1 - Bleday, R A1 - Dorazio, R A1 - Madoff, RD A1 - Smith, LE A1 - Gearhart, S A1 - Lillemoe, K A1 - Göhl, J J1 - Dis Colon Rectum Y1 - 2006/01// VL - 49 SN - 0012-3706 SP - 1 EP - 11 N2 - INTRODUCTION: Although Seprafilm has been demonstrated to reduce adhesion formation, it is not known whether its usage would translate into a reduction in adhesive small-bowel obstruction. METHODS: This was a prospective, randomized, multicenter, multinational, single-blind, controlled study. This report focuses on those patients who underwent intestinal resection (n = 1,701). Before closure of the abdomen, patients were randomized to receive Seprafilm or no treatment. Seprafilm was applied to adhesiogenic tissues throughout the abdomen. The incidence and type of bowel obstruction was compared between the two groups. Time to first adhesive small-bowel obstruction was compared during the course of the study by using survival analysis methods. The mean follow-up time for the occurrence of adhesive small-bowel obstruction was 3.5 years. RESULTS: There was no difference between the treatment and control group in overall rate of bowel obstruction. The incidence of adhesive small-bowel obstruction requiring reoperation was significantly lower for Seprafilm patients compared with no-treatment patients: 1.8 vs. 3.4 percent (P < 0.05). This finding represents an absolute reduction in adhesive small-bowel obstruction requiring reoperation of 1.6 percent and a relative reduction of 47 percent. In addition, a stepwise multivariate analysis indicated that the use of Seprafilm was the only predictive factor for reducing adhesive small-bowel obstruction requiring reoperation. In both groups, 50 percent of first adhesive small-bowel obstruction episodes occurred within 6 months after the initial surgery with nearly 30 percent occurring within the first 30 days. Additionally no first adhesive small-bowel obstruction events were reported in Years 4 and 5 of follow-up. CONCLUSIONS: The overall bowel obstruction rate was unchanged; however, adhesive small-bowel obstruction requiring reoperation was significantly reduced by the use of Seprafilm, which was the only factor that predicted this outcome. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16320005&query_hl=1 ER - TY - JFULL T1 - HMM assessment of quality of movement trajectory in laparoscopic surgery. A1 - Leong, JJ A1 - Nicolaou, M A1 - Atallah, L A1 - Mylonas, GP A1 - Darzi, AW A1 - Yang, GZ J1 - Med Image Comput Comput Assist Interv Int Conf Med Image Comput Comput Assist Interv Y1 - 2006/// VL - 9 SP - 752 EP - 759 N2 - Laparoscopic surgery poses many different constraints to the operating surgeon, this has resulted in a slow uptake of advanced laparoscopic procedures. Traditional approaches to the assessment of surgical performance rely on prior classification of a cohort of surgeons' technical skills for validation, which may introduce subjective bias to the outcome. In this study, Hidden Markov Models (HMMs) are used to learn surgical maneuvers from 11 subjects with mixed abilities. By using the leave-one-out method, the HMMs are trained without prior clustering subjects into different skills levels, and the output likelihood indicates the similarity of a particular subject's motion trajectories to the group. The experimental results demonstrate the strength of the method in ranking the quality of trajectories of the subjects, highlighting its value in minimizing the subjective bias in skills assessment for minimally invasive surgery. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17354958&query_hl=1 ER - TY - JFULL T1 - Homozygous L-SIGN (CLEC4M) plays a protective role in SARS coronavirus infection. A1 - Chan, VS A1 - Chan, KY A1 - Chen, Y A1 - Poon, LL A1 - Cheung, AN A1 - Zheng, B A1 - Chan, KH A1 - Mak, W A1 - Ngan, HY A1 - Xu, X A1 - Screaton, G A1 - Tam, PK A1 - Austyn, JM A1 - Chan, LC A1 - Yip, SP A1 - Peiris, M A1 - Khoo, US A1 - Lin, CL J1 - Nat Genet Y1 - 2006/01// VL - 38 SN - 1061-4036 SP - 38 EP - 46 N2 - Severe acute respiratory syndrome (SARS) is caused by infection of a previously undescribed coronavirus (CoV). L-SIGN, encoded by CLEC4M (also known as CD209L), is a SARS-CoV binding receptor that has polymorphism in its extracellular neck region encoded by the tandem repeat domain in exon 4. Our genetic risk association study shows that individuals homozygous for CLEC4M tandem repeats are less susceptible to SARS infection. L-SIGN is expressed in both non-SARS and SARS-CoV-infected lung. Compared with cells heterozygous for L-SIGN, cells homozygous for L-SIGN show higher binding capacity for SARS-CoV, higher proteasome-dependent viral degradation and a lower capacity for trans infection. Thus, homozygosity for L-SIGN plays a protective role during SARS infection. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16369534&query_hl=1 ER - TY - JFULL T1 - The use of a GripForce system to map force distribution patterns of laparoscopic instruments. A1 - Gupta, N A1 - Bello, F A1 - Arnarsson, H A1 - Riviere, P A1 - Hoult, S A1 - Darzi, A J1 - Stud Health Technol Inform Y1 - 2006/// VL - 119 SN - 0926-9630 SP - 170 EP - 175 N2 - While it is acknowledged that the forces required to manipulate laparoscopic instruments can be significant and are important in terms of potential discomfort after prolonged use, no systematic study has been conducted. In this paper we present a GripForce system that allows for the mapping of force distribution patterns of laparoscopic instruments. Initial results showed significant differences in force distribution between various instrument handles, thus demonstrating the viability of the system and proposed methodology. Analysis of force distribution patterns of laparoscopic instruments can help towards improving instrument design, better understanding the relationship between force applied and performance, as well as provide useful feedback to trainees and surgeons. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16404039&query_hl=1 ER - TY - JFULL T1 - Compression anastomoses revisited. A1 - Aggarwal, R A1 - Darzi, A J1 - J Am Coll Surg Y1 - 2005/12// VL - 201 SN - 1072-7515 SP - 965 EP - 971 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16310702&query_hl=1 ER - TY - JFULL T1 - Predictors of poor mid-term health related quality of life after primary isolated coronary artery bypass grafting surgery A1 - Al-Ruzzeh, S A1 - Athanasiou, T A1 - Mangoush, O A1 - Wray, J A1 - Modine, T A1 - George, S A1 - Amrani, M J1 - HEART Y1 - 2005/12// VL - 91 SN - 1355-6037 SP - 1557 EP - 1562 N2 - Objective: To assess the determinants of poor mid-term health related quality of life (HRQoL) at one year after primary isolated coronary artery bypass grafting (CABG).Methods: 463 patients who underwent primary isolated CABG for multivessel disease and came for their annual follow up at the outpatient clinic during one year at Harefield Hospital, Middlesex, were approached to participate in the present study. Prospective clinical data were collected as part of the clinical care of the patients and were retrospectively analysed when the patients consented to participate in the study at their outpatient visit. After their consent they were given three HRQoL assessment questionnaires. Scores, together with clinical data, were analysed by both univariate and multivariate analyses with regard to poor HRQoL outcome.Results: 437 (94.4%) patients consented to participate in the study and filled in the HRQoL questionnaires. Ten variables were identified in the univariate analysis as potential predictors of poor scores of the physical element of HRQoL; however, only three variables - gastrointestinal problems, congestive heart failure, and type D personality trait - predicted poor physical scores independently. Eleven variables were identified in the univariate analysis as potential predictors of poor scores of the mental element of HRQoL; however, only three variables - peripheral vascular disease, infective complications, and type D personality trait - predicted poor physical scores independently.Conclusion: Preoperative gastrointestinal problems, preoperative congestive heart failure, and type D personality trait were independent predictors of the poor physical component of HRQoL. Peripheral vascular disease, infective complications, and type D personality trait were independent predictors of the poor mental component of HRQoL. Interestingly, patients with type D personality were more than twice as likely to have poor physical HRQoL and more than five times as likely to have poor mental HRQoL. ER - TY - JFULL T1 - Does minimally invasive vein harvesting technique affect the quality of the conduit for coronary revascularization? A1 - Aziz, O A1 - Athanasiou, T A1 - Panesar, SS A1 - Massey-Patel, R A1 - Warren, O A1 - Kinross, J A1 - Purkayastha, S A1 - Casula, R A1 - Glenville, B A1 - Darzi, A J1 - Ann Thorac Surg Y1 - 2005/12// VL - 80 SN - 1552-6259 SP - 2407 EP - 2414 N2 - The effect of minimally invasive great saphenous vein harvest on patient morbidity (wound infection and other healing disturbances) has been extensively investigated, yet its impact on the quality of the venous conduit is less well known. This study aims to review the literature with regard to macroscopic quality, postoperative myocardial infarction rates, and angiographic patency of the minimally invasive versus conventionally harvested vein using meta-analytic techniques where appropriate. Results suggest that conduits are comparable in macroscopic quality with minimally invasively harvested veins requiring more repairs prior to grafting. Postoperative myocardial infarction rates were not significantly different between groups, which is supported by the limited evidence on angiographic patency. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16305930&query_hl=1 ER - TY - JFULL T1 - Consensus guidelines for validation of virtual reality surgical simulators. A1 - Carter, FJ A1 - Schijven, MP A1 - Aggarwal, R A1 - Grantcharov, T A1 - Francis, NK A1 - Hanna, GB A1 - Jakimowicz, JJ A1 - Work Group for Evaluation and Implementation of Simulators and Skills Training Programmes J1 - Surg Endosc Y1 - 2005/12// VL - 19 SN - 1432-2218 SP - 1523 EP - 1532 N2 - The Work Group for Evaluation and Implementation of Simulators and Skills Training Programmes is a newly formed sub-group of the European Association of Endoscopic Surgeons (EAES). This work group undertook a review of validation evidence for surgical simulators and the resulting consensus is presented in this article. Using clinical guidelines criteria, the evidence for validation for six different simulators was rated and subsequently translated to a level of recommendation for each system. The simulators could be divided into two basic types; systems for laparoscopic general surgery and flexible gastrointestinal endoscopy. Selection of simulators for inclusion in this consensus was based on their availability and relatively widespread usage as of July 2004. Whilst level 2 recommendations were achieved for a few systems, it was clear that there was an overall lack of published validation studies with rigorous experimental methodology. Since the consensus meeting, there have been a number of new articles, system upgrades and new devices available. The work group intends to update these consensus guidelines on a regular basis, with the resulting article available on the EAES website (http://www.eaes-eur.org ). L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16252077&query_hl=1 ER - TY - JFULL T1 - Robotic clinical trials of uni-condylar arthroplasty A1 - Rodriguez y Baena,F. A1 - Cobb,J. A1 - Henckel,J. A1 - Gomes,P. A1 - Harris,S. A1 - Jakopec,M. A1 - Barrett,A. A1 - Davies,B. J1 - International Journal of Medical Robotics and Computer Assisted Surgery Y1 - 2005/12// IS - 4 VL - 1 PB - John Wiley & Sons Ltd SN - 1478-5951 SP - 20 EP - 28 ER - TY - JFULL T1 - Hartmann's reversal is associated with high postoperative adverse events. A1 - Aydin, HN A1 - Remzi, FH A1 - Tekkis, PP A1 - Fazio, VW J1 - Dis Colon Rectum Y1 - 2005/11// VL - 48 SN - 0012-3706 SP - 2117 EP - 2126 N2 - PURPOSE: The aim of this study was to ascertain the preva lence and pattern of surgical and medical adverse events in patients undergoing Hartmann's reversal for diverticular dis ease. A comparison of postoperative outcomes is made be tween Hartmann's reversal and primary resection and anas tomosis. METHODS: Data were collected from patients who underwent successful Hartmann's reversal (Group 1 n=121) and primary resection and anastomosis (Group 2 n=731) for diverticular disease in a single center from January 1981 to May 2003. Multivariate logistic regression was used to compare early postoperative mortality, medical and surgical complications and readmission rates between the two groups. RESULTS: Hartmann's reversal was associ ated with a higher prevalence of surgical or medical com plications compared with primary resection and anastomo sis (43.8 percent and 9.1 percent for Hartmann's reversal vs. 26.0 percent and 4.8 percent for primary resection and anastomosis). There was no difference in the readmissior rates (7.2 percent vs. 7.6 percent, respectively, P = 0.88) or early postoperative mortality (1.7 percent vs. 0.7 percent, P = 0.25) between Hartmann's reversal and primary resection and anastomosis. The need for reoperation, prolonged ileus respiratory tract infections, and renal failure were more common adverse events in the Hartmann's reversal group (P < 0.01). Having controlled for the number of comorbid conditions, extent of diverticular disease, severity of peri toneal contamination (Mannheim Peritonitis Index), and op erative urgency, patients who underwent Hartmann's rever sal were 2.1 times more likely to have adverse surgical events during their postoperative period (95 percent confidence interval for odds ratio = 1.3-3.3). CONCLUSIONS: Hartmann's reversal is a complex surgical procedure that is associated with a high prevalence of postoperative adverse events in comparison with primary resection and anastomosis. To minimize the prevalence of such adverse events, patients who undergo Hartmann's reversal need careful preoperative evaluation and close monitoring in their postoperative period. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16228835&query_hl=1 ER - TY - JFULL T1 - Spontaneous resolution of type a aortic dissection. A1 - Mangoush, O A1 - Athanasiou, T A1 - Nair, KS A1 - Chambers, J J1 - J Card Surg Y1 - 2005/11// VL - 20 SN - 0886-0440 SP - 552 EP - 554 N2 - We present the case of a middle-aged man who presented with type A aortic dissection, which was resolved spontaneously over 5 weeks time. We also discuss the possible mechanism and the role of conservative management in very selected group of patients. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16309409&query_hl=1 ER - TY - JFULL T1 - Teaching communication skills for handover: perioperative specialist practitioners. A1 - Nestel, D A1 - Kneebone, R A1 - Barnet, A J1 - Med Educ Y1 - 2005/11// VL - 39 SN - 0308-0110 SP - 1157 EP - 1157 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16262830&query_hl=1 ER - TY - JFULL T1 - A human factors analysis of technical and team skills among surgical trainees during procedural simulations in a simulated operating theatre. A1 - Moorthy, K A1 - Munz, Y A1 - Adams, S A1 - Pandey, V A1 - Darzi, A J1 - Ann Surg Y1 - 2005/11// VL - 242 SN - 0003-4932 SP - 631 EP - 639 N2 - BACKGROUND: High-risk organizations such as aviation rely on simulations for the training and assessment of technical and team performance. The aim of this study was to develop a simulated environment for surgical trainees using similar principles. METHODS: A total of 27 surgical trainees carried out a simulated procedure in a Simulated Operating Theatre with a standardized OR team. Observation of OR events was carried out by an unobtrusive data collection system: clinical data recorder. Assessment of performance consisted of blinded rating of technical skills, a checklist of technical events, an assessment of communication, and a global rating of team skills by a human factors expert and trained surgical research fellows. The participants underwent a debriefing session, and the face validity of the simulated environment was evaluated. RESULTS: While technical skills rating discriminated between surgeons according to experience (P = 0.002), there were no differences in terms of the checklist and team skills (P = 0.70). While all trainees were observed to gown/glove and handle sharps correctly, low scores were observed for some key features of communication with other team members. Low scores were obtained by the entire cohort for vigilance. Interobserver reliability was 0.90 and 0.89 for technical and team skills ratings. CONCLUSIONS: The simulated operating theatre could serve as an environment for the development of surgical competence among surgical trainees. Objective, structured, and multimodal assessment of performance during simulated procedures could serve as a basis for focused feedback during training of technical and team skills. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16244534&query_hl=1 ER - TY - JFULL T1 - Does Doppler echography have a diagnostic role in patency assessment of internal thoracic artery grafts? A1 - Jones, CM A1 - Athanasiou, T A1 - Tekkis, PP A1 - Malinovski, V A1 - Purkayastha, S A1 - Haq, A A1 - Kokotsakis, J A1 - Darzi, A J1 - Eur J Cardiothorac Surg Y1 - 2005/11// VL - 28 SN - 1010-7940 SP - 692 EP - 700 N2 - The amount of literature published over the past decade comparing coronary angiography with transthoracic Doppler echocardiography assessment of internal thoracic artery graft patency after CABG is substantial. There has been no review of the available literature, and conflicting reports of diagnostic accuracy have prevented routine use of transthoracic Doppler in graft patency assessment. Thus, this article reviews the available literature on diagnostic accuracy of transthoracic Doppler echocardiography of coronary bypass grafts. Relevant studies were identified and meta-analysis of diagnostic accuracy was performed. Study quality was assessed. Quantitative data synthesis included calculation of sensitivity, specificity, summary receiver operating characteristic curve analysis, pooled analysis and meta-regression of accuracy against study quality, publication date, angina, probe frequency and diagnostic criteria. Twenty studies of 929 patients produced 26 results included for analysis. Grafts were not visualized in 93 (10%) patients. Pooled sensitivity (85%) and specificity (94%) and diagnostic odds ratio (100.7) were high. SROC analysis showed an area under the curve of 0.96. Heterogeneity of results was due to variations in diagnostic criteria and study size. Subgroup analysis showed best performance in patients with postoperative angina (p = 0.014). Study quality did not affect results. Diastolic fraction less than 0.5 (sensitivity 89%, specificity 94%) was shown to be the best criterion for prediction of stenosis. Performance was lower using peak diastolic to systolic velocity ratio less than 1 (sensitivity 85%, specificity 86%). Transthoracic Doppler echography is effective in first-line assessment of left internal thoracic artery graft patency. It shows high specificity, prevents invasive investigations and improves in patients with postoperative angina. TDE is best used in combination with other non-invasive tests due to its inability to visualize the graft. The potential for use in postoperative coronary bypass patients is high. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16194605&query_hl=1 ER - TY - JFULL T1 - Silver nanoparticles fabricated in Hepes buffer exhibit cytoprotective activities toward HIV-1 infected cells. A1 - Sun, RW A1 - Chen, R A1 - Chung, NP A1 - Ho, CM A1 - Lin, CL A1 - Che, CM J1 - Chem Commun (Camb) Y1 - 2005/10/28/ SN - 1359-7345 SP - 5059 EP - 5061 N2 - Silver nanoparticles fabricated in Hepes buffer exhibit potent cytoprotective and post-infected anti-HIV-1 activities toward Hut/CCR5 cells. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16220170&query_hl=1 ER - TY - JFULL T1 - A comparison of open vs. laparoscopic abdominal rectopexy for full-thickness rectal prolapse: a meta-analysis. A1 - Purkayastha, S A1 - Tekkis, P A1 - Athanasiou, T A1 - Aziz, O A1 - Paraskevas, P A1 - Ziprin, P A1 - Darzi, A J1 - Dis Colon Rectum Y1 - 2005/10// VL - 48 SN - 0012-3706 SP - 1930 EP - 1940 N2 - PURPOSE: Using meta-analytical techniques, this study was designed to compare open and laparoscopic abdominal procedures used to treat full-thickness rectal prolapse in adults. METHODS: Comparative studies published between 1995 and 2003, cited in the literature of open abdominal rectopexy vs. laparoscopic abdominal rectopexy, were used. The primary end points were recurrence and morbidity, and the secondary end points assessed were operative time and length of hospital stay. A random effect model was used to aggregate the studies reporting these outcomes, and heterogeneity was assessed. RESULTS: Six studies, consisting of a total of 195 patients (98 open and 97 laparoscopic) were included. Analysis of the data suggested that there is no significant difference in recurrence and morbidity between laparoscopic abdominal rectopexy and open abdominal rectopexy. Length of stay was significantly reduced in the laparoscopic group by 3.5 days (95 percent confidence interval, 3.1-4; P < 0.01), whereas the operative time was significantly longer in this group, by approximately 60 minutes (60.38 minutes; 95 percent confidence interval, 49-71.8). CONCLUSIONS: Laparoscopic abdominal rectopexy is a safe and feasible procedure, which may compare equally with the open technique with regards to recurrence and morbidity and favorably with length of stay. However large-scale randomized trials, with comparative, sound methodology are still needed to ascertain detailed outcome measures accurately. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15981060&query_hl=1 ER - TY - JFULL T1 - Adjuvant radiotherapy is associated with increased sexual dysfunction in male patients undergoing resection for rectal cancer: a predictive model. A1 - Heriot, AG A1 - Tekkis, PP A1 - Fazio, VW A1 - Neary, P A1 - Lavery, IC J1 - Ann Surg Y1 - 2005/10// VL - 242 SN - 0003-4932 N2 - OBJECTIVES: The objectives of this study were to evaluate the effect of radiotherapy (RT) on sexual function in patients undergoing oncologic resection for rectal cancer, and to develop a mathematical model for quantifying the risk of sexual dysfunction through time for this group of patients. METHODS: Data were prospectively collected on patients undergoing proctosigmoidectomy (group 1: n = 101) or adjuvant radiotherapy (40-50 Gy) and resection (group 2: n = 100) for rectal cancer at a tertiary referral center between December 1998 and July 2004. Study end points were recorded at 7 time intervals (preoperatively, 4 months, 8 months, 1 year, 2 years, 3 years, and 4 years after surgery) and included: 1) ability to have an erection, 2) maintain an erection, 3) attain orgasm, 4) dry orgasm, and 5) whether they were sexually active. Multilevel logistic regression analysis for repeated measures was used to identify factors associated with the sexual dysfunction. A predictive model was developed and internally validated by comparing observed and model-predicted outcomes. RESULTS: Radiotherapy had an adverse effect on the ability to get an erection, maintain an erection, attain orgasm, and being sexually active in comparison with patients undergoing surgery alone (7.4%, 12.6%, 16.2%, and 13.7% reduction 8 months after surgery respectively; P < 0.05). The effect of sexual dysfunction deteriorated with age (odds ratio for erectile function, 0.40 per 10-year increase in age; 95% confidence interval, 0.29-0.49; P < 0.001). A significant variability in sexual function was present among the 7 time points with a maximal deterioration occurring at 8 months after surgery with subsequent slow but not complete recovery (P < 0.001). The predictive model showed adequate discrimination on 4 of the 5 domains of sexual dysfunction (area under the receiver operating characteristic curve >0.70). CONCLUSIONS: Radiotherapy has an adverse effect on sexual function, the effect being maximal at 8 months after surgery. The risk of sexual dysfunction can be quantified preoperatively using the proposed index and can assist patients in making better informed choices on the type of treatment they receive. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16192810&query_hl=1 ER - TY - JFULL T1 - Risk factors associated with ileal pouch-related fistula following restorative proctocolectomy. A1 - Tekkis, PP A1 - Fazio, VW A1 - Remzi, F A1 - Heriot, AG A1 - Manilich, E A1 - Strong, SA J1 - Br J Surg Y1 - 2005/10// VL - 92 SN - 0007-1323 SP - 1270 EP - 1276 N2 - INTRODUCTION: Pouch-related fistula occurs in 5-10 per cent of patients after restorative proctocolectomy. The present study identified risk factors associated with the development of such fistulas. METHODS: Data on preoperative and postoperative risk factors were recorded from 1965 patients who underwent restorative proctocolectomy in a single tertiary centre between 1983 and 2001. Cox regression analysis was used to identify independent predictors of pouch-perineal, pouch-abdominal wall and pouch-vaginal fistula during follow-up. RESULTS: Median patient follow-up was 4.1 (range 0-19) years. By 15 years' follow-up, pouch-vaginal fistulas had occurred in 44 women (5.2 per cent). The prevalence of ileal pouch-perineal and pouch-abdominal wall fistula was 3.6 per cent (70 patients) and 1.5 per cent (30 patients) respectively. Independent predictors of pouch-related fistula identified by multivariate analysis were diagnosis of indeterminate colitis or Crohn's disease (hazard ratio (HR) 1.28 (95 per cent confidence interval (c.i.) 1.00 to 1.65) and 1.73 (95 per cent c.i. 1.07 to 3.48) respectively versus ulcerative colitis or familial adenomatous polyposis), previous anal pathology (HR 3.43 (95 per cent c.i. 2.43 to 4.84) and 4.02 (95 per cent c.i. 1.27 to 12.77) respectively for perineal abscess and fistula in ano versus no previous anal pathology), abnormal anal manometry (HR 4.29 (95 per cent c.i. 2.33 to 7.91)), patient sex (HR 0.74 (95 per cent c.i. 0.58 to 0.95) for men versus women) and pelvic sepsis (HR 3.79 (95 per cent c.i. 2.48 to 5.79)). CONCLUSION: This study suggests that Crohn's disease and the clinical signs that favour the diagnosis of Crohn's disease may contribute to the development of pouch-related fistula. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15988792&query_hl=1 ER - TY - JFULL T1 - Quantification of mortality risk after abdominal aortic aneurysm repair. A1 - Hadjianastassiou, VG A1 - Tekkis, PP A1 - Goldhill, DR A1 - Hands, LJ J1 - Br J Surg Y1 - 2005/09// VL - 92 SN - 0007-1323 SP - 1092 EP - 1098 N2 - BACKGROUND: The study was designed to evaluate the Acute Physiology And Chronic Health Evaluation (APACHE) II risk scoring system in abdominal aortic aneurysm (AAA) surgery. The aim was to create an APACHE-based risk stratification model for postoperative death. METHODS: Prospective postoperative APACHE II data were collected from patients undergoing AAA repair over a 9-year interval from 24 intensive care units (ICUs) in the Thames region. A multilevel logistic regression model (APACHE-AAA) for in-hospital mortality was developed to adjust for both case mix and the variation in outcome between ICUs. RESULTS: A total of 1896 patients were studied. The in-hospital mortality rate among the 1289 patients who had elective AAA repair was 9.6 (95 per cent confidence interval (c.i.) 8.0 to 11.2) per cent and that among the 605 patients who had an emergency repair was 46.9 (95 per cent c.i. 43.0 to 50.9) per cent. Four independent predictors of death were identified: age (odds ratio (OR) 1.05 (95 per cent c.i. 1.03 to 1.07) per year increase), Acute Physiology Score (OR 1.14 (95 per cent c.i. 1.12 to 1.17) per unit increase), emergency operation (OR 4.86 (95 per cent c.i. 3.64 to 6.52)) and chronic health dysfunction (OR 1.43 (95 per cent c.i. 1.04 to 1.97)). The APACHE-AAA model was internally valid, as shown by calibration (Hosmer-Lemeshow C statistic: chi(2) = 6.14, 8 d.f., P = 0.632), discrimination properties (area under receiver-operator characteristic curve 0.845) and subgroup analysis. There was no significant variation in outcome between hospitals. CONCLUSION: APACHE-AAA was shown to be an accurate risk-stratification model that could be used to quantify the risk of death after AAA surgery. It might also be used to determine the relative impact of ICU over high-dependency unit care. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15997450&query_hl=1 ER - TY - JFULL T1 - Do technical parameters affect the diagnostic accuracy of virtual bronchoscopy in patients with suspected airways stenosis? A1 - Jones, CM A1 - Athanasiou, T A1 - Nair, S A1 - Aziz, O A1 - Purkayastha, S A1 - Konstantinos, V A1 - Paraskeva, P A1 - Casula, R A1 - Glenville, B A1 - Darzi, A J1 - Eur J Radiol Y1 - 2005/09// VL - 55 SN - 0720-048X SP - 445 EP - 451 N2 - PURPOSE: Virtual bronchoscopy has gained popularity over the past decade as an alternative investigation to conventional bronchoscopy in the diagnosis, grading and monitoring of airway disease. The effect of technical parameters on diagnostic outcome from virtual bronchoscopy has not been determined. This meta-analysis aims to estimate accuracy of virtual compared to conventional bronchoscopy in patients with suspected airway stenosis, and evaluate the influence of technical parameters. MATERIALS AND METHODS: A MEDLINE search was used to identify relevant published studies. The primary endpoint was the "correct diagnosis" of stenotic lesions on virtual compared to conventional bronchoscopy. Secondary endpoints included the effects of the technical parameters (pitch, collimation, reconstruction interval, rendering method, and scanner type), and date of publication on the diagnostic accuracy of virtual bronchoscopy. RESULTS: Thirteen studies containing 454 patients were identified. Meta-analysis showed good overall diagnostic performance with 85% calculated pooled sensitivity (95% CI 77-91%), 87% specificity (95% CI 81-92%) and area under the curve (AUC) of 0.947. Subgroups included collimation of 3mm or more (AUC 0.948), pitch of 1 (AUC 0.955), surface rendering technique (AUC 0.935), and reconstruction interval of more than 1.25 mm (AUC 0.914). There was no significant difference in accuracy accounting for publication date, scanner type or any of the above variables. Weighted regression analysis confirmed none of these variables could significantly account for study heterogeneity. CONCLUSION: Virtual bronchoscopy performs well in the investigation of patients with suspected airway stenosis. Overall sensitivity and specificity and diagnostic odds ratio for diagnosis of airway stenosis were high. The effects of pitch, collimation, reconstruction interval, rendering technique, scanner type, and publication date on diagnostic accuracy were not significant. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16129255&query_hl=1 ER - TY - JFULL T1 - Assessment of psychomotor skills acquisition during laparoscopic cholecystectomy courses. A1 - Hance, J A1 - Aggarwal, R A1 - Moorthy, K A1 - Munz, Y A1 - Undre, S A1 - Darzi, A J1 - Am J Surg Y1 - 2005/09// VL - 190 SN - 0002-9610 SP - 507 EP - 511 N2 - BACKGROUND: Standardized short courses in laparoscopic cholecystectomy aim to teach laparoscopic skills to surgical trainees, although end-of-course assessments of performance remain subjective. The current study aims to objectively assess psychomotor skills acquisition of trainees attending laparoscopic cholecystectomy courses. METHODS: Thirty-seven junior surgical trainees had their laparoscopic skills assessed before and after attending 1 of 3 separate 2-day courses (A, B, and C), all with identical format. Assessments were comprised of a standardized simulated laparoscopic task, with performance measured using a valid electromagnetic hand-motion tracking device. RESULTS: Overall, trainees made significant improvements in path length (P=.006), number of movements (P<.001), and time taken (P<.001). Analyzing the 3 courses separately, only trainees attending courses A and C made significant improvements. DISCUSSION: Objective validated methods can be used to assess learning of psychomotor skills on courses. In addition to providing participants with an insight into their skills, these data can be used to demonstrate course efficacy. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16105545&query_hl=1 ER - TY - JFULL T1 - Magnetic resonance colonography versus colonoscopy as a diagnostic investigation for colorectal cancer: a meta-analysis. A1 - Purkayastha, S A1 - Tekkis, PP A1 - Athanasiou, T A1 - Aziz, O A1 - Negus, R A1 - Gedroyc, W A1 - Darzi, AW J1 - Clin Radiol Y1 - 2005/09// VL - 60 SN - 0009-9260 SP - 980 EP - 989 N2 - AIMS: Magnetic resonance colonography (MRC) is emerging as a potential complementary investigation for the diagnosis of colorectal cancer (CRC) and also for benign pathology such as diverticular disease. A meta-analysis reporting the use of MRC is yet to be performed. The aim of this study was to evaluate the diagnostic accuracy of MRC compared with the gold-standard investigation, conventional colonoscopy (CC). METHODS: A literature search was carried out to identify studies containing comparative data between MRC findings and CC findings. Quantitative meta-analysis for diagnostic tests was performed, which included the calculation of independent sensitivities, specificities, diagnostic odds ratios, the construction of summary receiver operating characteristic (SROC) curves, pooled analysis and sensitivity analysis. The study heterogeneity was evaluated by the Q-test using a random-effect model to accommodate the cluster of outcomes between individual studies. RESULTS: In all, 8 comparative studies were identified, involving 563 patients. The calculated pooled sensitivity for all lesions was 75% (95% CI: 47% to 91%), the specificity was 96% (95% CI: 86% to 98%) and the area under the ROC curve was 90% (weighted). On sensitivity analysis, MRC had a better diagnostic accuracy for CRC than for polyps, with a sensitivity of 91% (95% CI: 97% to 91%), a specificity of 98% (95% CI: 66% to 99%) and an area under the ROC curve of 92%. There was no significant heterogeneity between the studies with regard to the diagnostic accuracy of MRC for CRC. CONCLUSION: This meta-analysis suggests that MRC is an imaging technique with high discrimination for cases presenting with colorectal cancer. The exact diagnostic role of MRC needs to be clarified (e.g. suitable for an elderly person with suspected CRC). Further evaluation is necessary to refine its applicability and diagnostic accuracy in comparison with other imaging methods such as computed tomography colonography. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16124980&query_hl=1 ER - TY - JFULL T1 - Intraperitoneal aerosolization of local anaesthetic reduced postoperative pain in laparoscopic surgery A1 - Alkhamesi, NA A1 - Peck, DH A1 - Lomax, DL A1 - Darzi, AW J1 - J AM COLL SURGEONS Y1 - 2005/09// VL - 201 SN - 1072-7515 SP - S11 EP - S11 ER - TY - JFULL T1 - Peritoneal nebulizer: a novel technique for delivering intraperitoneal therapeutics in laparoscopic surgery to prevent locoregional recurrence. A1 - Alkhamesi, NA A1 - Ridgway, PF A1 - Ramwell, A A1 - McCullough, PW A1 - Peck, DH A1 - Darzi, AW J1 - Surg Endosc Y1 - 2005/08// VL - 19 SN - 1432-2218 SP - 1142 EP - 1146 N2 - BACKGROUND: Peritoneal involvement is a significant issue in the treatment of gastrointestinal malignancies. Current statistics indicate that after surgical intervention, up to 20% of patients will present with locoregional metastasis. The ability to inhibit initial tumor adhesion to the mesothelial lining of the peritoneum may be considered critical in the inhibition of tumor development. This article describes, the use of a novel nebulizer system capable of delivering high-concentration, low-dose therapeutics to the peritoneal cavity. METHODS: For this study, 30 male WAG rats were inoculated with CC531 colorectal tumor cells. The rats were randomized into three groups: control group (n = 10), heparin-treated group (n = 10), and high-molecular-weight hyaluronan-treated group (n = 10). A peritoneal cancer index was used to determine tumor burden at 15 days. Analysis of variance (ANOVA) was used to compare multiple group means. RESULTS: Nebulization therapy was performed without any complication in the cohort. Heparin inhibited macroscopic intraperitoneal tumor growth completely (p = 0.0001) without affecting tumor cell viability. The introduction of hyaluronan attenuated both tumor size and distribution, was compared with the control group (p = 0.002). CONCLUSION: Nebulized heparin and hyaluronic acid using a novel nebulization technique attenuates peritoneal tumor growth after laparoscopic surgery. The technique itself is easy to use and safe. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16021376&query_hl=1 ER - TY - JFULL T1 - Image-guided navigation in oral and maxillofacial surgery. A1 - Nijmeh, AD A1 - Goodger, NM A1 - Hawkes, D A1 - Edwards, PJ A1 - McGurk, M J1 - Br J Oral Maxillofac Surg Y1 - 2005/08// VL - 43 SN - 0266-4356 SP - 294 EP - 302 N2 - Image-guided surgery is the logical extension of imaging as it integrates previously acquired radiological or nuclear medicine images with the operative field. In conventional image-guided surgery, a surgeon uses a surgical instrument or a pointer to establish correspondence between features in the preoperative images and the surgical scene. This is not ideal because the surgeon has to look away from the operative field to view the data. Augmented reality guidance systems offer a solution to this problem but are limited by deformation of soft tissues. Real-time intraoperative imaging offers a potential solution but is currently only experimental. The additional precision and confidence that this technology provides make it a useful tool, and recent advances in image-guided surgery offer new opportunities in the field of oral and maxillofacial surgery. Here, we review the development, current technologies, and applications of image-guided surgery and illustrate them with two case reports. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15993282&query_hl=1 ER - TY - JFULL T1 - Skills acquisition for laparoscopic gastric bypass in the training laboratory - An innovative approach A1 - Aggarwal, R A1 - Boza, C A1 - Hance, J A1 - Lacy, A A1 - Darzi, A J1 - OBES SURG Y1 - 2005/08// VL - 15 SN - 0960-8923 SP - 969 EP - 969 ER - TY - JFULL T1 - Selection of individuals for training in surgery. A1 - Bann, S A1 - Darzi, A J1 - Am J Surg Y1 - 2005/07// VL - 190 SN - 0002-9610 SP - 98 EP - 102 N2 - Surgical training in the United Kingdom and Europe is in transition given the pressure to decrease the number of workweek hours and the numbers of years in training. To achieve this shortened training in the United Kingdom, the primary component will be the foundational education, which will last for 2 years, with the second year perhaps counting toward specialist training. It would be a potential advantage for achieving rapid surgical training if we could preselect those students with the necessary attributes of a surgeon. During the foundation period there is exists the question of assessment, so this might be a natural point at which to preselect these students. This article considers psychometric assessment as a methodology of preselecting surgeons and considers objective assessment as a possibility during the foundational education period. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15972179&query_hl=1 ER - TY - JFULL T1 - Evaluation of the learning curve in laparoscopic colorectal surgery: comparison of right-sided and left-sided resections. A1 - Tekkis, PP A1 - Senagore, AJ A1 - Delaney, CP A1 - Fazio, VW J1 - Ann Surg Y1 - 2005/07// VL - 242 SN - 0003-4932 SP - 83 EP - 91 N2 - OBJECTIVE: To provide a multidimensional analysis of the learning curve in major laparoscopic colonic and rectal surgery and compare outcomes between right-sided versus left-sided resections. SUMMARY BACKGROUND DATA: The laparoscopic learning curve is known to vary between surgeons, may be influenced by the patient selection and operative complexity, and requires appropriate case-mix adjustment. METHODS: This is a descriptive single-center study using routinely collected clinical data from 900 patients undergoing laparoscopic surgery between November 1991 and April 2003. Outcome measures included operation time, conversion rate (CR), and readmission and postoperative complication rates. Multifactorial logistic regression analysis was used to identify patient-, surgeon-, and procedure-related factors associated with conversion of laparoscopic to open surgery. A risk-adjusted Cumulative Sum (CUSUM) model was used for evaluating the learning curve for right and left-sided resections. RESULTS: The conversion rate for right-sided colonic resections was 8.1% (n = 457) compared with 15.3% for left-sided colorectal resections (n = 443). Independent predictors of conversion of laparoscopic to open surgery were the body mass index (BMI) (odds ratio [OR] = 1.07 per unit increase), ASA grade (OR = 1.63 per unit increase), type of resection (left colorectal versus right colonic procedures, OR = 1.5), presence of intra-abdominal abscess (OR = 5.0) or enteric fistula (OR = 4.6), and surgeon's experience (OR 0.9 per 10 additional cases performed). Having adjusted for case-mix, the CUSUM analysis demonstrated a learning curve of 55 cases for right-sided colonic resections versus 62 cases for left-sided resections. Median operative time declined with operative experience (P<0.001). Readmission rates and postoperative complications remained unchanged throughout the series and were not dependent on operative experience. CONCLUSIONS: Conversion rates for laparoscopic colectomy are dependent on a multitude of factors that require appropriate adjustment including the learning curve (operative experience) for individual surgeons. The laparoscopic model described can be used as the basis for performance monitoring between or within institutions. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15973105&query_hl=1 ER - TY - JFULL T1 - A practical approach towards accurate dense 3D depth recovery for robotic laparoscopic surgery. A1 - Stoyanov, D A1 - Darzi, A A1 - Yang, GZ J1 - Comput Aided Surg Y1 - 2005/07// VL - 10 SN - 1092-9088 SP - 199 EP - 208 N2 - OBJECTIVE: Recovering tissue deformation during robotic-assisted minimally invasive surgery (MIS) is an important step towards motion compensation and stabilization. This article presents a practical strategy for dense 3D depth recovery and temporal motion tracking for deformable surfaces. METHODS: The method combines image rectification with constrained disparity registration for reliable depth estimation. The accuracy and practical value of the technique are validated using a tissue phantom with known 3D geometry and motion characteristics and in vivo data. RESULTS: Results from the phantom model correctly follow the motion trend indicated from the ground truth provided by CT scanning, and regression analysis shows the intrinsic accuracy that can be achieved with the proposed technique. Results applied to in vivo robotic-assisted MIS data are also provided, indicating the practical value of the proposed method. CONCLUSION: The proposed method presents a practical strategy for dense depth recovery of surface structure in robotic-assisted MIS that incorporates stereo vision. Results on phantom and in vivo data indicate the quality of the method and also highlight the importance of further considering the effects of specular highlights. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16393789&query_hl=1 ER - TY - JFULL T1 - Comparison of circumferential margin involvement between restorative and nonrestorative resections for rectal cancer. A1 - Tekkis, PP A1 - Heriot, AG A1 - Smith, J A1 - Thompson, MR A1 - Finan, P A1 - Stamatakis, JD A1 - Association of Coloproctology of Great Britain and Ireland J1 - Colorectal Dis Y1 - 2005/07// VL - 7 SN - 1462-8910 SP - 369 EP - 374 N2 - OBJECTIVE: To study circumferential margin involvement (CMI) in patients undergoing restorative, compared with nonrestorative, surgery for rectal cancer. DATA SOURCE: Descriptive multicentre study, using routinely collected clinical data from the Association of Coloproctology of Great Britain and Ireland (ACPGBI) Bowel Cancer Audit database. The study encompassed 1403 newly diagnosed patients with rectal cancer undergoing either restorative (anterior resection (AR)), or nonrestorative (abdominoperineal excision of rectum (APER) or Hartmann's procedure), surgery. Operations were carried out in 39 hospitals during a variable period between April 1999 to March 2002. A logistic regression analysis was used to control for variables associated with circumferential margin involvement. RESULTS: One thousand and thirty-six patients satisfied the inclusion criteria. The average CMI was 12.5% (range 0-33.3% between hospitals). CMI for anterior resection was 7.5% (n = 629) compared with a CMI of 16.7% for APER (n = 306) and a CMI of 31.7% for Hartmann's procedure (n = 101); P < or = 0.001. CMI for patients undergoing curative surgery was 7.1% (423 anterior resections, CMI 3.8% (n = 16); 181 APER, CMI 13.3% (n = 24); 29 Hartmann's procedure, CMI 17.2%). On multivariate analysis, having controlled for Dukes' stage and operative intent, the CMI was significantly different between APER and AR (odds ratio 3.3, 95%CI 2.0-5.4), but less so between Hartmann's procedure and AR (odds ratio 2.2, 95%CI 1.1-4.2). CONCLUSIONS: APER is associated with a significantly higher CMI than anterior resection. Attention to surgical technique, with a wide perineal dissection and the use of pre-operative adjuvant therapy, may reduce CMI in patients undergoing APER. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15932561&query_hl=1 ER - TY - JFULL T1 - Objective assessment of technical skills in cardiac surgery. A1 - Hance, J A1 - Aggarwal, R A1 - Stanbridge, R A1 - Blauth, C A1 - Munz, Y A1 - Darzi, A A1 - Pepper, J J1 - Eur J Cardiothorac Surg Y1 - 2005/07// VL - 28 SN - 1010-7940 SP - 157 EP - 162 N2 - OBJECTIVE: Reduced training time combined with no rigorous assessment for technical skills makes it difficult for trainees to monitor their competence. We have developed an objective bench-top assessment of technical skills at a level commensurate with a junior registrar in cardiac surgery. METHODS: Forty cardiothoracic surgeons were recruited for the study, consisting of 12 junior trainees (year 1-3), 15 senior trainees (year 4-6) and 13 consultants. The assessment consisted of four key tasks on standardised bench-top models: aortic root cannulation, vein-graft to aorta anastomosis, vein-graft to Left Anterior Descending (LAD) anastomosis and femoral triangle dissection. An expert surgeon was present at each station to provide passive assistance and rate performance on a validated global rating scale giving rise to a total possible score of 40. Three expert surgeons repeated the ratings retrospectively, using blinded video recordings. Data analysis employed non-parametric tests. RESULTS: Both live and video scores differentiated significantly between performances of all groups of surgeons for all four stations (P < 0.01) (median live and video score for LAD; Junior 19,17; Senior 29,22; Consultant 36,28). Correlations between live and blinded rating were high (r = 0.67-0.84; P < 0.001) as was inter-rater reliability between the three expert video raters (alpha = 0.81). CONCLUSIONS: The use of bench-top tasks to differentiate between cardiac surgeons of differing technical abilities has been validated for the first time. Furthermore, it is unnecessary to perform post-hoc video rating to obtain objective data. These measures can provide formative feedback for surgeons-in-training and lead to the development of a competency-based technical skills curriculum. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15982599&query_hl=1 ER - TY - JFULL T1 - Analysis of errors enacted by surgical trainees during skills training courses. A1 - Tang, B A1 - Hanna, GB A1 - Cuschieri, A J1 - Surgery Y1 - 2005/07// VL - 138 SN - 0039-6060 SP - 14 EP - 20 N2 - BACKGROUND: Despite the emphasis on medical error as a major cause of hospital morbidity and mortality, there has been little published work on errors committed by trainees. This issue is particularly relevant to the training of surgeons and was addressed by our study. METHODS: Sixty simulated laparoscopic cholecystectomies performed on restructured pig tissue models by 60 surgical trainees provided the study material. The unedited videotapes were analyzed by observational HRA of the component steps of the procedures. Ten generic forms of observable error types were used to categorize patterns of failure. Error probabilities with specific instruments were also calculated. RESULTS: A total of 1067 errors were identified by observational HRA: 331 consequential and 736 without consequence (ie, total error rate of 18 [SD +/- 10]) per procedure. The study documented a wide variation in the number of errors between the 60 trainee surgeons. The important underlying factors for the trainee errors were (1) omission of important steps, (2) execution of steps in the wrong sequence, and (3) use of excessive force. These 3 errors accounted for 92% of consequential errors. CONCLUSIONS: This study has shown that trainees vary considerably in their propensity to commit errors. This variability indicates that the surgical training in component skills for laparoscopic surgery should be flexible and individualized. Three mechanisms account for the majority of errors and indicate that skills training in surgery has to be structured, menu driven, and tailored to individual needs. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16003310&query_hl=1 ER - TY - JFULL T1 - The reliability of multiple objective measures of surgery and the role of human performance. A1 - Bann, S A1 - Davis, IM A1 - Moorthy, K A1 - Munz, Y A1 - Hernandez, J A1 - Khan, M A1 - Datta, V A1 - Darzi, A J1 - Am J Surg Y1 - 2005/06// VL - 189 SN - 0002-9610 SP - 747 EP - 752 N2 - BACKGROUND: There is a need for reliable and valid objective methods of technical skills in surgery. Six-bench surgical top stations have been combined to assess basic surgical trainees (BSTs) objectively. The current study examines its reliability and validity across repeat sittings. METHODS: Eleven surgical trainees (6 senior BSTs and 5 higher surgical trainees [HSTs]) undertook 5 sittings of the 6-station assessment designed to be completed within 90 minutes. The 6 stations consisted of knot tying, suturing, closure of enterotomy, excision of sebaceous cyst, laparoscopic task, and instrument examination. Methods of analysis employed were motion analysis, observation with criteria, and inbuilt simulation metrics. RESULTS: On analysis 3 knot tying and suturing stations exhibited significant differences in either time or movement; any difference was over by the second run. The intertest reliabilities were .66, .74, .55, .51, and .65 for the 5 runs. The intratest reliability across repeated sittings varied from .56 to .96. The inter-rater reliability for video assessment varied from .77 to .94. CONCLUSION: The assessment is reliable and valid across repeated sittings. Its use in assessment of basic technical skills needs to be encouraged. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15910731&query_hl=1 ER - TY - JFULL T1 - Inguinal hernia. A1 - Purkayastha, S A1 - Tekkis, P A1 - Athanasiou, T A1 - Darzi, A J1 - Clin Evid Y1 - 2005/06// SN - 1462-3846 SP - 535 EP - 555 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16135273&query_hl=1 ER - TY - JFULL T1 - Two-chamber intracardiac mesothelioma. A1 - Ashrafian, H A1 - Athanasiou, T A1 - Yap, J A1 - DeSouza, AC J1 - Asian Cardiovasc Thorac Ann Y1 - 2005/06// VL - 13 SN - 0218-4923 SP - 184 EP - 186 N2 - Primary intracardiac malignant mesotheliomas are extremely rare and carry a very poor prognosis. We present such a case where the lesion encompassed two chambers, the left atrium and ventricle, with no pericardial involvement. Initial echocardiography mimicked a myxoma, and urgent surgical intervention was required in view of significant cardiorespiratory compromise. To the best of our knowledge this is the first case of a primary two-chamber intracardiac malignant sarcomatoid mesothelioma. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15905353&query_hl=1 ER - TY - JFULL T1 - Blurring the boundaries: scenario-based simulation in a clinical setting. A1 - Kneebone, RL A1 - Kidd, J A1 - Nestel, D A1 - Barnet, A A1 - Lo, B A1 - King, R A1 - Yang, GZ A1 - Brown, R J1 - Med Educ Y1 - 2005/06// VL - 39 SN - 0308-0110 SP - 580 EP - 587 N2 - CONTEXT: The ability to perform clinical procedures safely is a key skill for health care professionals. Performing such procedures on conscious patients is challenging and requires a combination of technical and communication skills. We have developed quasi-clinical scenarios, where inanimate models attached to simulated patients provide a convincing learning environment. Procedures are rated by expert observers and by the 'patient' and recorded for subsequent review. This study explores the potential of locating such scenarios within a real clinical setting, allowing participants to experience the challenges of the workplace while ensuring patient safety. An innovative portable digital recording device (the 'Virtual Chaperone') is evaluated for use in clinical settings. METHODS: A qualitative design (observation and interview studies) investigated volunteer medical students undertaking 2 procedure scenarios (insertion of urinary catheter and wound closure with sutures) within the accident unit of a large London hospital. All procedures were observed in real time and recorded digitally (using the Virtual Chaperone). A protocol was used for structured feedback. Observational and interview data was analysed using standard qualitative techniques. RESULTS: Seven sessions with 22 undergraduate medical students took place over 9 months within 1 centre. Data confirmed the feasibility of using a moveable, self-contained training scenario within an authentic clinical setting. Overall, the response from participants was positive. CONCLUSION: Scenario-based teaching within an authentic clinical environment is feasible and perceived by participants to be educationally useful. This approach blurs traditional boundaries between skills laboratory teaching and clinical practice and may offer considerable advantages in training for clinical procedures. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15910434&query_hl=1 ER - TY - JFULL T1 - Evaluating clinical simulations for learning procedural skills: a theory-based approach. A1 - Kneebone, R J1 - Acad Med Y1 - 2005/06// VL - 80 SN - 1040-2446 SP - 549 EP - 553 N2 - Simulation-based learning is becoming widely established within medical education. It offers obvious benefits to novices learning invasive procedural skills, especially in a climate of decreasing clinical exposure. However, simulations are often accepted uncritically, with undue emphasis being placed on technological sophistication at the expense of theory-based design. The author proposes four key areas that underpin simulation-based learning, and summarizes the theoretical grounding for each. These are (1) gaining technical proficiency (psychomotor skills and learning theory, the importance of repeated practice and regular reinforcement), (2) the place of expert assistance (a Vygotskian interpretation of tutor support, where assistance is tailored to each learner's needs), (3) learning within a professional context (situated learning and contemporary apprenticeship theory), and (4) the affective component of learning (the effect of emotion on learning). The author then offers four criteria for critically evaluating new or existing simulations, based on the theoretical framework outlined above. These are: (1) Simulations should allow for sustained, deliberate practice within a safe environment, ensuring that recently-acquired skills are consolidated within a defined curriculum which assures regular reinforcement; (2) simulations should provide access to expert tutors when appropriate, ensuring that such support fades when no longer needed; (3) simulations should map onto real-life clinical experience, ensuring that learning supports the experience gained within communities of actual practice; and (4) simulation-based learning environments should provide a supportive, motivational, and learner-centered milieu which is conducive to learning. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15917357&query_hl=1 ER - TY - JFULL T1 - Variant Creutzfeldt-Jakob disease: a cause for concern. Review of the evidence for risk of transmission through abdominal lymphoreticular tissue surgery. A1 - Olsen, SB A1 - Sheikh, A A1 - Peck, D A1 - Darzi, A J1 - Surg Endosc Y1 - 2005/06// VL - 19 SN - 1432-2218 SP - 747 EP - 750 N2 - BACKGROUND: Concern has long existed regarding the possible iatrogenic spread of variant Creutzfeldt-Jakob disease (v-CJD) through surgery. This had been fueled by recent reports of bovine spongiform encephalopathy in U.S. cattle and the first probable case of blood transmission of v-CJD in the UK. METHODS: Systematic review of experimental and nonexperimental studies. Studies identified from searches of Medline, Embase, Cochrane Library, Science Citation Index medical databases, searching bibliographies of retrieved papers, and personal communication with international experts in the field. RESULTS: Six articles satisfied our search criteria. Evidence stems from case reports, case series, and cross-sectional studies. There are no published cases of surgically transmitted v-CJD. CONCLUSION: We found evidence of v-CJD prion agents in the spleen, appendix, rectum, and adrenal glands of affected patients and evidence of v-CJD prion in the appendix of patients in the preclinical stage of the disease. The risk of transmission of v-CJD prion during abdominal surgery is currently unquantifiable. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15868249&query_hl=1 ER - TY - JFULL T1 - Technical skills errors in laparoscopic cholecystectomy by expert surgeons. A1 - Sarker, SK A1 - Chang, A A1 - Vincent, C A1 - Darzi, AW J1 - Surg Endosc Y1 - 2005/06// VL - 19 SN - 1432-2218 SP - 832 EP - 835 N2 - BACKGROUND: Performing laparoscopic surgery involves a complex cascade of cognitive skills, which may inherently have a constant technical error rate. We assess generic and specific minor and major error rates in laparoscopic cholecystectomies (LCs) performed by consultant surgeons. METHODS: Checklists of generic (11) and specific technical minor (six) and major events (eight) were devised for LCs. Two experienced surgeons assessed each full-length operation blindly and independently. RESULTS: A total of 37 LCs were performed by eight consultants. There were no major intraoperative or postoperative complications. Mean inter-rater reliability was kappa = 0.91 (range 0.80-0.98) for each of the error categories. Error rates were generic (27/407) 6.6%, minor (59/222) 26.6%, and major (8/296) 2.7%, respectively. There was a significant statistical difference between the minor error group and the other groups, p 200 mumol/L or postoperative mechanical renal support). METHODS: The study was based on 2,041 patients with no known preoperative renal disease having first-time isolated coronary artery bypass grafting of multiple coronary arteries between January 2001 and November 2003, at St. Mary's Hospital, Harefield Hospital, and Hammersmith Hospital, in West London; 1,224 patients had on-pump coronary artery bypass grafting and 817 patients had OPCAB. Selection bias for surgical technique was addressed by calculating the propensity score for each patient and using it as an independent variable for adjustment in the multivariate analysis. Univariate and multivariate ordered logistic regressions were used to identify factors associated with renal adverse outcome ordered as none, minor, and major. RESULTS: The number of grafts was 3.22 +/- 0.82 for the on-pump coronary artery bypass grafting group and 3.35 +/- 0.95 for the OPCAB group. On-pump coronary artery bypass grafting and increasing age were found to be the strongest independent predictors (p < 0.001) of renal adverse outcome. Other independent predictors included hypertension (p = 0.005), diabetes (p = 0.032), and preoperative serum creatinine (p = 0.001). A left ventricular ejection fraction of 0.30 to 0.49 (p = 0.099) and an ejection fraction of 0.50 or greater (p < 0.001) were associated with decreased risk compared with patients with an ejection fraction of less than 0.30. Interestingly, the use of non-left internal mammary arterial conduits significantly decreased the likelihood of renal adverse outcome (p = 0.034). CONCLUSIONS: The results of this propensity-based study show that the OPCAB technique may reduce the risk for minor and major renal adverse outcome after coronary artery bypass grafting. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15854936&query_hl=1 ER - TY - JFULL T1 - Training in laparoscopy--which model to use? A1 - Aggarwal, R A1 - Darzi, A J1 - Indian J Gastroenterol Y1 - 2005/05// VL - 24 SN - 0254-8860 SP - 95 EP - 96 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16041098&query_hl=1 ER - TY - JFULL T1 - Risk-adjustment in hepatobiliary pancreatic surgery. A1 - Kocher, HM A1 - Tekkis, PP A1 - Gopal, P A1 - Patel, AG A1 - Cottam, S A1 - Benjamin, IS J1 - World J Gastroenterol Y1 - 2005/04/28/ VL - 11 SN - 1007-9327 SP - 2450 EP - 2455 N2 - AIM: The present study evaluates the performance of the POSSUM, the American Society of Anesthetists (ASA), APACHE and Childs classification in predicting mortality and morbidity in hepatopancreaticobiliary (HPB) surgery. We describe especially the limitations and advantages of risk in stratifying the patients. METHODS: We investigated 177 randomly chosen patients undergoing elective complex HPB surgery in a single institution with a total of 71 pre-operative and intra-operative risk factors. Primary endpoint was in-hospital mortality and morbidity. Ordered logistic regression analysis was used to identify individual predictors of operative morbidity and mortality. RESULTS: The operative mortality in the series was 3.95%. This compared well with the p-POSSUM and APACHE predicted mortality of 4.31% and 4.29% respectively. Post-operative complications amounted to 45% with 24 (13.6%) patients having a major adverse event. On multivariate analysis the pre-operative POSSUM physiological score (OR = 1.18, P = 0.009) was superior in predicting complications compared to the ASA (P = 0.108), APACHE (P = 0.117) or Childs classification (P = 0.136). In addition, serum sodium, creatinine, international normalized ratio (INR), pulse rate, and intra-operative blood loss were independent risk factors. A combination of the POSSUM variables and INR offered the optimal combination of risk factors for risk prognostication in HPB surgery. CONCLUSION: Morbidity for elective HPB surgery can be accurately predicted and applied in everyday surgical practice as an adjunct in the process of informed consent and for effective allocation of resources for intensive and high-dependency care facilities. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15832416&query_hl=1 ER - TY - JFULL T1 - New professional roles in surgery. A1 - Kneebone, R A1 - Darzi, A J1 - BMJ Y1 - 2005/04/09/ VL - 330 SN - 1468-5833 SP - 803 EP - 804 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15817532&query_hl=1 ER - TY - JFULL T1 - New professional roles in surgery - Would be effective in selected surgical settings and can offer benefits A1 - Kneebone, R A1 - Darzi, A J1 - BRIT MED J Y1 - 2005/04/09/ VL - 330 SN - 0959-8146 SP - 803 EP - 804 ER - TY - JFULL T1 - Assessment of technical skills in open and laparoscopic surgery A1 - Sarker, SK A1 - Chang, A A1 - Vincent, C A1 - Darzi, AW J1 - BRIT J SURG Y1 - 2005/04// VL - 92 SN - 0007-1323 SP - 22 EP - 23 ER - TY - JFULL T1 - Magnetic resonance colonography: a new imaging modality for diagnosing colorectal cancer. A meta-analysis A1 - Purkayastha, S A1 - Tekkis, PP A1 - Athanasiou, T A1 - Aziz, O A1 - Negus, R A1 - Gedroyc, W A1 - Darzi, AW J1 - BRIT J SURG Y1 - 2005/04// VL - 92 SN - 0007-1323 SP - 153 EP - 153 ER - TY - JFULL T1 - Triplate fixation - A new technique in limb-salvage surgery A1 - Cobb, JP A1 - Ashwood, N A1 - Robbins, G A1 - Witt, JD A1 - Unwin, PS A1 - Blunn, G J1 - J BONE JOINT SURG BR Y1 - 2005/04// VL - 87B SN - 0301-620X SP - 534 EP - 539 N2 - Massive endoprostheses using a cemented intramedullary stem are widely used to allow early resumption of activity after surgery for tumours. The survival of the prosthesis varies with the anatomical site, the type of prosthesis and the mode of fixation. Revision surgery is required in many cases because of aseptic loosening. Insertion of a second cemented endoprosthesis may be difficult because of the poor quality of the remaining bone, and loosening recurs quickly.We describe a series of 14 patients with triplate fixation in difficult revision or joint sparing tumour surgery with a minimum follow-up of four years. The triplate design incorporated well within a remodelled cortex to achieve osseomechanical integration with;ill patients regaining their original level of function within five months.Our preliminary results suggest that this technique may provide an easy, biomechanically friendly alternative to insertion of a further device with an intramedullary stem, which has a shorter lifespan in revision or joint-sparing tumour surgery. A short segment of bone remaining after resection of a tumour will not accept an intramedullary item, but may be soundly fixed using this method. ER - TY - JFULL T1 - Assessing the teaching of technical skills. A1 - Sarker, SK A1 - Vincent, C A1 - Darzi, AW J1 - Am J Surg Y1 - 2005/04// VL - 189 SN - 0002-9610 SP - 416 EP - 418 N2 - BACKGROUND: There is a lack of structured instruments to assess how technical skills are taught. We aimed to develop a practical assessment tool that is easy to use and will assess the teaching of technical skills. METHODS: A 5-point Likert global rating scale was constructed. An experienced surgeon independently assessed each surgery using the assessment tool. Trainees also used the assessment tool after the surgery. RESULTS: Forty-two surgeries were assessed: 26 open and 16 laparoscopic surgeries. Interrater reliability between the independent assessor and trainees was performed using a kappa coefficient of .77 and a P value of less than .05. CONCLUSIONS: Our study shows that our assessment instrument has a potential ability to assess any taught technical task. We will continue and expand the study in surgery, and we aim to expand it further to medical specialties (eg, internal medicine, and so forth) that also teach technical tasks (eg, chest drain insertion, and so forth). L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15820452&query_hl=1 ER - TY - JFULL T1 - Surgical skill is predicted by the ability to detect errors. A1 - Bann, S A1 - Khan, M A1 - Datta, V A1 - Darzi, A J1 - Am J Surg Y1 - 2005/04// VL - 189 SN - 0002-9610 SP - 412 EP - 415 N2 - BACKGROUND: Objective analysis methods of surgical performance are now available so comparison between surgeons is available. One such method is by direct observation using the Objective Structured Assessment of Technical Skills (OSATS), but this is a time-consuming process; therefore, a simple screening tool for the ability to detect errors (previously validated) was analyzed and considered as a predictor of qualitative performance. METHODS: Thirty-eight volunteer surgeons were recruited to the skills laboratory to undertake 3 exercises. Two were bench-top surgical tasks that were scored using the global rating of the OSATS technique. The third task was the ability to detect simple errors in 22 synthetic models of common surgical procedures, some of which contained purposefully made errors. P<.05 was deemed to be statistically significant. RESULTS: The scores (interquartile ranges in parentheses) for the 3 sections were excision of sebaceous cyst=21 (19,24), closure of small bowel enterotomy=23 (21,27), and identification of errors=31 (27,34). Three scorers blinded to the operative models exhibited an interobserver reliability of .9 and .91 for the video tasks, respectively. Spearman's rank correlations between the error examination and performance on the 2 tasks were both statistically significant at .69 (cystectomy) and .54 (enterotomy). CONCLUSIONS: The ability to detect simple surgical errors is a predictor of technical skill and performance of bench tasks. What must be answered is whether the use of such models and principles can shorten the qualitative surgical learning curve. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15820451&query_hl=1 ER - TY - JFULL T1 - Assessment of surgical skills for open inguinal hernia repair A1 - Jacklin, R A1 - Aggarwal, R A1 - Hance, J A1 - Munshi, S A1 - Darzi, A J1 - BRIT J SURG Y1 - 2005/04// VL - 92 SN - 0007-1323 SP - 22 EP - 22 ER - TY - JFULL T1 - Evaluation of colonoscopy for colorectal cancer: a prospective multicentre study A1 - Purkayastha, S A1 - Tekkis, PP A1 - Darzi, AW A1 - Radford, AR A1 - Smith, JJ A1 - Thompson, MR A1 - Stamatakis, JD J1 - BRIT J SURG Y1 - 2005/04// VL - 92 SN - 0007-1323 SP - 151 EP - 151 ER - TY - JFULL T1 - A potential role for the chemokine receptor CXCR4 and its ligand CXCL12 in the locoregional spread of colorectal cancer A1 - Bailey, C A1 - Negus, R A1 - Roberts, G A1 - Goldin, R A1 - Peck, D A1 - Darzi, A J1 - GUT Y1 - 2005/04// VL - 54 SN - 0017-5749 SP - A83 EP - A83 ER - TY - JFULL T1 - We still need to operate at night! A1 - Faiz, OD A1 - Banerjee, S A1 - Tekkis, PP A1 - Rennie, JA A1 - Leather, AJ J1 - BRIT J SURG Y1 - 2005/04// VL - 92 SN - 0007-1323 SP - 96 EP - 97 ER - TY - JFULL T1 - Surgical performance assessment: a comparison of views from general surgical and cardiothoracic consultants A1 - Kessaris, N A1 - Tekkis, PP A1 - Perry-Kessaris, A J1 - BRIT J SURG Y1 - 2005/04// VL - 92 SN - 0007-1323 SP - 105 EP - 105 ER - TY - JFULL T1 - Preoperative prediction of lymph node metastases in oesophageal and gastric surgery: a prospective multicentre study A1 - Tekkis, PP A1 - Purkayastha, S A1 - Hanna, GN A1 - Darzi, AW A1 - McCulloch, P J1 - BRIT J SURG Y1 - 2005/04// VL - 92 SN - 0007-1323 SP - 5 EP - 5 ER - TY - JFULL T1 - Comparison of Hospital Episode Statistics with the Association of Coloproctology of Great Britain and Ireland colorectal cancer database A1 - Garout, M A1 - Tekkis, P A1 - Darzi, AW A1 - Stamatakis, J A1 - Aylin, P J1 - BRIT J SURG Y1 - 2005/04// VL - 92 SN - 0007-1323 SP - 155 EP - 156 ER - TY - JFULL T1 - Dexterity analysis for the assessment of laparoscopic procedures in the operating theatre A1 - Aggarwal, R A1 - Moorthy, K A1 - Grantcharov, T A1 - Papasavas, P A1 - Milland, T A1 - Dosis, A A1 - Bello, F A1 - Darzi, A J1 - BRIT J SURG Y1 - 2005/04// VL - 92 SN - 0007-1323 SP - 52 EP - 52 ER - TY - JFULL T1 - Plaque echolucency and plasma inflammatory markers predict embolisation during carotid angioplasty A1 - Jindal, R A1 - Bicknell, C A1 - Peck, D A1 - Rice, A A1 - Dhanjil, S A1 - Wolfe, J A1 - Jenkins, M A1 - Darzi, A A1 - Cheshire, N J1 - BRIT J SURG Y1 - 2005/04// VL - 92 SN - 0007-1323 SP - 12 EP - 12 ER - TY - JFULL T1 - Tissue deformation and shape models in image-guided interventions: a discussion paper. A1 - Hawkes, DJ A1 - Barratt, D A1 - Blackall, JM A1 - Chan, C A1 - Edwards, PJ A1 - Rhode, K A1 - Penney, GP A1 - McClelland, J A1 - Hill, DL J1 - Med Image Anal Y1 - 2005/04// VL - 9 SN - 1361-8415 SP - 163 EP - 175 N2 - This paper promotes the concept of active models in image-guided interventions. We outline the limitations of the rigid body assumption in image-guided interventions and describe how intraoperative imaging provides a rich source of information on spatial location of anatomical structures and therapy devices, allowing a preoperative plan to be updated during an intervention. Soft tissue deformation and variation from an atlas to a particular individual can both be determined using non-rigid registration. Established methods using free-form deformations have a very large number of degrees of freedom. Three examples of deformable models--motion models, biomechanical models and statistical shape models--are used to illustrate how prior information can be used to restrict the number of degrees of freedom of the registration algorithm and thus provide active models for image-guided interventions. We provide preliminary results from applications for each type of model. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15721231&query_hl=1 ER - TY - JFULL T1 - Hypoxia augments gelatinase activity in a variety of adenocarcinomas in vitro. A1 - Ridgway, PF A1 - Ziprin, P A1 - Alkhamesi, N A1 - Paraskeva, PA A1 - Peck, DH A1 - Darzi, AW J1 - J Surg Res Y1 - 2005/04// VL - 124 SN - 0022-4804 SP - 180 EP - 186 N2 - BACKGROUND: Hypoxia within solid adenocarcinomas and protease up-regulation has been independently implicated as poor prognostic indicators in a variety of tumor types. The authors hypothesize that Matrix Metalloproteases (MMP) are up-regulated in direct response to a hypoxic environment. MATERIALS AND METHODS: Colonic (SW1222), breast (MDA-MB231), and pancreatic (PSN-1) tumor cell lines were exposed to hypoxia (1% oxygen/94% nitrogen/5% carbon dioxide) for periods of up to 24 h. Reaction to a hypoxic environment was determined via invasion across a Matrigel-coated 8-microm Transwell filter. Activity of MMP 2 and 9 was assessed using gelatin zymography. Expression of tissue inhibitor of metalloproteases 1 (TIMP-1) was quantified using ELISA (Biotrak). Correlation between protease expression and invasive capacity was determined using a specific gelatinase inhibitor (MMPI; Calbiochem). RESULTS: All tumor lines demonstrated augmented invasion over 72 h (P < 0.01 all groups). Concomitant significant increase in MMP 2 and 9 activity was observed in the SW1222 and PSN-1 lines. MDA-MB231s showed increase in MMP 9 expression and in a unidentified 103-kDa gelatinase (P < 0.001). The hypoxia-augmented invasion was attenuated by the addition of a specific gelatinase inhibitor confirming interdependence. CONCLUSIONS: Hypoxia induces an increased invasive capacity via gelatinase up-regulation without loss of cell viability. This suggests a mechanism explaining the poorer prognosis seen in patients with protease-secreting solid adenocarcinomas. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15820246&query_hl=1 ER - TY - JFULL T1 - A randomised controlled trial of minor surgery in general practice and in hospital A1 - Pockney, P A1 - George, S A1 - Primrose, J A1 - Smith, H A1 - Little, P A1 - Kinley, H A1 - Lattimer, V A1 - Lowy, A A1 - Kneebone, R J1 - BRIT J SURG Y1 - 2005/04// VL - 92 SN - 0007-1323 SP - 2 EP - 2 ER - TY - JFULL T1 - Impact of technical factors on outcome of restorative proctocolectomy for familial adenomatous polyposis A1 - Tekkis, PP A1 - Heriot, AG A1 - Von-Roon, A A1 - Truvolon, S A1 - Cornaglia, S A1 - Nichos, RJ A1 - Phillips, RKS J1 - BRIT J SURG Y1 - 2005/04// VL - 92 SN - 0007-1323 SP - 120 EP - 120 ER - TY - JFULL T1 - Simulation based training A1 - Moorthy, K A1 - Vincent, C A1 - Darzi, A J1 - BRIT MED J Y1 - 2005/03/05/ VL - 330 SN - 0959-8146 SP - 493 EP - 494A ER - TY - JFULL T1 - Laparoscopic environmental changes during surgery enhance the invasive potential of tumours. A1 - Paraskeva, PA A1 - Ridgway, PF A1 - Jones, T A1 - Smith, A A1 - Peck, DH A1 - Darzi, AW J1 - Tumour Biol Y1 - 2005/03// VL - 26 SN - 1010-4283 SP - 94 EP - 102 N2 - OBJECTIVE: The use of laparoscopic techniques in resection of malignant tumours has been proposed to offer potential benefit to the patient in the form of earlier recovery and less immune paresis; however, reported tumour seeding, both peritoneal and at port site, has put this approach into question. The biological effects of the introduction of carbon dioxide or helium to form a pneumoperitoneum on tumour invasion and dissemination are unknown. METHODS: A human colonic adenocarcinoma cell line (SW1222) was exposed to in vitro laparoscopic environment of either carbon dioxide or helium for 4 h, mimicking the duration of a laparoscopic colorectal resection. Alteration in production of matrix metalloproteinase (MMP)-2, MMP-9 and urokinase-type plasminogen activator (uPA) due to exposure to a laparoscopic environment was determined by zymography and correlated to invasive capacity by a standard Matrigel-based invasion assay. Incorporation of specific gelatinase inhibitors or antibodies directed at the uPA receptor was utilized to determine the relative importance of proteases. RESULTS: Exposure to the laparoscopic environment significantly enhanced production of the proteases MMP-2, MMP-9 and uPA. A concomitant enhancement of invasive capacity was also observed, being blocked by specific protease inhibitors. Changes in both protease production and aggression were observable for at least 24 h following the removal of the operative environment, indicating the possible long-term effects of the initial insult. CONCLUSION: Exposure to the laparoscopic environment enhances the invasive capacity of colonic adenocarcinomas via a well-defined protease-determined pathway. It therefore appears likely that tumour cells released into the operative field can be made increasingly aggressive by a laparoscopic operative environment and can thus contribute to disease dissemination. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15897689&query_hl=1 ER - TY - JFULL T1 - Evaluation of surgical outcomes for the treatment of complicated diverticular disease - A prospective national study A1 - Senapati, A A1 - Tekkis, PP J1 - DIS COLON RECTUM Y1 - 2005/03// VL - 48 SN - 0012-3706 SP - 653 EP - 653 ER - TY - JFULL T1 - Evaluation of colonoscopy for colorectal cancer: a prospective multi-centre study A1 - Purkayastha, S A1 - Tekkis, PP A1 - Darzi, AW A1 - Radford, AR A1 - Smith, JJ A1 - Thompson, MR A1 - Stamatakis, JD J1 - DIS COLON RECTUM Y1 - 2005/03// VL - 48 SN - 0012-3706 SP - 674 EP - 675 ER - TY - JFULL T1 - Adverse outcomes relate to operative experience following ileal pouch anal anastomosis (IPAA) A1 - Tekkis, PP A1 - Fazio, VW A1 - Remzi, FH A1 - Heriot, AG A1 - Merlino, J A1 - Lavery, IC A1 - Senagore, A A1 - Delaney, CP A1 - Strong, SA A1 - Hull, TL A1 - Church, JM J1 - DIS COLON RECTUM Y1 - 2005/03// VL - 48 SN - 0012-3706 SP - 626 EP - 627 ER - TY - JFULL T1 - Boerhaave's syndrome secondary to epigastric hernia. A1 - Aziz, O A1 - Panwalkar, P A1 - Hanna, G J1 - Hosp Med Y1 - 2005/03// VL - 66 SN - 1462-3935 SP - 172 EP - 173 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15791878&query_hl=1 ER - TY - JFULL T1 - Synchronized video and motion analysis for the assessment of procedures in the operating theater. A1 - Dosis, A A1 - Aggarwal, R A1 - Bello, F A1 - Moorthy, K A1 - Munz, Y A1 - Gillies, D A1 - Darzi, A J1 - Arch Surg Y1 - 2005/03// VL - 140 SN - 0004-0010 SP - 293 EP - 299 N2 - HYPOTHESIS: Objective assessment of surgical skill has recently been shown to be possible through the use of dexterity-based and video analysis systems. The aim of this study was to synchronize these 2 modalities to produce a comprehensive surgical assessment tool. DESIGN: The Imperial College Surgical Assessment Device is a dexterity-based motion analysis device that has been developed in the Department of Surgical Oncology and Technology by the Surgical Computing and Imaging Research Group. Further advances to this system have been made to enable synchronized acquisition of hand kinematics and video from real procedures, and their concurrent analysis. To test the feasibility of the system, 10 laparoscopic cholecystectomies performed by 5 different surgeons on consenting patients were recorded. Analysis focused on the entire procedure and also on specific parts of the operation such as the clipping and cutting of the cystic duct and artery. RESULTS: Dexterity analysis was performed using the objective measures of time, path length, number of movements, velocities, and trajectories. Comparative analysis of a surgeon's dexterity was carried out on the whole procedure and by using the synchronized zoom facility in the software. Kinematic signals revealed rapid changes in velocity caused by alternating between different instruments or occurring after complications such as bleeding. CONCLUSION: This new motion analysis system has been shown to be an effective tool for the comprehensive assessment of operative procedures. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15781796&query_hl=1 ER - TY - JFULL T1 - Effect of fixation of shoulder and elbow joint movement on the precision of laparoscopic instrument manipulations. A1 - Patil, PV A1 - Hanna, GB A1 - Frank, TG A1 - Cuschieri, A J1 - Surg Endosc Y1 - 2005/03// VL - 19 SN - 1432-2218 SP - 366 EP - 368 N2 - BACKGROUND: Motion analysis of the upper limb and the surgical instruments is used for objective assessment of endoscopic manipulations. The aim of this study was to investigate the effect of fixation of shoulder and elbow joint movement on the precision of laparoscopic instrument manipulations. METHODS: Two experiments were conducted to correlate hand movement with instrument tip during free and restricted movement of the shoulder and elbow joints. A three-dimensional infrared optical tracking system has been used. Five subjects participated in the study, and each completed the range of movements twice. End points were velocity (m/s), angular velocity (r/s) and acceleration (m/s2). RESULTS: There was a weak correlation for all end points between the instrument tip and individual joint movement during free upper limb movement (r < 0.4). With restricted movement of the shoulder and elbow joints, the correlation between hand movement and instrument tip was found to be good for the velocity (r = 0.66 for flexion; r = 0.72 for abduction; r = 0.56 for supination) and angular velocity (r = -0.83 for flexion; r = -0.48 for abduction; r = -0.70 for supination), but weak for the acceleration (r < 0.4). CONCLUSIONS: The characteristics of hand movements do not correlate with movement of the laparoscopic instrument tip when the upper limb is unsupported. The precision of laparoscopic surgical manipulations is increased if both joints (shoulder and elbow) are supported. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15624067&query_hl=1 ER - TY - JFULL T1 - Management and outcome of pouch-vaginal fistulas following restorative proctocolectomy. A1 - Heriot, AG A1 - Tekkis, PP A1 - Smith, JJ A1 - Bona, R A1 - Cohen, RG A1 - Nicholls, RJ J1 - Dis Colon Rectum Y1 - 2005/03// VL - 48 SN - 0012-3706 SP - 451 EP - 458 N2 - PURPOSE: The aim of this study was to assess the short-term and long-term outcomes of surgical repair of patients with pouch-vaginal fistulas after restorative proctocolectomy. METHODS: A descriptive study was undertaken of all patients developing pouch-vaginal fistulas following restorative proctocolectomy between 1978 and 2003 in a single tertiary referral institution. Kaplan-Meier survival analysis was used to evaluate the time to first pouch-vaginal fistula recurrence and pouch-vaginal fistula-free survival at last follow-up. RESULTS: Sixty-eight patients (mean age, 32.2 years; standard deviation, 10.7) were identified with a median follow-up of 5.5 (range, 0.2-25.5) years. The origin of the pouch-vaginal fistulas was the pouch-anal anastomosis in 52 (76.5 percent) patients, pouch body/top in 9 (13.2 percent), or cryptoglandular or other source in 7 (10.3 percent). Associated early complications in patients with pouch-vaginal fistulas included pelvic sepsis in 20 (29 percent) patients, anastomotic separation in 6 (24 percent), anastomotic stricture in 16 (24 percent), small bowel obstruction in 17 (25 percent), hemorrhage in 2 (3 percent), or pouchitis in 12 (18 percent). Surgery was undertaken in 59 (87 percent) patients with 14 (20.6 percent) of them undergoing pouch excision/diversion or seton drainage. Forty-five (66 percent) patients underwent primary repair. First recurrence of pouch-vaginal fistula occurred in 27 of 45 (60 percent) patients with a median pouch-vaginal fistula-free interval of 1.6 years (95 percent confidence interval, 0.6-2.7). Fourteen (51.9 percent) patients with recurrent pouch-vaginal fistulas healed following one or more repeat procedures. The diagnosis of Crohn's disease was made in eight (12 percent) patients, with pouch-vaginal fistulas persisting or recurring in all patients with Crohn's disease within five years of the primary treatment. Median pouch-vaginal fistula-free survival was 1.4 years for patients with Crohn's disease and 8.1 years for patients with ulcerative colitis or familial adenomatous polyposis. The pouch-vaginal fistula-free survival improved with repeated local or abdominal repairs for patients with ulcerative colitis. The overall pouch failure rate for patients with pouch-vaginal fistulas was 35 percent (median pouch survival, 4.2 years). CONCLUSIONS: Pouch-vaginal fistulas can persist and recur indefinitely, even after repeated repairs. Repair in those patients with Crohn's disease uniformly failed within five years from primary repair. Patients with recurrent pouch-vaginal fistulas and ulcerative colitis should be offered salvage surgery because successful closure following initial failure occurs in approximately 50 percent. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15747067&query_hl=1 ER - TY - JFULL T1 - Impact of technical factors on outcome of restorative proctocolectomy for familial adenomatous poylposis A1 - Tekkis, PP A1 - Heriot, AG A1 - Von-Roon, A A1 - Truvolon, S A1 - Cornaglia, S A1 - Darzi, AW A1 - Phillips, RK A1 - Nicholls, RJ J1 - DIS COLON RECTUM Y1 - 2005/03// VL - 48 SN - 0012-3706 SP - 656 EP - 656 ER - TY - JFULL T1 - Salvage or stoma after chemo radiotherapy for anal cancer: probability, predictors, and outcome A1 - Heriot, A A1 - Oncel, M A1 - Tekkis, P A1 - Neary, P A1 - Remzi, F A1 - Fazio, VW A1 - Lavery, I J1 - DIS COLON RECTUM Y1 - 2005/03// VL - 48 SN - 0012-3706 SP - 657 EP - 657 ER - TY - JFULL T1 - Assessment of shape variation of the levator ani with optimal scan planning and statistical shape modeling. A1 - Lee, SL A1 - Horkaew, P A1 - Caspersz, W A1 - Darzi, A A1 - Yang, GZ J1 - J Comput Assist Tomogr Y1 - 2005/03// VL - 29 SN - 0363-8715 SP - 154 EP - 162 N2 - OBJECTIVE: To capture 3D shape variation of the levator ani during straining with open access MR imaging. METHODS: Optimal scan-planning based on statistical shape modeling is developed for recovering the entire 3D structure of the levator ani from a limited number of 2D imaging planes. Statistical shape modeling ensures optimum material correspondence, and Subspace Reprojection is used to identify the optimum orientation of the imaging plans. The accuracy of the method in using limited 2D imaging planes to instantiate the dynamic structure of the levator ani is assessed with data acquired from 10 asymptomatic subjects. RESULTS: Leave-one-out analysis was performed whereby a model based on a training set consisting of all but one surface was used to instantiate the dynamic surface structure from the corresponding optimal planes. The mean surface distance error for the proposed Subspace Reprojection method is 3.989 +/- 0.790 mm, which is significantly smaller than other approaches. CONCLUSIONS: Surfaces of the levator ani may be instantiated using a limited number of imaging planes as well as a statistical shape model based on a training set of subjects. The proposed technique offers a new way forward for studying dynamic shape changes of 3D structures where complete volumetric imaging is prohibited by the inherent temporal resolution of the scanning technique. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15772530&query_hl=1 ER - TY - JFULL T1 - Hypoxia increases reepithelialization via an alphavbeta6-dependent pathway. A1 - Ridgway, PF A1 - Ziprin, P A1 - Peck, DH A1 - Darzi, AW J1 - Wound Repair Regen Y1 - 2005/03// VL - 13 SN - 1067-1927 SP - 158 EP - 164 N2 - Reepithelialization is an essential step in successful cutaneous wound healing. Human keratinocytes, integral in this process, have been shown to have increased motility in the hypoxic healing edge of wounds correlating with the clinical success of semiocclusive hypoxic dressings, although the underlying mechanisms remain poorly understood. Subconfluent human keratinocyte cell monolayers were exposed to 1% hypoxia for up to 24 hours or control conditions. Re-oxygenation studies were performed up to 72 hours. Cellular alphav subunit and alphavbeta6 integrin expression was measured by flow cytometry. Migration scratch assays on fibronectin following hypoxic exposure were performed over 24 hours. Relative matrix metallo-proteinase (MMP)-2, 9 activity was determined by gelatin zymography with TIMP-1 levels assayed by enzyme-linked immunoassay. Sustained increases in alphav and alphavbeta6 expression were shown up to 48 hours in re-oxygenation studies (P < 0.001). Standardized scratch assays confirmed increased migration in the hypoxic group (P < 0.05). This effect was attenuated by the addition of a specific inhibitor of the alphavbeta6 integrin. MMP-2 and -9 activity was up-regulated following hypoxic exposure (P < 0.001; P < 0.05, respectively), whereas increased MMP expression was significantly retarded by addition of an alphavbeta6 inhibitor (P < 0.05). Migration on fibronectin was attenuated by a specific gelatinase inhibitor. We conclude that integrin alphavbeta6-dependent MMP-2 and -9 up-regulation is an important feature of increased migration in hypoxic human keratinocytes. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15828940&query_hl=1 ER - TY - JFULL T1 - Phenotypic factors can predict the risk of proctectomy after total colectomy and ileorectal anastomosis for patients with familial adenomatous polyposis (FAP) - A multifactorial model A1 - Tekkis, PP A1 - Heriot, AG A1 - Gallagher, M A1 - Nicholls, RJ A1 - Fazio, VW A1 - Phillips, RK A1 - Church, J J1 - DIS COLON RECTUM Y1 - 2005/03// VL - 48 SN - 0012-3706 SP - 613 EP - 613 ER - TY - JFULL T1 - Sentinel node biopsy can replace four-node-sampling in staging early breast cancer. A1 - Agarwal, T A1 - Kakkos, SK A1 - Cunningham, DA A1 - Darzi, A A1 - Lee, D A1 - Rajan, P A1 - Hadjiminas, DJ J1 - Eur J Surg Oncol Y1 - 2005/03// VL - 31 SN - 0748-7983 SP - 122 EP - 127 N2 - AIM: Four-node axillary sampling for breast cancer is an established method of staging the axilla in the United Kingdom. We report the sensitivity of sentinel node (SN) biopsy and compare it with that of four-node sampling. METHODS: SN identification was attempted in 234 consecutive patients with unifocal breast cancers up to 25 mm in diameter on pre-operative ultrasound. A combination of isotope-labelled nanocolloid and patent blue dye techniques were used and SN were identified in 221 (94.5%). All patients underwent back-up four-node sampling and those with positive sentinel nodes on frozen section (FS) underwent immediate full axillary clearance. RESULTS: Among those patients who had SN successfully identified, an average of 1.38 SN were identified per patient. Histological examination of the SN alone would have identified all node-positive patients that the four-node sample identified. CONCLUSION: In patients who have SN identified, four-node axillary sampling does not provide any additional information. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15698726&query_hl=1 ER - TY - JFULL T1 - Indoleamine 2, 3-dioxygenase (IDO) is essential for dendritic cell activation and chemotactic responsiveness to chemokines. A1 - Hwang, SL A1 - Chung, NP A1 - Chan, JK A1 - Lin, CL J1 - Cell Res Y1 - 2005/03// VL - 15 SN - 1001-0602 SP - 167 EP - 175 N2 - Indoleamine 2, 3-dioxygenase (IDO) is a rate-limiting enzyme for the tryptophan catabolism. In human and murine cells, IDO inhibits antigen-specific T cell proliferation in vitro and suppresses T cell responses to fetal alloantigens during murine pregnancy. In mice, IDO expression is an inducible feature of specific subsets of dendritic cells (DCs), and is important for T cell regulatory properties. However, the effect of IDO and tryptophan deprivation on DC functions remains unknown. We report here that when tryptophan utilization was prevented by a pharmacological inhibitor of IDO, 1-methyl tryptophan (1MT), DC activation induced by pathogenic stimulus lipopolysaccharide (LPS) or inflammatory cytokine TNF-alpha was inhibited both phenotypically and functionally. Such an effect was less remarkable when DC was stimulated by a physiological stimulus, CD40 ligand. Tryptophan deprivation during DC activation also regulated the expression of CCR5 and CXCR4, as well as DC responsiveness to chemokines. These results suggest that tryptophan usage in the microenvironment is essential for DC maturation, and may also play a role in the regulation of DC migratory behaviors. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15780178&query_hl=1 ER - TY - JFULL T1 - Laparoscopic surgery for colon cancer. A1 - Paraskeva, PA A1 - Aziz, O A1 - Darzi, A J1 - Surg Clin North Am Y1 - 2005/02// VL - 85 SN - 0039-6109 SP - 49 EP - 60 N2 - Acceptance of laparoscopy for the management of oncological disease has been slow due to the increased complexity of the technique, requirement of technological advances, and fears for the oncological safety of the approach. Laparoscopic oncological surgery has a role in the management of oncological patients at all stages of disease. Good evidence exists for the laparoscopic approach being a viable option for colon cancer patients. Current large multicenter trials will report the true outcomes of laparoscopic colon cancer surgery and how it compares with open surgery. This article examines some of the parameters by which laparoscopic colectomy will be judged. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15619528&query_hl=1 ER - TY - JFULL T1 - Evaluation of the learning curve in ileal pouch-anal anastomosis surgery. A1 - Tekkis, PP A1 - Fazio, VW A1 - Lavery, IC A1 - Remzi, FH A1 - Senagore, AJ A1 - Wu, JS A1 - Strong, SA A1 - Poloneicki, JD A1 - Hull, TL A1 - Church, JM J1 - Ann Surg Y1 - 2005/02// VL - 241 SN - 0003-4932 SP - 262 EP - 268 N2 - SUMMARY BACKGROUND DATA: We define the learning curve required to attain satisfactory training in ileal pouch-anal anastomosis (IPAA) and identify possible differences in the learning curve for stapled and hand-sewn IPAA surgery. Various studies have addressed the differences in failure rate between stapled and hand-sewn IPAA, but there is no literature that evaluates the differences in attaining satisfactory training in each of these techniques. METHODS: Data were collected from 1965 patients undergoing IPAA surgery by 12 surgeons in a single center between 1983 and 2001. Using ileoanal pouch failure as the primary end point, a parametric survival model was used to adjust for case mix (patient comorbidity, preoperative diagnosis, manometric findings, and prior anal pathology). A risk-adjusted cumulative sum (CUSUM) model was used for monitoring outcomes in IPAA surgery. RESULTS: The 5-year ileal pouch survival was 95.6% (median patient follow-up of 4.2 years; range 0-19 years). Fifty percent of trainee staff demonstrated a learning curve in IPAA surgery. Having adjusted for case mix, trainee staff undertaking stapled IPAA surgery showed an improvement in the pouch failure rate following an initial training period of 23 cases versus 40 cases for senior staff. The learning curve for hand-sewn IPAA surgery was quantified only for senior staff who attained adequate results following an initial period of 31 procedures. CONCLUSIONS: The CUSUM method was a useful tool for objectively measuring performance during the learning phase of IPAA surgery. With adequate training, supervision, and monitoring, the learning curve in IPAA surgery may be reduced even further. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15650636&query_hl=1 ER - TY - JFULL T1 - Dobutamine improves thoracic aortic blood flow during off-pump coronary artery bypass surgery: results of a prospective randomised controlled trial A1 - Modine, T A1 - Decoene, C A1 - Al-Ruzzeh, S A1 - Athanasiou, T A1 - Poivre, P A1 - Pol, A A1 - Fayad, G J1 - EUR J CARDIO-THORAC Y1 - 2005/02// VL - 27 SN - 1010-7940 SP - 289 EP - 295 N2 - Objective: Dobutamine is commonly used to improve ventricular performance in cardiac surgery. The aim of this prospective randomised controlled study was to assess the effectiveness of using tow doses of dobutamine during off-pump coronary artery bypass (OPCAB) surgery in order to reduce haemodynamic compromise due to heart displacement. Methods: Thirty-two patients undergoing elective coronary artery bypass grafting (CABG) surgery using OPCAB technique for more than two vessels were approached and recruited. We analysed the changes in the thoracic aortic blood flow (TABF) during OPCAB using transoesophageal Doppler and by other conventional monitoring methods as cardiac output, invasive pulmonary and radial pressures and mixed venous oxygen saturation. Results: The two groups were similar in preoperative characteristics. No postoperative complications were observed in the study patients. The heart rate, right atrial pressure, cardiac output measured by thermodilution and TABF changed significantly during the procedure. Also significant changes in descending thoracic aortic diameter were observed. The postoperative creatinine was significantly lower in the dobutamine group (P=0.04). Dobutamine was found responsible for the improvement in the descending TABF (P=0.006). Conclusions: This study showed that intra-operative intravenous infusion of dobutamine at 5 mug/kg per min in routine OPCAB patients safety increased cardiac output even without such changes been detected by conventional monitoring methods. (C) 2004 Elsevier B.V. All rights reserved. ER - TY - JFULL T1 - Up-regulation of macrophage migration inhibitory factor in infants with acute neonatal necrotizing enterocolitis. A1 - Ren Y A1 - Lin CL A1 - Li Z A1 - Chen XY A1 - Huang X A1 - Lui V A1 - Nicholls J A1 - Lan HY A1 - Tam PKH J1 - Histopathology Y1 - 2005/// VL - 46 SP - 659 EP - 667 ER - TY - JFULL T1 - ICAM-1 mediated peritoneal carcinomatosis, a target for therapeutic intervention. A1 - Alkhamesi, NA A1 - Ziprin, P A1 - Pfistermuller, K A1 - Peck, DH A1 - Darzi, AW J1 - Clin Exp Metastasis Y1 - 2005/// VL - 22 SN - 0262-0898 SP - 449 EP - 459 N2 - Development of peritoneal metastasis is a significant issue in the treatment of abdominal cancers. Primary interaction between tumour cells and the mesothelium is a vital step in initiating this process. Our aim was to determine the role of the intercellular adhesion molecule-1 (ICAM-1) in mesothelial-tumour adhesion and the effectiveness of therapeutic intervention. Mesothelial cells were derived from omental tissue. ICAM-1 expression in resting state, in the presence of TNF-alpha or after the application of heparin or hyaluronan was determined by flow cytometry. Functional effects on tumour adhesion to a mesothelial monolayer were determined via a Calcein-AM in vitro adhesion assay. In vivo studies were performed utilising 30 WAG/rij rats, which underwent mini-laparotomy with the injection of 1 x 10(5 )CC 513 tumour cells intraperitoneally. Tumour growth was assessed macroscopically and microscopically by two independent examiners. Mesothelial cells expressed high level of ICAM-1, which was up-regulated by the presence of TNF-alpha. The introduction of heparin caused a decrease in ICAM-1 expression, however hyaluronan did not affect the expression. A significant decrease in tumour-mesothelial cell adhesion in vitro and complete aberration of tumour growth in vivo was observed with heparin application. In vitro studies showed utilisation of high molecular weight hyaluronan, which was more limited in vivo. These data imply that heparin may be used as a potential therapeutic through a defined molecular mechanism both in vitro and in vivo. Hyaluronan appears to function as a barrier and hence may be unreliable in blocking peritoneal recurrence. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16320108&query_hl=1 ER - TY - JFULL T1 - Conversion rates in laparoscopic colorectal surgery: a predictive model with, 1253 patients. A1 - Tekkis, PP A1 - Senagore, AJ A1 - Delaney, CP J1 - Surg Endosc Y1 - 2005/01// VL - 19 SN - 1432-2218 SP - 47 EP - 54 N2 - BACKGROUND: This study aimed all develop a mathematical model for predicting the conversion rate for patients undergoing laparoscopic colorectal surgery. METHOD: This descriptive single-center study used routinely collected clinical data from 1,253 patients undergoing laparoscopic surgery between November 1991 and April 2003. A two-level hierarchical regression model was used to identify patient, surgeon, and procedure-related factors associated with conversion of laparoscopic to open surgery. The model was internally validated and tested using measures of discrimination and calibration. Exclusion criteria for laparoscopic colectomy included a body mass greater than 50, lesion diameter exceeding 15 cm, and multiple prior major laparotomies (exclusive of appendectomy, hysterectomy, and cholecystectomy). RESULTS: The average conversion rate for the study population was 10.0% (95% confidence interval [CI], 8.3-11.7%). The independent predictors of conversion of laparoscopic to open surgery were the body mass index (odds ratio [OR], 2.1 per 10 Americans Society of Anesthesiology units increase), (ASA) grade 3 or 4, 1 or 2 (OR, 3.2, 5.8), type of resection (low rectal, left colorectal, right colonic vs small/other bowel procedures; OR, 8.82, 4.76, 2.98), presence of intraoperative abscess (OR, 3.60) or fistula (OR, 4.73), and surgeon seniority (junior vs senior staff OR, 1.56). The model offered adequate discrimination (area under receiver operator characteristic curve, 0.74) and excellent agreement (p = 0.384) between observed and model-predicted conversion rates (range of calibration, 3-32% conversion rate). CONCLUSIONS: Laparoscopic conversion rates are dependent on a multitude of factors that require appropriate adjustment for case mix before comparisons are made between or within centers. The Cleveland Clinic Foundation (CCF) laparoscopic conversion rate model is a simple additive score that can be used in everyday practice to evaluate outcomes for laparoscopic colorectal surgery. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15549630&query_hl=1 ER - TY - JFULL T1 - Skills training in telerobotic surgery. A1 - Hance, J A1 - Aggarwal, R A1 - Undre, S A1 - Darzi, A J1 - Int J Med Robot Y1 - 2005/01// VL - 1 SN - 1478-596X SP - 7 EP - 12 N2 - Surgical robots have the potential to expand the repertoire of minimally invasive surgery resulting in more patients benefiting from lower operative morbidity and shorter hospital stays. However, in a similar manner to all new surgical interventions it necessary to explore the learning curves of practitioners as they adopt this new technology to enable optimisation of future training programs. Only when the standard of practice is firmly established, should the proliferation of robotic practitioners be encouraged thus ensuring patient safety is not compromised. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17518373&query_hl=1 ER - TY - JFULL T1 - Clinical simulation for learning procedural skills: a theory-based approach A1 - Kneebone, R J1 - Academic Medicine Y1 - 2005/// VL - 80;6 SP - 549 EP - 553 ER - TY - JFULL T1 - Handheld computers in veterinary medical education: a view from human medical education. A1 - Nestel, D A1 - Brenton, H A1 - Kneebone, R J1 - J Vet Med Educ Y1 - 2005/// VL - 32 SN - 0748-321X SP - 121 EP - 126 N2 - Handheld computers are widely used in clinical practice, and their use in both human medical education and veterinary medical education is increasing, especially, for the former, in activities involving point-of-care access. This article references the insights that can be obtained from the usage and activities that are gaining a strong foothold in human medical education. Handheld computer technology gives students access to a large and changing knowledge base for clinical practice, especially when they are geographically dispersed. Differences in use between education and practice largely relate to the importance clinicians place on patient information. Student use focuses on progress mapping and ready access to clinical reference material. Suggestions are made for future use in medical education. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15834831&query_hl=1 ER - TY - JFULL T1 - The level of persistent viraemia below 50 copies/ml is associated with subsequent rebound to above 50 HIV RNA copies/mL for nelfinavir-treated subjects but not lopinavir/ritonavir-treated subjects A1 - King, M A1 - Palmer, S A1 - Wiegand, A A1 - Maldarelli, F A1 - Brun, S A1 - Kempf, D A1 - Hanna, G A1 - Coffin, J A1 - Mellors, J J1 - ANTIVIR THER Y1 - 2005/01// VL - 10 SN - 1359-6535 SP - S36 EP - S36 ER - TY - JFULL T1 - Laparoscope self-calibration for robotic assisted minimally invasive surgery. A1 - Stoyanov, D A1 - Darzi, A A1 - Yang, GZ J1 - Med Image Comput Comput Assist Interv Int Conf Med Image Comput Comput Assist Interv Y1 - 2005/// VL - 8 SP - 114 EP - 121 N2 - For robotic assisted minimal access surgery, recovering 3D soft tissue deformation is important for intra-operative surgical guidance, motion compensation, and prescribing active constraints. We propose in this paper a method for determining varying focal lengths of stereo laparoscope cameras during robotic surgery. Laparoscopic images typically feature dynamic scenes of soft-tissue deformation and self-calibration is difficult with existing approaches due to the lack of rigid temporal constraints. The proposed method is based on the direct derivation of the focal lengths from the fundamental matrix of the stereo cameras with known extrinsic parameters. This solves a restricted self-calibration problem, and the introduction of the additional constraints improves the inherent accuracy of the algorithm. The practical value of the method is demonstrated with analysis of results from both synthetic and in vivo data sets. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16685950&query_hl=1 ER - TY - JFULL T1 - Soft tissue deformation using a nonlinear hierarchical finite element model with real-time online refinement. A1 - Faraci, A A1 - Bello, F A1 - Darzi, A J1 - Stud Health Technol Inform Y1 - 2005/// VL - 111 SN - 0926-9630 SP - 137 EP - 144 N2 - Simulating soft tissue deformation in real-time is a requirement for realistically rendering the VR interaction between human organs and surgical tools. Finite Element Model (FEM) describes complex mechanical and physiological behaviour but it is computationally too demanding especially when a nonlinear model is to be implemented. For this reason, we introduce a multiresolution approach to FEM that only employs the region of the object under deformation to find the solution of the differential equations of motion. In order to increase the quality of the deformation, refinement of the original mesh is performed with the insertion of new surface nodes in real-time in the region of interaction. To guarantee the stability of the nonlinear model, the presence of flat tetrahedra (slivers) has to be avoided; therefore a sliver elimination technique has been implemented resulting in a more stable simulation. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15718715&query_hl=1 ER - TY - JFULL T1 - Can the use of the radial artery be expanded to all patients with different surgical grafting techniques? Early clinical and angiographic results in 600 patients. A1 - Al-Ruzzeh, S A1 - Modine, T A1 - Athanasiou, T A1 - Mazrani, W A1 - Azeem, F A1 - Nakamura, K A1 - Bustami, M A1 - Ilsley, C A1 - Amrani, M J1 - J Card Surg Y1 - 2005/01// VL - 20 SN - 0886-0440 SP - 1 EP - 7 N2 - OBJECTIVE: The use of the radial artery (RA) as a conduit for coronary artery bypass grafting (CABG) is gaining in popularity worldwide and is being increasingly adopted by many cardiac surgeons. Encouraged by our satisfactory early experience with the use of the RA conduit, we have expanded its use to more than 90% of all coronary surgery patients. The aim of the present study was to review our clinical and angiographic results when the use of the RA conduit was expanded to all patients including those aged 65 years and older and diabetics with different surgical grafting techniques. METHODS: The records of 600 consecutive patients who underwent isolated CABG using the RA graft at Harefield Hospital between January 1999 and August 2002 were reviewed retrospectively. Ninety-three (15.5%) patients consented and underwent angiography before discharge at the earliest on the fourth postoperative day, aiming to look at the quality of anastomoses and the patency of the RA grafts. RESULTS: The 600 patients had 613 RA grafts to perform 652 distal RA anastomoses. The proximal ends of 515 (84%) RA grafts were anastomosed to the aorta, 98 (16%) RA grafts were constructed as Y-grafts with 49 (8%) RA off a vein graft hood, and 49 (8%) RA grafts were constructed as T- or Y-grafts off an internal thoracic artery (ITA) graft. The proximal ends of 19 (19/294 or 6.5%) vein grafts were constructed as Y-grafts off the RA grafts. Two hundred and sixty-one (43.5%) patients were above the age of 65 years and 111 (18.5%) patients were diabetics. There were four in-hospital deaths (0.6%) among the study patients. Six (1%) patients developed forearm hematoma/seroma postoperatively. The operation time, the hospital stay, and the incidence of conduit harvest site infection for the patients who had vein grafts in addition to the RA grafts were significantly higher than those of patients who had RA grafts only. On postoperative angiography, 86 out of 93 (92.5%) RA grafts were found to be patent with good quality distal anastomoses. The maximum stenosis of the coronary arteries bypassed by the patent 86 RA grafts was 82.6 +/- 6.2%, while it was 56.3 +/- 15.4% for the coronary arteries bypassed by the occluded seven RA grafts, p < 0.001. CONCLUSION: The use of the RA can be expanded to all patients with different surgical grafting techniques and provides satisfactory clinical and angiographic outcomes. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15673403&query_hl=1 ER - TY - JFULL T1 - Physiologically stable vanadium(iv) porphyrins as a new class of anti-HIV agents. A1 - Wong SY A1 - Wai-Yin Sun R A1 - Chung NP A1 - Lin CL A1 - Che CM J1 - Chem Commun (Camb) Y1 - 2005/// VL - 28 SP - 3544 EP - 3546 ER - TY - JFULL T1 - Gaze-contingent soft tissue deformation tracking for minimally invasive robotic surgery. A1 - Mylonas, GP A1 - Stoyanov, D A1 - Deligianni, F A1 - Darzi, A A1 - Yang, GZ J1 - Med Image Comput Comput Assist Interv Int Conf Med Image Comput Comput Assist Interv Y1 - 2005/// VL - 8 SP - 843 EP - 850 N2 - The introduction of surgical robots in Minimally Invasive Surgery (MIS) has allowed enhanced manual dexterity through the use of microprocessor controlled mechanical wrists. Although fully autonomous robots are attractive, both ethical and legal barriers can prohibit their practical use in surgery. The purpose of this paper is to demonstrate that it is possible to use real-time binocular eye tracking for empowering robots with human vision by using knowledge acquired in situ. By utilizing the close relationship between the horizontal disparity and the depth perception varying with the viewing distance, it is possible to use ocular vergence for recovering 3D motion and deformation of the soft tissue during MIS procedures. Both phantom and in vivo experiments were carried out to assess the potential frequency limit of the system and its intrinsic depth recovery accuracy. The potential applications of the technique include motion stabilization and intra-operative planning in the presence of large tissue deformation. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16685925&query_hl=1 ER - TY - JFULL T1 - Laparoscopic task recognition using Hidden Markov Models. A1 - Dosis, A A1 - Bello, F A1 - Gillies, D A1 - Undre, S A1 - Aggarwal, R A1 - Darzi, A J1 - Stud Health Technol Inform Y1 - 2005/// VL - 111 SN - 0926-9630 SP - 115 EP - 122 N2 - Surgical skills assessment has been paid increased attention over the last few years. Stochastic models such as Hidden Markov Models have recently been adapted to surgery to discriminate levels of expertise. Based on our previous work combining synchronized video and motion analysis we present preliminary results of a HMM laparoscopic task recognizer which aims to model hand manipulations and to identify and recognize simple surgical tasks. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15718711&query_hl=1 ER - TY - JFULL T1 - Post-operative magnetic resonance evaluation of children after laparoscopic anorectoplasty for imperforate anus. A1 - Wong, KK A1 - Khong, PL A1 - Lin, SC A1 - Lam, WW A1 - Lan, LC A1 - Tam, PK J1 - Int J Colorectal Dis Y1 - 2005/01// VL - 20 SN - 0179-1958 SP - 33 EP - 37 N2 - BACKGROUND AND AIMS: Laparoscopic anorectoplasty (LAR) is a relatively new procedure in the treatment of imperforate anus. Using magnetic resonance imaging (MRI), we evaluated the anatomical features of the anorectal region of children treated with LAR and compared this with conventional posterior sagittal anorectoplasty (PSARP). The findings were correlated with functional outcome. PATIENT/METHODS: A retrospective review of ten children with the high/intermediate types of imperforate anus underwent LAR between May 2000 and December 2002. MRI of the pelvis was performed post-operatively and a semi-quantitative score was used to assess the degree of sphincter symmetry, peri-rectal fibrosis, and the position of the pull-through rectum. The defecation status of these patients was also recorded. Eight historical patients who had undergone PSARP served as a control group. RESULTS/FINDINGS: When compared with PSARP patients, a significantly lower proportion of LAR patients had sphincter asymmetry (40 vs. 100%, p < 0.05) and peri-rectal fibrosis (40 vs. 87.5%, p < 0.05). The positioning of the rectum was, however, central for both groups (90 vs. 87.5%). No statistical correlation was found between defecation status and the degree of sphincter asymmetry or peri-rectal fibrosis. INTERPRETATION/CONCLUSION: LAR allows more optimal anatomical reconstruction for patients with the high/intermediate types of imperforate anus. However, additional factors that are not correctable by surgery, such as intrinsic innervation deficiency, also influence the clinical outcome. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15322835&query_hl=1 ER - TY - JFULL T1 - Attitudes towards skills examinations for basic surgical trainees. A1 - Bann, SD A1 - Datta, VK A1 - Khan, MS A1 - Ridgway, PF A1 - Darzi, AW J1 - Int J Clin Pract Y1 - 2005/01// VL - 59 SN - 1368-5031 SP - 107 EP - 113 N2 - Objective measures of surgical skill and cognition are becoming available. A questionnaire study examining surgeons' beliefs towards a skills-based examination, current standards and possible benefits was devised. Three hundred pairs of standardised anonymous questionnaires were sent to consultants and their basic surgical trainees (BSTs) irrespective of surgical specialty. Responses were requested using a Likert scale (1-5, 3=neutral response). Two-hundred and two replies were received (including 54 pairs). BST experience ranged from 6 to 60 months (mean 24 months). When questioned regarding current training in basic surgical skills, only 34% believed that they were given adequate training at present. Sixty-four per cent of respondents believed the introduction of a skills examination would raise standards and 66% believed it necessary. Eighty-three per cent of respondents believed that they or their BST would practice these skills, if an examination were introduced and 85% wanted or would provide dedicated teaching time for this. However, 68% had no access to a dedicated skills facility, and uptake of these, where available, was variable. When questioned about their ability to perform the six appropriate tasks, there was a poor correlation of scoring between the groups. Consultants and their BSTs do not believe that they are given adequate training in basic skills. The introduction of an examination would lead to practice of these skills and is seen as a positive move. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15707474&query_hl=1 ER - TY - JFULL T1 - Summary receiver operating characteristic curve analysis techniques in the evaluation of diagnostic tests. A1 - Jones, CM A1 - Athanasiou, T J1 - Ann Thorac Surg Y1 - 2005/01// VL - 79 SN - 1552-6259 SP - 16 EP - 20 N2 - The number of studies in the literature using summary receiver operating characteristic (SROC) analysis of diagnostic accuracy is rising. The SROC is useful in many such meta-analyses, but is often poorly understood by clinicians, and its use can be inappropriate. The academic literature on this topic is not always easy to comprehend. Interpretation is therefore difficult. This report aims to explain the concept of SROC analysis, its advantages, disadvantages, indications, and interpretation for the cardiothoracic surgeon. We use a practical approach to show how SROC analysis can be applied to meta-analysis of diagnostic accuracy by using a contrived dataset of studies on virtual bronchoscopy in the diagnosis of airway lesions. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15620907&query_hl=1 ER - TY - JFULL T1 - [The development of a surgical education program] A1 - Aggarwal, R A1 - Hance, J A1 - Darzi, A J1 - Cir Esp Y1 - 2005/01// VL - 77 SN - 0009-739X SP - 1 EP - 2 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16420874&query_hl=1 ER - TY - JFULL T1 - Is virtual bronchoscopy an efficient diagnostic tool for the thoracic surgeon? A1 - Jones, CM A1 - Athanasiou, T J1 - Ann Thorac Surg Y1 - 2005/01// VL - 79 SN - 1552-6259 SP - 365 EP - 374 N2 - Virtual bronchoscopy has emerged over the past decade as a potentially complementary investigation to conventional bronchoscopy in the diagnosis, grading, and monitoring of pulmonary disease. A meta-analysis reporting on the use of virtual bronchoscopy has not yet been performed. The primary aim of this study is to evaluate its diagnostic accuracy compared to the gold standard investigation of conventional bronchoscopy (fiberoptic or rigid). Quantitative data synthesis included the calculation of independent sensitivity and specificity, construction of summary receiver operating characteristic curves, pooled analysis, and sensitivity analysis. Seventeen studies were identified comprising 459 patients. The calculated pooled sensitivity was 84% (95% CI, 78% to 89%), specificity 75% (95% CI, 62% to 85%) and area under the curve was 0.92, which shows good diagnostic performance. Meta-analysis confirms virtual bronchoscopy is very discriminating in the evaluation of patients with significant airway stenosis that is due to a wide spectrum of pathologic conditions. It can potentially have a beneficial role in selected thoracic patients (with bronchoesophageal fistulas, postlung transplantation, anastomoses, and suspected foreign body aspiration). L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15620990&query_hl=1 ER - TY - JFULL T1 - Invisible shadow for navigation and planning in minimal invasive surgery. A1 - Nicolaou, M A1 - James, A A1 - Lo, BP A1 - Darzi, A A1 - Yang, GZ J1 - Med Image Comput Comput Assist Interv Int Conf Med Image Comput Comput Assist Interv Y1 - 2005/// VL - 8 SP - 25 EP - 32 N2 - Depth estimation is one of the most fundamental challenges for performing minimally invasive surgical (MIS) procedures. The requirement of accurate 3D instrument navigation using limited visual depth cues makes such tasks even more difficult. With the constant expectation of improving safety for MIS, there is a growing requirement for overcoming such constraints during MIS. We present in this paper a method of improving the surgeon's perception of depth by introducing an "invisible shadow" in the operative field cast by an endoscopic instrument. Although, the shadow is invisible to human perception, it can be digitally detected, enhanced and re-displayed. Initial results from our study suggest that this method improves depth perception especially when the endoscopic instrument is in close proximity to the surface. Experiment results have shown that the method could potentially be used as an instrument navigation aid allowing accurate maneuvering of the instruments whilst minimizing tissue trauma. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16685939&query_hl=1 ER - TY - JFULL T1 - Haemostasis using a ready-to-use collagen sponge coated with activated thrombin and fibrinogen. A1 - Aziz, O A1 - Athanasiou, T A1 - Darzi, A J1 - Surg Technol Int Y1 - 2005/// VL - 14 SN - 1090-3941 SP - 35 EP - 40 N2 - Adequate haemostasis is an important part of any surgical procedure, but particularly so in the case of visceral organ surgery where apparently insignificant ooze can ultimately result in significant haemorrhage and coagulopathy. To achieve haemorrhage control, the surgeon may use conventional techniques (eg, suture ligation, diathermy, and swab compression), but failing this has the option of using physical coagulation tools (eg, the argon beam coagulator) and haemostasis adjuncts (eg, fibrin glues and collagen sheets). Advances in manufacturing have led to development of several other haemostatic products including absorbable gelatin sponges, cyanoacrylates, and polymer-based adhesives. One such product consists of a fixed, ready-to-use equine collagen sponge coated with human thrombin and fibrinogen. It may be applied directly to the bleeding surface, without the need for preparation or reconstitution. This chapter reviews the published evidence and compares its use to other classes of haemostasis adjuncts across a range of surgical specialties, namely hepatic, splenic, thoracic, vascular, and minimally invasive surgery. It also aims to highlight the apparent advantages and limitations of the fibrinogen and thrombin-coated collagen sponge compared to other commercially available haemostasis adjuncts, and identify potential applications for the product. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16525952&query_hl=1 ER - TY - JFULL T1 - Is routine use of stentless aortic prostheses justified in an elderly (aged > or =75 years) population? A1 - Ali, A A1 - Kumar, P A1 - Athanasiou, T A1 - Halstead, J A1 - Ashrafian, H A1 - Ali, Z A1 - Kumar, S A1 - Theodorou, P A1 - Pepper, JR J1 - J Heart Valve Dis Y1 - 2005/01// VL - 14 SN - 0966-8519 N2 - BACKGROUND AND AIM OF THE STUDY: Stentless prostheses in the aortic position produce a superior hemodynamic profile in comparison to that with stented valves. To determine whether routine use of stentless valves in an elderly population is justified, a 10-year retrospective review was performed of a consecutive series of patients aged > or =75 years undergoing stentless aortic valve replacement (AVR). METHODS: Demographic, operative and mortality data were obtained retrospectively. Survivors were interviewed by telephone according to a defined protocol. Univariate and multivariate analysis was used to identify independent predictors of 30-day and overall medium-term mortality. Definitions and analyses were in accordance with joint STS/AATS guidelines. RESULTS: A total of 103 patients (57 males, 46 females; mean age 79.8 years; range: 75-91 years) underwent AVR with a either a Toronto stentless porcine valve (size range: 21-29 mm; n = 74) or an aortic homograft (n = 29). Twenty-eight patients (27%) had either urgent/emergency surgery, 12 (11%) underwent redo surgery, and in 54 cases (52%), the preoperative left ventricular function was significantly impaired (ejection fraction <50%). Forty patients (39%) also underwent concomitant coronary artery bypass grafting. The mean cross-clamp and cardiopulmonary bypass times were 105+/-22 min and 144+/-47 min, respectively. The overall 30-day mortality was 11.6% (n = 12). The 30-day mortality for all elective cases was 5.3%, but for isolated elective AVR was only 2.5%. Using a multivariate model, the only independent predictor of 30-day mortality and medium-term overall mortality was increasing age. The mean follow up period was 3.6 years (range: 0.1-9.3 years), and the Kaplan-Meier actuarial five-year survival was 52%. At follow up, 92% of patients were in NYHA functional classes I and II. CONCLUSION: Stentless AVR in elderly patients is associated with excellent functional and survival outcome in the medium term. Furthermore, in elective cases, age alone should not be a deterrent to the routine use of stentless aortic valves. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15700438&query_hl=1 ER - TY - JFULL T1 - Soft-tissue motion tracking and structure estimation for robotic assisted MIS procedures. A1 - Stoyanov, D A1 - Mylonas, GP A1 - Deligianni, F A1 - Darzi, A A1 - Yang, GZ J1 - Med Image Comput Comput Assist Interv Int Conf Med Image Comput Comput Assist Interv Y1 - 2005/// VL - 8 SP - 139 EP - 146 N2 - In robotically assisted laparoscopic surgery, soft-tissue motion tracking and structure recovery are important for intraoperative surgical guidance, motion compensation and delivering active constraints. In this paper, we present a novel method for feature based motion tracking of deformable soft-tissue surfaces in totally endoscopic coronary artery bypass graft (TECAB) surgery. We combine two feature detectors to recover distinct regions on the epicardial surface for which the sparse 3D surface geometry may be computed using a pre-calibrated stereo laparoscope. The movement of the 3D points is then tracked in the stereo images with stereo-temporal constrains by using an iterative registration algorithm. The practical value of the technique is demonstrated on both a deformable phantom model with tomographically derived surface geometry and in vivo robotic assisted minimally invasive surgery (MIS) image sequences. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16685953&query_hl=1 ER - TY - JFULL T1 - Subject specific finite element modelling of the levator ani. A1 - Lee, SL A1 - Darzi, A A1 - Yang, GZ J1 - Med Image Comput Comput Assist Interv Int Conf Med Image Comput Comput Assist Interv Y1 - 2005/// VL - 8 SP - 360 EP - 367 N2 - Understanding of the dynamic behaviour of the levator ani is important to the assessment of pelvic floor dysfunction. Whilst shape modelling allows the depiction of 3D morphological variation of the levator ani between different patient groups, it is insufficient to determine the underlying behaviour of how the muscle deforms during contraction and strain. The purpose of this study is to perform a subject specific finite element analysis of the levator ani with open access magnetic resonance imaging. The method is based on a Mooney-Rivlin hyperelastic model and permits dynamic study of subjects under natural physiological loadings. The value of the proposed modelling framework is demonstrated with dynamic 3D data from nulliparous, female subjects. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16685866&query_hl=1 ER - TY - JFULL T1 - Organising a surgical skills centre. A1 - Aggarwal, R A1 - Darzi, A J1 - Minim Invasive Ther Allied Technol Y1 - 2005/// VL - 14 SN - 1364-5706 SP - 275 EP - 279 N2 - The aim of this paper is to define a strategy for the development and organisation of a surgical skills centre. The areas of interest can be divided into decisions about who, what and where to teach, the importance of an approach which is competency-based, definition of staff to run the centre, and also the use of the centre for the purposes of assessment, as well as training. The efficient delivery of this service will be augmented by adopting a multi-disciplinary and multi-professional approach, and must also be malleable enough to adopt future developments, such as web-based learning. Simulation is now the preferred mode of practice for commencement of surgical training. Surgical skills centres must be able to supply users with tools in a suitably designed environment, which enables them to move along a curriculum which is delivered in a competency-based manner. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16754175&query_hl=1 ER - TY - JFULL T1 - High frequency of functional anti-YMDD and -mutant cytotoxic T lymphocytes after in vitro expansion correlates with successful response to lamivudine therapy for chronic hepatitis B. A1 - Lin, CL A1 - Tsai, SL A1 - Lee, TH A1 - Chien, RN A1 - Liao, SK A1 - Liaw, YF J1 - Gut Y1 - 2005/01// VL - 54 SN - 0017-5749 SP - 152 EP - 161 N2 - BACKGROUND: Many determinants for a sustained response to lamivudine therapy have been reported but the role of T cell responsiveness remains unclear. The finding that tyrosine-methionine-aspartate-aspartate (YMDD) motif of the reverse transcriptase domain of hepatitis B virus (HBV) DNA polymerase carries a HLA-A2 restricted cytotoxic T lymphocyte (CTL) epitope makes quantitative measurement of the numbers of peptide specific CTLs feasible using MHC tetramer-peptide complex staining. AIM: To investigate the correlation between anti-YMDD motif CTL activity and the efficacy of lamivudine therapy in HLA-A2 positive patients with chronic hepatitis B (CH-B). METHODS: The function and phenotype of peptide and interleukin 2 expanded peripheral blood mononuclear cells were quantified by cell lytic assay and immunocytochemical analysis by staining with HLA-A2-peptide tetramer complexes. RESULTS: After in vitro expansion, sustained responders had more potent CTL responses against YMDD, YVDD, and YIDD, as well as other epitopes on HBV antigens than non-responders. The frequency of YMDD/YVDD/YIDD motif specific CTLs increased significantly with an effective cell lytic function during and after therapy in sustained responders but not in non-responders. YMDD specific CTLs cross reacted with YIDD and YVDD mutant epitopes, and shared T cell receptor gene usages with YIDD and YVDD specific CTLs. CONCLUSIONS: Sustained responders, at least HLA-A2 patients, elicited a more potent CTL immunity against YMDD and its mutants. YMDD specific CTLs are cross reactive with YVDD and YIDD mutant epitopes, which may further contribute to immune clearance of the mutant viruses and a successful response to lamivudine therapy in CH-B patients. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15591521&query_hl=1 ER - TY - JFULL T1 - Handheld computers and the 21st century surgical team: a pilot study. A1 - Aziz, O A1 - Panesar, SS A1 - Netuveli, G A1 - Paraskeva, P A1 - Sheikh, A A1 - Darzi, A J1 - BMC Med Inform Decis Mak Y1 - 2005/// VL - 5 SN - 1472-6947 SP - 28 EP - 28 N2 - BACKGROUND: The commercial development and expansion of mobile phone networks has led to the creation of devices combining mobile phones and personal digital assistants, which could prove invaluable in a clinical setting. This pilot study aimed to look at how one such device compared with the current pager system in facilitating inter-professional communication in a hospital clinical team. METHODS: The study looked at a heterogeneous team of doctors (n = 9) working in a busy surgical setting at St. Mary's Hospital in London and compared the use of a personal digital assistant with mobile phone and web-browsing facilities to the existing pager system. The primary feature of this device being compared to the conventional pager was its use as a mobile phone, but other features evaluated included the ability to access the internet, and reference data on the device. A crossover study was carried out for 6 weeks in 2004, with the team having access to the personal digital assistant every alternate week. The primary outcome measure for assessing efficiency of communication was the length of time it took for clinicians to respond to a call. We also sought to assess the ease of adoption of new technology by evaluating the perceptions of the team (n = 9) to personal digital assistants, by administering a questionnaire. RESULTS: Doctors equipped with a personal digital assistant rather than a pager, responded more quickly to a call and had a lower of failure to respond rate (RR: 0.44; 95%CI 0.20-0.93). Clinicians also found this technology easy to adopt as seen by a significant reduction in perceptions of nervousness to the technology over the six-week study period (mean (SD) week 1: 4.10 (SD 1.69) vs. mean (SD) week 6: 2.20 (1.99); p = 0.04). CONCLUSION: The results of this pilot study show the possible effects of replacing the current hospital pager with a newer, more technologically advanced device, and suggest that a combined personal digital assistant and mobile phone device may improve communication between doctors. In the light of these encouraging preliminary findings, we propose a large-scale clinical trial of the use of these devices in facilitating inter-professional communication in a hospital setting. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16109177&query_hl=1 ER - TY - JFULL T1 - Assessment of operative risk in colorectal cancer surgery: the Cleveland Clinic Foundation colorectal cancer model. A1 - Fazio, VW A1 - Tekkis, PP A1 - Remzi, F A1 - Lavery, IC J1 - Dis Colon Rectum Y1 - 2004/12// VL - 47 SN - 0012-3706 SP - 2015 EP - 2024 N2 - INTRODUCTION: Predictive models play a pivotal role in the provision of risk-adjusted, operative mortality rates. The purpose of the study was to describe the development of a dedicated prognostic index for quantifying operative risk in colorectal cancer surgery. METHODS: Data were collected from 5,034 consecutive patients undergoing major surgery in a single center from October 1976 to July 2002. Primary end point was 30-day operative mortality. A multilevel Bayesian logistic regression model was developed to adjust for case-mix and accommodate the variability of outcomes between surgeons. The model was internally validated (split-sample) and tested using measures of discrimination, calibration, and subgroup analysis. RESULTS: The patients' median age was 66 (range, 18-98) years. Operative mortality was 2.3 percent with no significant variability between surgeons or through time. Multivariate analysis identified the following independent risk factors: age (odds ratio = 1.5 per 10-year increase), American Society of Anesthesiologists grade (odds ratio for ASA II, III, IV-V vs. I = 2.6, 4.3, 6.8), TNM staging (odds ratio for Stage IV vs. I-III = 2.6), mode of surgery (odds ratio for urgent vs. nonurgent = 2.1) no-cancer resection vs. cancer resection (odds ratio = 4.5), and hematocrit level. The model offered adequate discrimination (area under receiver operator characteristic curve = 0.801) and excellent agreement between observed and model-predicted outcomes over ten major colorectal procedures (P = 0.191). CONCLUSIONS: The colorectal cancer model provided an accurate means of estimating risk for individual patients in the preoperative setting. It has important implications in everyday practice, because it may be used as an adjunct in the process of informed consent and for monitoring surgical performance through time. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15657649&query_hl=1 ER - TY - JFULL T1 - Laparoscopic skills training and assessment. A1 - Aggarwal, R A1 - Moorthy, K A1 - Darzi, A J1 - Br J Surg Y1 - 2004/12// VL - 91 SN - 0007-1323 SP - 1549 EP - 1558 N2 - 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. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15547882&query_hl=1 ER - TY - JFULL T1 - Aortic valve replacement in a patient with Takayasu's disease without cross-clamping the calcified ascending aorta. A1 - Athanasiou, T A1 - Kumar, P A1 - Ashrafian, H A1 - Nair, S A1 - Charitou, A A1 - Stanbridge, RD J1 - Asian Cardiovasc Thorac Ann Y1 - 2004/12// VL - 12 SN - 0218-4923 SP - 376 EP - 378 N2 - The case of a 42-year-old female requiring surgical management of aortic regurgitation, secondary to Takayasu's disease, with a co-existing heavily calcified ascending aorta is described. In order to address aortic valve surgery with such calcific disease affecting the ascending aorta and peripheral vessels, we present a simple and safe technique that allows aortic valve replacement using a vascular intra-aortic occlusion catheter. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15585715&query_hl=1 ER - TY - JFULL T1 - Surgical education in the new millennium: the European perspective. A1 - Dumon, KR A1 - Traynor, O A1 - Broos, P A1 - Gruwez, JA A1 - Darzi, AW A1 - Williams, NN J1 - Surg Clin North Am Y1 - 2004/12// VL - 84 SN - 0039-6109 SP - 1471 EP - 1491 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15501270&query_hl=1 ER - TY - JFULL T1 - Analysis of technical surgical errors during initial experience of laparoscopic pyloromyotomy by a group of Dutch pediatric surgeons. A1 - Tang, B A1 - Hanna, GB A1 - Bax, NM A1 - Cuschieri, A J1 - Surg Endosc Y1 - 2004/12// VL - 18 SN - 1432-2218 SP - 1716 EP - 1720 N2 - BACKGROUND: The adoption of laparoscopic pyloromyotomy (LPM) by pediatric surgeons has been limited due to concerns about long execution times and higher-than-expected morbidity. The aim of the present study was to examine the performance of LPM by pediatric surgeons during the initial stages of their experience. METHODS: Complete videotapes of 50 early LPM performed in one hospital were subjected to Observational Clinical Human Reliability Analysis (OCHRA) by an independent team. RESULTS: This series had a total morbidity of 6% (one intraoperative bleed, one gastric perforation, one incomplete pyloromyotomy). Using OCHRA, we identified 77 consequential and 233 inconsequential errors (mean of 6 +/- 5.4 per operation, 16.7% total error probability) during an average operative time of 29.8 min. Eighty percent of the errors were of the execution type. A high probability of error was observed with the use of the following key instruments: holding graspers (68%), retractable blade (79%), and splitting forceps (77%). The OCHRA system confirmed that task III was the hazard zone for LPM. Excessive force (task III) resulted in gastric perforation and bleeding from the pyloric mass. Movement in the wrong direction and misorientation in tissue planes were the external error modes underlying misaligned cuts of the pyloric mass and poor tissue splitting (task zones II and III). CONCLUSIONS: This early series of LPM was associated with an appreciable execution error rate, largely due to the poor functionality of the specific instruments used for the procedure. Human factors identified by the external error modes played a subsidiary but important role, underscoring the importance of skills training and experience (proficiency-gain curve). L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15809778&query_hl=1 ER - TY - JFULL T1 - Effective antibiotic regime for postoperative acute cholangitis in biliary atresia--an evolving scene. A1 - Wong, KK A1 - Fan, AH A1 - Lan, LC A1 - Lin, SC A1 - Tam, PK J1 - J Pediatr Surg Y1 - 2004/12// VL - 39 SN - 1531-5037 SP - 1800 EP - 1802 N2 - PURPOSE: The prompt use of empirical antibiotics is vital in managing post-Kasai cholangitis. The authors published findings of their clinical trial in 1991 and established the use of cefoperazone, with a response rate of 88.9%. Here its clinical use since its introduction is reviewed and the trend in its efficacy is assessed. METHODS: A retrospective review was carried out between 1997 and 2003. All episodes of acute cholangitis in patients who underwent Kasai procedure were recorded. Cholangitis was defined as unexplained fever with derangement of liver enzymes. Cefoperazone was started empirically according to the established protocol, and the response to treatment was analyzed. RESULTS: There were 19 patients with a total of 49 episodes of cholangitis. Cefoperazone was used as the first-line empirical antibiotic in 40 of these episodes. Only 30 showed successful response (75%). For the 10 unresponsive episodes, meropenem was used as second-line antibiotic with complete response in all. CONCLUSIONS: The efficacy of cefoperazone in the treatment of post-Kasai cholangitis has decreased over the last years. This suggests a need for a more effective first-line empirical antibiotic. From this review, meropenem seems to be a suitable candidate, and a future prospective clinical trial is warranted. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15616934&query_hl=1 ER - TY - JFULL T1 - The use of positron emission tomography in detecting hepatoblastoma recurrence--a cautionary tale. A1 - Wong, KK A1 - Lan, LC A1 - Lin, SC A1 - Tam, PK J1 - J Pediatr Surg Y1 - 2004/12// VL - 39 SN - 1531-5037 SP - 1779 EP - 1781 N2 - PURPOSE: The use of positron emission tomography (PET) with [18F] fluorodeoxyglucose (FDG) in the detection of recurrences has been well established in many tumor types. Here the authors present their experience using this modality in the evaluation of posttreatment hepatoblastoma patients. METHODS: The authors conducted a retrospective review on patients with hepatoblastoma diagnosed from 1996 to 2003. FDG-PET imaging was performed together with measurement of alpha-fetal protein (AFP) during posttreatment follow-up. RESULTS: Sixteen patients (8 boys and 8 girls) were identified in this series. The mean age was 23.5 months (range, 5 months to 4 years). Three posttreatment patients had PET results suggestive of tumor recurrence. One of these patients had normal AFP level and suspected recurrence in the caudate lobe. Radiologic-guided biopsy was performed 3 times, and there was no evidence of tumor. The other 2 patients underwent further liver resections because of mildly raised AFP levels. The histology of these showed regenerative liver tissue only with no hepatoblastoma recurrence. CONCLUSIONS: Although PET has been gaining popularity as a tool in the detection of tumor recurrences worldwide, it has been shown in this series that PET may not be useful in hepatoblastoma patients, and caution must be taken in the interpretation of positive results. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15616927&query_hl=1 ER - TY - JFULL T1 - Attitudes to changing technology in health care. A1 - Aziz, O A1 - Panesar, SS A1 - James, R A1 - Darzi, A J1 - Hosp Med Y1 - 2004/12// VL - 65 SN - 1462-3935 SP - 708 EP - 709 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15624442&query_hl=1 ER - TY - JFULL T1 - Identification and categorization of technical errors by Observational Clinical Human Reliability Assessment (OCHRA) during laparoscopic cholecystectomy. A1 - Tang, B A1 - Hanna, GB A1 - Joice, P A1 - Cuschieri, A J1 - Arch Surg Y1 - 2004/11// VL - 139 SN - 0004-0010 SP - 1215 EP - 1220 N2 - HYPOTHESIS: Surgical operative performance benefits from analysis of the mechanisms underlying technical errors committed during surgery. DESIGN: Prospective study using the Observational Clinical Human Reliability Assessment (OCHRA) system and complete unedited videotapes of the operations. SETTING: Three National Health Service hospitals within the United Kingdom. PATIENTS: Two hundred consecutive patients with symptomatic gallstone disease. INTERVENTIONS: Elective laparoscopic cholecystectomy for symptomatic gallstone disease by surgeons, who were blind to the nature and objectives of the study, using their usual operative technique. MAIN OUTCOME MEASURES: Surgical consequential and inconsequential operative errors. RESULTS: The analysis of 38 062 steps of the 200 laparoscopic cholecystectomies performed by 26 surgeons identified 2242 errors. The mean +/- SD total, inconsequential, and consequential errors per surgical procedure were 11.0 +/- 8.0, 8.0 +/- 6.0, and 4.0 +/- 3.0, respectively. Dissection of the Calot triangle (second task zone of the operation) incurred more total errors (6.5 +/- 5.4) compared with the first (2.9 +/- 2.8, P<.001) and third (5.1 +/- 3.9, P<.05) task zones. This translated to a higher error probability (6.9% vs 3.5% for the first and 5.5% for third task zones). The combined sharp and blunt dissection method had fewer errors than the blunt/teasing dissection technique (9.45 +/- 7.6 vs 13.9 +/- 7.3, P<.001) although different surgeons were involved. The most serious consequences were encountered during dissection with the electrosurgical hook knife. CONCLUSION: This study has confirmed that the Observational Clinical Human Reliability Assessment system provides a comprehensive objective assessment of the quality of surgical operative performance by documenting the errors, the stage of the operation in which errors are enacted most frequently, and where these errors have serious consequences (hazard zones). L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15545569&query_hl=1 ER - TY - JFULL T1 - Deranged smooth muscle alpha-actin as a biomarker of intestinal pseudo-obstruction: a controlled multinational case series. A1 - Knowles, CH A1 - Silk, DB A1 - Darzi, A A1 - Veress, B A1 - Feakins, R A1 - Raimundo, AH A1 - Crompton, T A1 - Browning, EC A1 - Lindberg, G A1 - Martin, JE J1 - Gut Y1 - 2004/11// VL - 53 SN - 0017-5749 SP - 1583 EP - 1589 N2 - BACKGROUND AND AIMS: Chronic idiopathic intestinal pseudo-obstruction (CIIP) is a severe motility disorder associated with significant morbidity. Several histopathological (neuropathic and myopathic) phenotypes have been described but only a single adult with jejunal smooth (circular) muscle alpha-actin deficiency. We present a prospective multinational case series investigating smooth muscle alpha-actin deficiency as a biomarker of this disease. METHODS: A total of 115 fully clinically and physiologically (including prolonged (24 hour) ambulatory jejunal manometry) characterised CIIP patients from three European centres were studied. Immunohistochemical localisation of actins and other cytoskeletal proteins were performed on laparoscopic full thickness jejunal biopsies and compared with adult controls. Distribution of alpha-actin was also characterised in other gut regions and in the developing human alimentary tract. RESULTS: Twenty eight of 115 (24%) CIIP patient biopsies had absent (n = 22) or partial (n = 6) jejunal smooth muscle alpha-actin immunostaining in the circular muscle layer. In contrast, smooth muscle alpha-actin staining was preserved in the longitudinal muscle and in adult jejunal controls (n = 20). Comparative study of other adult alimentary tract regions and fetal small intestine, suggested significant spatial and temporal variations in smooth muscle alpha-actin expression. CONCLUSIONS: The ability to modulate alpha-smooth muscle actin expression, evident in development, is maintained in adult life and may be influenced by disease, rendering it a valuable biomarker even in the absence of other structural abnormalities. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15479676&query_hl=1 ER - TY - JFULL T1 - The relationship between plasma MMP-1, -7, -8 and -13 levels and embolic potential during carotid endoluminal intervention. A1 - Bicknell, CD A1 - Peck, D A1 - Lau, NM A1 - Alkhamesi, NA A1 - Cowling, MG A1 - Clark, MW A1 - Jenkins, MP A1 - Wolfe, JH A1 - Darzi, AW A1 - Cheshire, NJ J1 - Eur J Vasc Endovasc Surg Y1 - 2004/11// VL - 28 SN - 1078-5884 SP - 500 EP - 507 N2 - BACKGROUND: Patients undergoing carotid endoluminal intervention are at risk of embolic stroke even with the use of distal protection devices. Matrix metalloproteinases (MMPs) have been implicated as a causal factor in plaque instability leading to spontaneous embolisation. We investigated whether plasma MMP levels correlated with the embolisation during carotid endoluminal intervention. METHODS: Thirty circumferentially intact carotid endarterectomy specimens were subjected to a standardised angioplasty procedure in a pulsatile ex vivo model. Emboli collected in a series of distal filters were counted and sized. Plasma samples were collected pre-operatively and analysed for MMP-7 and MMP-8 levels using Western immunoblotting. MMP-1 and MMP-13 levels were determined using ELISA. Emboli number and maximum size were correlated with plasma levels of the MMPs using Spearmans rank. RESULTS: Total MMP-8 levels were related to maximum embolus size (r=0.442, p=0.005) but not emboli number (r=0.342, p=0.052). MMP-1, -7 and -13 were not correlated with either emboli number or with maximum embolus size. CONCLUSION: Pre-operative plasma MMP-8 levels are related to the size of emboli from plaques during carotid endovascular intervention. Further in vivo studies need to be performed to assess the importance of this finding. There is potential for development of plasma markers to identify those patients at greater risk of embolic stroke during carotid endoluminal intervention. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15465371&query_hl=1 ER - TY - JFULL T1 - Are wound healing disturbances and length of hospital stay reduced with minimally invasive vein harvest? A meta-analysis. A1 - Athanasiou, T A1 - Aziz, O A1 - Al-Ruzzeh, S A1 - Philippidis, P A1 - Jones, C A1 - Purkayastha, S A1 - Casula, R A1 - Glenville, B J1 - Eur J Cardiothorac Surg Y1 - 2004/11// VL - 26 SN - 1010-7940 SP - 1015 EP - 1026 N2 - Minimally invasive great saphenous vein harvest for coronary artery bypass grafting aims to reduce post-operative leg-wound related morbidity. In a meta-analysis of randomised trials we have shown leg wound infection rates to be significantly lower in patients undergoing minimally invasive harvest. This study aims to use meta-analysis to compare the two techniques with regards to non-infective wound healing disturbances (NIWHD) (wound drainage, haematoma, dehiscence, necrosis, need for surgical debridement, and seroma formation). A meta-analysis of all studies published between 1995 and 2002 reporting a comparison between the two techniques was performed. Primary outcomes of interest were the six wound healing disturbances mentioned above and length of hospital stay. Heterogeneity was assessed using graphical exploration and sensitivity analysis with subgroup analysis. Twenty-seven studies published between 1997 and 2002 matched our selection criteria, with a combined total of 4953 subjects, of which 2442(49%) underwent minimally invasive harvest and 2511(51%) underwent conventional surgery. When considering only randomised studies, the total number of non-infective wound disturbances was lower in minimally invasive (4%) as compared to the conventional (13%) group (random effect OR 0.24, CI 0.16-0.38). Similar results were found when only fully matched studies were considered. The absolute risk reduction when comparing the two techniques was calculated to be 0.10, which translates to a number of patients needed to treat of 10. Length of stay was significantly reduced in the minimally invasive group in comparison to the conventional group (random effect weighted mean difference of -1.04, CI -1.92 to -0.16). Our results suggest that NIWHD all reduced with minimally invasive harvest techniques. Despite the limitations of this meta-analysis, we feel we have once again illustrated an important link between minimally invasive great saphenous vein harvest and improved tissue healing when compared to conventional open surgery. This has the potential to reduce wound-related morbidity, infection, post-operative pain, length of hospital stay, and re-admission rate. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15519197&query_hl=1 ER - TY - JFULL T1 - Anatomy: the future teaching of undergraduates. A1 - James, DR A1 - Purkayastha, S A1 - Athanasiou, T A1 - Shafiq, O A1 - Paraskevas, P A1 - Darzi, A J1 - Hosp Med Y1 - 2004/11// VL - 65 SN - 1462-3935 SP - 681 EP - 685 N2 - The time devoted to the teaching of anatomy to medical students has long been under pressure. Much work has been devoted to how best to teach anatomy in both a time-efficient and cost-effective manner. This article discusses the main methods of teaching anatomy and their respective advantages and disadvantages as evidenced in the literature. Suggestions are made as to how best to teach anatomy to medical students in the future. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15566061&query_hl=1 ER - TY - JFULL T1 - Re-do aortic valve replacement: does a previous homograft influence the operative outcome? A1 - Kumar, P A1 - Athanasiou, T A1 - Ali, A A1 - Nair, S A1 - Oz, BS A1 - DeSouza, A A1 - Moat, N A1 - Shore, DF A1 - Pepper, JR J1 - J Heart Valve Dis Y1 - 2004/11// VL - 13 SN - 0966-8519 N2 - BACKGROUND AND AIM OF THE STUDY: Late reoperation for failed aortic homograft is widely regarded as a high-risk procedure. A review is presented of the authors' experience of redo-aortic valve replacement (re-do AVR) examining factors which affect, and whether a previous aortic homograft replacement influences, operative outcome. METHODS: A retrospective review was conducted of consecutive re-do AVR performed at the authors' institution between 1998 and 2002. RESULTS: During the study period, 178 patients (125 males, 53 females; mean age 52.4 years; range: 16-85 years) underwent re-do AVR. The group included first-time (72%), second-time (20%), and more than third-time re-do AVR (8%). Forty-six patients (26%) received a homograft (group I), and 132 (74%) a stented biological/mechanical valve (group II). The two groups were matched for baseline clinical characteristics and operative variables. The type of explanted valve, and preoperative and operative variables, were analyzed using univariate and multivariate models. Primary outcome was defined as 30-day mortality, and secondary outcome as postoperative complications. The overall 30-day mortality was 12.3%, but was much lower (4.5%) for elective isolated and multiple re-do AVR. Univariate analysis showed significant predictors of 30-day mortality to be: age >65 years (p = 0.02); renal dysfunction (p = 0.005); preoperative unstable status (p = 0.03); preoperative NYHA class III/IV dyspnea (p = 0.02); non-elective operation (p = 0.01); preoperative arrhythmia (p = 0.005); history of chronic obstructive pulmonary disease (COPD) (p = 0.002); preoperative cardiogenic shock (p = 0.03); impaired left ventricular ejection fraction (LVEF) <50% (p = 0.04); and other valvular procedure(s) performed simultaneously (p = 0.01). In a multivariate analysis, the only significant predictors of 30-day mortality were impaired LVEF (p = 0.03) and a history of COPD (p = 0.007). Group I patients had a significantly shorter mean hospital stay (10.2+/-5.9 versus 14.1+/-12.5 days; p = 0.009), but there were no significant differences between groups in terms of postoperative complications. CONCLUSION: A previous aortic homograft replacement was not associated with an increased operative risk at the time of re-do AVR. A history was COPD was an important predictor of 30-day mortality, and this finding requires further investigation. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15597580&query_hl=1 ER - TY - JFULL T1 - Bimodal assessment of laparoscopic suturing skills: construct and concurrent validity. A1 - Moorthy, K A1 - Munz, Y A1 - Dosis, A A1 - Bello, F A1 - Chang, A A1 - Darzi, A J1 - Surg Endosc Y1 - 2004/11// VL - 18 SN - 1432-2218 SP - 1608 EP - 1612 N2 - 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. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15931486&query_hl=1 ER - TY - JFULL T1 - Perioperative diagnosis of cystosarcoma phyllodes of the breast may be enhanced by MIB-1 index. A1 - Ridgway, PF A1 - Jacklin, RK A1 - Ziprin, P A1 - Harbin, L A1 - Peck, DH A1 - Darzi, AW A1 - Rajan, PB J1 - J Surg Res Y1 - 2004/11// VL - 122 SN - 0022-4804 SP - 83 EP - 88 N2 - BACKGROUND: The recurring theme in cystosarcoma phyllodes (CSP) is one of underdiagnosis by pathologists and undertreatment by surgeons. Major areas of investigation relating to the diagnosis of CSP center on accurate preoperative diagnosis, elucidating the relevance of histological classification with respect to outcome, and identifying novel markers to reliably differentiate CSP from fibroadenoma (FA). MATERIALS AND METHODS: Fifteen CSP and 7 cellular FA controls (where the preoperative diagnosis was unclear) were retrospectively investigated. Preoperative histological and radiological investigations were reviewed for efficacy. The ability of MIB-1 antibody to differentiate the two fibroepithelial lesions was investigated using immunohistochemical estimation of the MIB-1 index. RESULTS AND DISCUSSION: Preoperative core biopsy had a sensitivity of 75% but was carried out in only 23% of cases. Fine needle aspiration cytology and radiological assessment were not efficacious in preoperative diagnosis. Proliferative activity (MIB-1 indices) was significantly higher in CSP than in a selected population of FA where there was preoperative diagnostic uncertainty (P < 0.0001). Indices were also able to determine CSP subclassification. This suggests MIB-1 as a constructive adjunctive investigation when evaluating histological features to differentiate CSP from FA in difficult cases. CONCLUSIONS: The use of MIB-1 may increase the sensitivity of preoperative core biopsy diagnosis, offering more effective surgical planning and decreasing immediate reoperation rates. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15522319&query_hl=1 ER - TY - JFULL T1 - An innovative method for the assessment of skills in lower gastrointestinal endoscopy. A1 - Moorthy, K A1 - Munz, Y A1 - Orchard, TR A1 - Gould, S A1 - Rockall, T A1 - Darzi, A J1 - Surg Endosc Y1 - 2004/11// VL - 18 SN - 1432-2218 SP - 1613 EP - 1619 N2 - 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. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15931472&query_hl=1 ER - TY - JFULL T1 - Time-motion analysis of operation theater time use during laparoscopic cholecystectomy by surgical specialist residents. A1 - Geryane, MH A1 - Hanna, GB A1 - Cuschieri, A J1 - Surg Endosc Y1 - 2004/11// VL - 18 SN - 1432-2218 SP - 1597 EP - 1600 N2 - BACKGROUND: Data on man-machine interfaces in the operation theater are essential to the improvement of surgical efficiency. This study analyzed the activity of the operating team during laparoscopic cholecystectomy by surgical trainees. METHODS: The endoscopic image and overview of the operating room were recorded during 20 laparoscopic cholecystectomies performed by specialist residents. Time-motion analysis of the recorded tapes was performed. RESULTS: The median (interquartile range [IQR]) for theater time was 134 +/- min (IQR, 52 min). The components of operative time for the surgeon were 26% for insertion of access ports and wound closure, 57% for intracorporeal endoscopic work, and 17% for instrument change. Only 52% of the scrub nurse time was related to the operation. Machine and video setup, adjustment of ancillary equipment together, and delivery of instruments and items requested by the surgeon and scrub nurse accounted for 13% of the circulating nurse time. CONCLUSIONS: With the current nonergonomic theater design and structure, a significant proportion of theater time during routine uncomplicated laparoscopic surgery is used for nonoperative functions. The study highlights the need for improved ergonomic design, integrated bus operating systems under the control of the surgeon, and multifunctional laparoscopic instruments. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16237585&query_hl=1 ER - TY - JFULL T1 - Clinical and angiographic outcomes of coronary artery bypass grafting with and without cardiopulmonary bypass: Harefield prospective randomized trial A1 - Al-Ruzzeh, S A1 - George, S A1 - Bustami, M A1 - Kemp, M A1 - Chambers, J A1 - Wray, J A1 - Partridge, J A1 - Hooper, J A1 - Ali, K A1 - Athanasiou, T A1 - Yacoub, M A1 - Ilsey, C A1 - Amrani, M J1 - CIRCULATION Y1 - 2004/10/26/ VL - 110 SN - 0009-7322 SP - 546 EP - 546 ER - TY - JFULL T1 - Full arterial revascularisation provides a better clinical outcome when combined with off-pump coronary artery bypass surgery: A propensity score analysis A1 - Al-Ruzzeh, S A1 - Athanasiou, T A1 - Glenville, B A1 - Casula, R A1 - Amrani, M J1 - CIRCULATION Y1 - 2004/10/26/ VL - 110 SN - 0009-7322 SP - 467 EP - 467 ER - TY - JFULL T1 - Surgical education and training in the new millennium. A1 - Aggarwal, R A1 - Hance, J A1 - Darzi, A J1 - Surg Endosc Y1 - 2004/10// VL - 18 SN - 1432-2218 SP - 1409 EP - 1410 L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15791360&query_hl=1 ER - TY - JFULL T1 - The longer patients are in hospital before Intensive Care admission the higher their mortality. A1 - Goldhill, DR A1 - McNarry, AF A1 - Hadjianastassiou, VG A1 - Tekkis, PP J1 - Intensive Care Med Y1 - 2004/10// VL - 30 SN - 0342-4642 SP - 1908 EP - 1913 N2 - OBJECTIVE: To explore the relationship between hospital mortality and time spent by patients on hospital wards before admission to the intensive care unit (ICU). DESIGN: Observational study of prospectively collected data. SETTING: Participating intensive care units within the North East Thames Regional Database. PATIENTS AND PARTICIPANTS: Patients, 7,190, admitted to ICU from the hospital wards of 24 hospitals. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Of ICU admissions from the wards, 40.1% were in hospital for more than 3 days and 11.7% for more than 15 days. ICU patients who died in hospital were in-patients longer (p=0.001) before admission (median 3 days; interquartile range 1-9) than those discharged alive (median 2 days; interquartile range 1-5). Hospital mortality increased significantly (p<0.0001) in relation to time on hospital wards before ICU: 47.1% (standardised mortality ratio 1.09) for patients in hospital 0-3 days before ICU admission up to 67.2% (standardised mortality ratio 1.39) for patients on the wards for more than 15 days before ICU. Length of stay before ICU admission was an independent predictor of hospital mortality (odds ratio per day 1.019; 95% confidence interval 1.014-1.024). There were significant differences (p<0.001) in patient age, APACHE II score and predicted mortality in relation to time on wards before ICU admission. CONCLUSIONS: Mortality was high among patients admitted from the wards to ICU; many were inpatients for days or weeks before admission. The longer these patients were in hospital before ICU admission, the higher their mortality. Patients with delayed admission differed in some respects compared to those admitted earlier. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15278266&query_hl=1 ER - TY - JFULL T1 - Does off-pump coronary artery bypass reduce the incidence of post-operative atrial fibrillation? A question revisited. A1 - Athanasiou, T A1 - Aziz, O A1 - Mangoush, O A1 - Al-Ruzzeh, S A1 - Nair, S A1 - Malinovski, V A1 - Casula, R A1 - Glenville, B J1 - Eur J Cardiothorac Surg Y1 - 2004/10// VL - 26 SN - 1010-7940 SP - 701 EP - 710 N2 - Atrial fibrillation (AF) is the most common post-operative complication in patients undergoing coronary artery bypass grafting, with an increased incidence associated with advancing age. This study aims to determine whether off-pump coronary artery bypass (OPCAB) reduces the incidence of AF in a generalized population (mean age <70 years). A meta-analysis was performed including all randomised and propensity score matched non-randomised studies published between 2001 and 2003 reporting a comparison between the two techniques in a generalised patient group (average age <70 years). The primary outcome of interest was post-operative AF. Sensitivity analysis was performed to evaluate consistency of the calculated treatment effect. Fourteen studies fulfilled our inclusion criteria, including a total of 16,505 subjects. The incidence of AF was 19% (1612/8265) in the off-pump group versus 24% (1976/8240) in the on-pump group. When considering only the 11 randomised studies (2207 subjects), we found a significant reduction in the incidence of post-operative AF in the off-pump group using a random-effect model (odds ratio (OR)=0.60, 95% confidence interval (CI)=0.45-0.82, and chi-square of heterogeneity=18.02, P=0.05). Sensitivity analysis highlighted one randomised study causing funnel plot asymmetry, exclusion of which resulted in a significant reduction in the incidence of post-operative AF in the off-pump group (OR=0.71, 95% CI=0.57-0.90), with a non-significant heterogeneity of 3.91 (P=0.92). When only studies of high quality were considered (898 patients), no significant difference was seen between on and off-pump groups (OR=0.78, 95% CI=0.57-1.07, and heterogeneity=0.53, P=0.91). This may be due to small number of patients in this group. Our results suggest that although OPCAB surgery may reduce the incidence of post-operative AF in a generalised population (age <70 years) this finding is not clearly supported by high quality randomised trials. Although previous evidence suggests that the incidence of post-operative AF is reduced in an elderly population (>70 years) with off-pump surgery, our results show that the evidence is less clear in a younger population group. The question of whether off-pump surgery in this patient group results in a lower rate of post-operative AF remains to be answered by further high quality randomised research. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15450560&query_hl=1 ER - TY - JFULL T1 - The Ross II procedure: pulmonary autograft in the mitral position. A1 - Athanasiou, T A1 - Cherian, A A1 - Ross, D J1 - Ann Thorac Surg Y1 - 2004/10// VL - 78 SN - 1552-6259 SP - 1489 EP - 1495 N2 - The surgical management of mitral valve disease in women of childbearing age, young patients, and children with congenital mitral valve defects is made difficult by the prospect of lifelong anticoagulation. We suggest the use of a pulmonary autograft in the mitral position (Ross II procedure) as an alternative surgical technique. We present a review of the literature, historical perspectives, indications, selection criteria, and surgical technique for the Ross II procedure. Our literature search identified 14 studies that reported results from the Ross II operation. Performed in 103 patients, the overall in-hospital mortality was 7 (6.7%), with a late mortality of 10 (9%). Although further research is needed, current evidence suggests the Ross II operation is a valuable alternative in low-risk young patients where valve durability and the complication rate from other procedures is unsatisfactory and anticoagulation not ideal. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15464534&query_hl=1 ER - TY - JFULL T1 - The simulated operating theatre: comprehensive training for surgical teams. A1 - Aggarwal, R A1 - Undre, S A1 - Moorthy, K A1 - Vincent, C A1 - Darzi, A J1 - Qual Saf Health Care Y1 - 2004/10// VL - 13 Suppl 1 SN - 1475-3898 SP - i27 EP - i32 N2 - 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. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15465952&query_hl=1 ER - TY - JFULL T1 - Comparison of bench test evaluations of surgical skill with live operating performance assessments. A1 - Datta, V A1 - Bann, S A1 - Beard, J A1 - Mandalia, M A1 - Darzi, A J1 - J Am Coll Surg Y1 - 2004/10// VL - 199 SN - 1072-7515 SP - 603 EP - 606 N2 - BACKGROUND: Attempts at assessing surgical proficiency have generally used laboratory simulation to evaluate skill. The aim of this study was to compare technical ability as measured on a bench simulation with actual operative performance. STUDY DESIGN: Twenty-two general surgeons and trainees were recruited: consultants (n = 4), specialist registrars (n = 14), and senior house officers (n = 4). They were assessed while performing a saphenofemoral dissection on an anesthetized patient in the operating theater, and performing the same procedure on an inanimate model within the laboratory. The Objective Structured Assessment of Technical Skill method, consisting of a 7-parameter global rating (maximum score 35) and 17-point step-by-step checklist (maximum score 17) was used to measure performance in both environments. Face, content, and construct validity of the synthetic model were established as part of this study. RESULTS: There was a significant relationship between technical skill as measured on the bench test model and performance within the operating theater with respect to both global rating (Spearman correlation coefficient 0.824, p < 0.001; alpha coefficient 0.89) and checklist ratings (r = 0.514, p < 0.02; alpha coefficient 0.68) rating assessments. Global rating scores correlated with experience for both operative (r = 0.822, p < 0.001) and bench (r = 0.515, p < 0.05) settings. There was no difference in level of measured performance between operating theater and bench model (global rating mean 23.25 +/- 6.66 versus 23.75 +/- 5.62, respectively; paired t-test p = 0.559). CONCLUSIONS: Assessment of technical skill using inanimate procedural simulation translates to actual surgical performance within the operating theater. This further validates use of bench test evaluations to measure surgical technical ability. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15454146&query_hl=1 ER - TY - JFULL T1 - Simulation and clinical practice: strengthening the relationship. A1 - Kneebone, RL A1 - Scott, W A1 - Darzi, A A1 - Horrocks, M J1 - Med Educ Y1 - 2004/10// VL - 38 SN - 0308-0110 SP - 1095 EP - 1102 N2 - INTRODUCTION: This discussion paper argues for a creative synthesis between simulation and clinical practice, where an iterative process of continual interaction ensures that skills are learned and reinforced within the context of everyday professional life. BACKGROUND: Evidence is mounting that long-established approaches to surgical training are no longer acceptable in the current ethical and professional climate. This paper considers alternatives to the traditional approach of 'learning by doing' in a clinical context, focusing on recent developments in the technology of simulation and virtual reality. Clinical expertise is a complex phenomenon and no single theory can account for its acquisition. After a brief contextualising overview, Vygotsky's 'zone of proximal development' is proposed as a conceptual framework for task-based surgical learning that takes place within skills laboratories. The discussion is located within a wider context of educational theory, drawing on current thinking about situated learning and apprenticeship. The notion of 'legitimate peripheral participation' in a complex professional environment places technical skill alongside a range of other competencies that are necessary to safe practice. CONCLUSIONS: Simulation offers a safe environment within which learners can repeatedly practise a range of clinical skills without endangering patients. Comprehensive simulated environments allow a move away from isolated tasks to more complex clinical situations, recreating many of the challenges of real life. Such simulations, however, can operate in isolation from their clinical context, ignoring the learning needs of individuals within a real health care environment. To realise its full potential as a learning aid, simulation must be used alongside clinical practice and linked closely with it. L1 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15461655&query_hl=1 ER - TY - JFULL T1 - [Laparoscopic and general surgery guided by open interventional magnetic resonance] A1 - Lauro, A A1 - Gould, SW A1 - Cirocchi, R A1 - Giustozzi, G A1 - Darzi, A J1 - Minerva Chir Y1 - 2004/10// VL - 59 SN - 0026-4733 SP - 507 EP - 516 N2 - Interventional magnetic resonance (IMR) machines have produced unique opportunity for image-guided surgery. The open configuration design and fast pulse sequence allow virtual real time intraoperative scanning to monitor the progre