A research agenda for gastrointestinal and endoscopic surgery

Background

Development of a research agenda may help to inform researchers and research-granting agencies about the key research gaps in an area of research and clinical care. The authors sought to develop a list of research questions for which further research was likely to have a major impact on clinical care in the area of gastrointestinal and endoscopic surgery.

Methods

A formal group process was used to conduct an iterative, anonymous Web-based survey of an expert panel including the general membership of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). In round 1, research questions were solicited, which were categorized, collapsed, and rewritten in a common format. In round 2, the expert panel rated all the questions using a priority scale ranging from 1 (lowest) to 5 (highest). In round 3, the panel re-rated the 40 questions with the highest mean priority score in round 2.

Results

A total of 241 respondents to round 1 submitted 382 questions, which were reduced by a review panel to 106 unique questions encompassing 33 topics in gastrointestinal and endoscopic surgery. In the two successive rounds, respectively, 397 and 385 respondents ranked the questions by priority, then re-ranked the 40 questions with the highest mean priority score. High-priority questions related to antireflux surgery, the oncologic and immune effects of minimally invasive surgery, and morbid obesity. The question with the highest mean priority ranking was: “What is the best treatment (antireflux surgery, endoluminal therapy, or medication) for GERD?” The second highest-ranked question was: “Does minimally invasive surgery improve oncologic outcomes as compared with open surgery?” Other questions covered a broad range of research areas including clinical research, basic science research, education and evaluation, outcomes measurement, and health technology assessment.

Conclusions

An iterative, anonymous group survey process was used to develop a research agenda for gastrointestinal and endoscopic surgery consisting of the 40 most important research questions in the field. This research agenda can be used by researchers and research-granting agencies to focus research activity in the areas most likely to have an impact on clinical care, and to appraise the relevance of scientific contributions.     

Development of ASMBS research agenda for bariatric surgery using the Delphi methodology

BackgroundWhile the number of research publications related to bariatric surgery have increased remarkably in the past decade, research efforts remain uncoordinated and have limited focus, and numerous important questions remain unanswered.ObjectiveTo generate a research agenda in bariatric surgery.SettingNational survey.MethodsThe membership of the American Society of Metabolic and Bariatric Surgery (ASMBS) was asked to submit research questions needed to advance the field of bariatric surgery. An expert panel grouped and collated submitted questions and redistributed them back to the membership to rate their importance on a 5-point Likert scale using a 3-round modified Delphi methodology. The top research questions were determined based on provided rankings.ResultsTwo hundred ninety-two research questions were initially submitted that were collapsed to 59 unique questions. The ratings for the top 40 questions ranged from 2.67–4.33 (overall mean, 3.46). The highest-ranked questions centered on the mechanisms of effectiveness of bariatric surgery for weight loss and diabetes resolution, the underlying etiology of weight recidivism, and predictors of success.ConclusionsA research agenda for bariatric surgery was developed using the Delphi methodology. This research agenda may enhance the ability of investigators and funding organizations, including the ASMBS, to focus attention to areas most likely to advance the field, and by editors and reviewers to assess the merit and relevance of scientific contributions.     

Lasers in endoscopic gastrointestinal surgery

Lasers have been used for endoscopic gastrointestinal surgery at our institution since 1977. The argon and Nd-YAG lasers are valuable for coagulating upper gastrointestinal hemorrhage, arteriovenous malformations, and benign and malignant lesions, as well as a variety of anatomic anomalies. Between December 1977 and September 1983, 222 procedures were performed in 122 patients. Hospital charts were reviewed and a scale constructed to assess the results of treatment. When information was available, a comparison of transfusion requirements before and after laser therapy was made. Success was achieved in 84 percent of the patients regardless of initial diagnosis. Laser therapy was not effective in 12 patients (10 percent). In 27 patients with gastrointestinal atrioventricular malformations, transfusion requirements fell from a mean of 17 +/- 5.9 units in the year before laser therapy to 1 +/- 0.8 units in the year after laser phototherapy (p less than 0.01). Complications rarely occurred (6 percent of all procedures). There were no perforations of the gastrointestinal tract and only one death (0.8 percent) partially attributable to laser application. Endoscopic laser surgery is minimally invasive and can be performed on an outpatient basis without anesthesia. It is especially valuable in patients with a high operative risk.     

Defining the research agenda for surgical infection: a consensus of experts using the Delphi approach

BACKGROUND: A substantial proportion of operative procedures are complicated by infections, either remote from or related to the surgical site. These infections account for substantive morbidity and health care costs. With limited research funds available to study interventions designed to either prevent or reduce the morbidity associated with infections in surgical patients, we developed a research agenda to develop priorities to aid in study design and to focus both human and capital resources more effectively. METHODS: A Delphi survey approach was used. Consensus was developed among experts in the field of surgical infection and the membership of the Surgical Infection Society. RESULTS: Thirty-six experts generated a total of 62 questions that were submitted for two rounds of consensus ranking. A total of 31 questions were ranked in the final round and are available at www.sisna.org. The most highly ranked question was "Does strict glycemic control compared with standard care reduce the risk of surgical site infection in patients undergoing abdominal surgery?" Most of the questions had little available data, suggesting these are both important and necessary areas for further research. CONCLUSIONS: This research agenda, developed by a consensus of experts, provides direction and focus to the development of interventional trials geared toward reducing the morbidity associated with infections in surgical patients.     

Distal rectus femoris surgery in children with cerebral palsy: results of a Delphi consensus project

PurposeThe purpose of this study was for an international panel of experts to establish consensus indications for distal rectus femoris surgery in children with cerebral palsy (CP) using a modified Delphi method.MethodsThe panel used a five-level Likert scale to record agreement or disagreement with 33 statements regarding distal rectus femoris surgery. The panel responded to statements regarding general characteristics, clinical indications, computerized gait data, intraoperative techniques and outcome measures. Consensus was defined as at least 80% of responses being in the highest or lowest two of the five Likert ratings, and general agreement as 60% to 79% falling into the highest or lowest two ratings. There was no agreement if neither threshold was reached.ResultsConsensus or general agreement was reached for 17 of 33 statements (52%). There was general consensus that distal rectus femoris surgery is better for stiff knee gait than is proximal rectus femoris release. There was no consensus about whether the results of distal rectus femoris release were comparable to those following distal rectus femoris transfer. Gross Motor Function Classification System (GMFCS) level was an important factor for the panel, with the best outcomes expected in children functioning at GMFCS levels I and II. The panel also reached consensus that they do distal rectus femoris surgery less frequently than earlier in their careers, in large part reflecting the narrowing of indications for this surgery over the last decade.ConclusionThis study can help paediatric orthopaedic surgeons optimize decision-making for, and outcomes of, distal rectus femoris surgery in children with CP.Level of evidenceV     

Bladder tumours treated by endoscopic surgery: Long-term results

Eighty per cent of bladder tumours can be treated by endoscopic resection of the tumour if the urological surgeon is proficient in this technique. The survival of patients having this treatment is better than more radical surgery in all grades and in all stages except stages C and D.     

Caustic injury of the upper gastrointestinal tract in adults: a clinical and endoscopic study

During the past 8 1/2 years, we have treated 34 adult patients admitted for ingestion of caustic materials. In 19 patients the injury was accidental, and in 15 patients ingestion was a suicide attempt. Ingested agents included hydrochloric acid in four patients, sulfuric acid in one patient, a strong alkali such as sodium hydroxide or Drano in 15 patients, liquid bleach in eight patients, detergents in four patients, and ammonia in two patients. Each patient underwent early fiberoptic endoscopic evaluation. The extent and severity of the injury varied according to the ingested agent. Seven patients who had second- or third-degree injury had surgery. One patient who ingested sulfuric acid required hemigastrectomy for pyloric stenosis. Two patients with Drano ingestion had necrosis of the stomach and required total gastrectomy. Five patients with strong alkali ingestion had esophageal strictures, and colonic interposition was performed on four of these patients. No patient who had ingested bleach, ammonia, or detergent required surgery. Panendoscopy after caustic ingestion can be performed safely and provides an accurate guide for therapy. The ingestion of strong acid or alkali may produce profound pathologic changes, which may require surgery for perforation or stricture. Bleach, detergent, and ammonia usually cause mild injuries that will respond with medical treatment.     

Laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor dissection

BACKGROUND: Laparoscopic wedge resections are increasingly applied for gastric submucosal tumors such as gastrointestinal stromal tumor (GIST). Despite this, no defined strategy exists to guide the surgeon in choosing the appropriate laparoscopic technique for an individual case on the basis of tumor characteristics such as location or size. This study aimed to introduce a laparoscopic and endoscopic cooperative surgery (LECS) for gastric wedge resection that is applicable for submucosal tumor resection independent of tumor location and size. METHODS: Seven patients underwent LECS for the resection of gastric submucosal tumors. Both mucosal and submucosal layers around the tumor were circumferentially dissected using endoscopic submucosal dissection via intraluminal endoscopy. Subsequently, the seromusclar layer was laparoscopically dissected on the exact three-fourths cut line around the tumor. The submucosal tumor then was exteriorized to the abdominal cavity and dissected with a standard endoscopic stapling device. RESULTS: In all cases, the LECS procedure was successful for dissecting out the gastric submucosal tumor. In four of seven cases, the tumor was located in the upper gastric portion near the esophagogastric junction. The remaining three tumors were in the posterior gastric wall. In two cases, the tumors were more than 5 cm in diameter, and one was a GIST of the remnant stomach. The mean operation time was 169 +/- 17 min, and the estimated blood loss was 7 +/- 2 ml. The postoperative course was uneventful in all cases. CONCLUSIONS: The LECS procedure for dissection of gastric submucosal tumors such as GIST may be performed safely with reasonable operation times, less bleeding, and adequate cut lines. In addition, the success of the procedure does not depend on the tumor location such as the vicinity of the esophagogastric junction or pyloric ring.     

Mobility and HIV care engagement: a research agenda

Introduction

Mobility is common and an essential livelihood strategy in sub-Saharan Africa (SSA). Mobile people suffer worse outcomes at every stage of the HIV care cascade compared to non-mobile populations. Definitions of mobility vary widely, and research on the role of temporary mobility (as opposed to permanent migration) in HIV treatment outcomes is often lacking. In this article, we review the current landscape of mobility and HIV care research to identify what is already known, gaps in the literature, and recommendations for future research.

Discussion

Mobility in SSA is closely linked to income generation, though caregiving, climate change and violence also contribute to the need to move. Mobility is likely to increase in the coming decades, both due to permanent migration and increased temporary mobility, which is likely much more common. We outline three central questions regarding mobility and HIV treatment outcomes in SSA. First, it is unclear what aspects of mobility matter most for HIV care outcomes and if high-risk mobility can be identified or predicted, which is necessary to facilitate targeted interventions for mobile populations. Second, it is unclear what groups are most vulnerable to mobility-associated treatment interruption and other adverse outcomes. And third, it is unclear what interventions can improve HIV treatment outcomes for mobile populations.

Conclusions

Mobility is essential for people living with HIV in SSA. HIV treatment programmes and broader health systems must understand and adapt to human mobility, both to promote the rights and welfare of mobile people and to end the HIV pandemic.     

Sellar repair in endoscopic endonasal transsphenoidal surgery: results of 170 cases

OBJECTIVE: To describe techniques and materials used in sellar repair after an endoscopic endonasal transsphenoidal approach. METHODS: Different techniques of sellar closure and indications for each specific condition are reviewed in a series of 170 consecutive patients. RESULTS: Only 47 (27.6%) of 170 patients were considered candidates for sellar reconstruction after the endoscopic operation, mainly because of intraoperative cerebrospinal fluid leaks (14.1%). The overall rate of postoperative cerebrospinal fluid leakage was 2.3%, which was cured by means of an early reoperation in three cases and with lumbar drainage in the fourth case. CONCLUSION: Reconstruction of the sella was considered necessary in only one-third of the patients who underwent operations via an endoscopic transsphenoidal procedure. Some minor expedients can be useful for the reconstruction, and the ideal material for the repair should be chosen.     

Complications of endoscopic spinal surgery: a retrospective study of thoracoscopy and retroperitoneoscopy

Background Since 1996, we have applied endoscopic techniques to the treatment of various spinal disorders. The purpose of this study was to clarify the complications of endoscopic spinal surgery using thoracoscopy and retroperitoneoscopy. Methods Fifty-two patients (26 male patients, 26 female patients, mean age: 49.7 years) underwent endoscopic surgery for various spinal disorders including burst fracture (20 cases), pyogenic spondylitis (10 cases), tumor (8 cases), scoliosis (4 cases), thoracic disc herniation (3 cases), and others. Thoracoscopy was performed in 20 patients, retroperitoneoscopy in 20 patients, and a combination of thoracoscopy and retroperitoneoscopy in 12 patients. Intraoperative and postoperative complications were retrospectively examined for these cases. Results The intraoperative complications for thoracoscopic surgery were two cases of extensive bleeding (more than 2500 ml); for retroperitoneoscopic surgery, there were three cases of extensive bleeding and one case of penetration of the peritoneum; and for the combination of thoracoscopy and retroperitoneoscopy, there were two cases of extensive bleeding. The postoperative complications for thoracoscopic surgery were three cases of atelectasis and other respiratory complications; for retroperitoneoscopic surgery, the most common complication was transient neurological dysfunction (five cases); and for the combination of thoracoscopy and retroperitoneoscopy, three cases of atelectasis were observed. The overall incidence of complications in endoscopic spinal surgery was 42.3% (20/52 cases). Of the intraoperative complications, extensive bleeding was most frequent, and of postoperative complications, respiratory problems and transient neural damage were most frequent. The incidences of extensive bleeding and respiratory problems during the past 4 years were significantly fewer than during the first 4 years of surgical experience. Intraoperative bleeding and the operative time were significantly decreased after the first five cases of burst fracture. Conclusions Complications of endoscopic spinal procedures occurred in 42.3% of our cases, but decreased with increase in surgical experience.     

腔镜甲状腺手术的临床应用研究

目的 :探索用腔镜进行甲状腺手术的可行性及其应用价值。方法 :对 2 2例甲状腺良性肿物的患者用超声刀行腔镜甲状腺良性肿物切除术。结果 :手术成功 2 0例 ,中转开刀 2例。手术时间 4 0～ 180min平均 90min ,术中出血 5～ 10 0ml。术后 6h下床活动、进流质饮食 ,无恶心、呕吐。颈部引流管于术后第 2d拔除 ,术后 3～ 4d出院。 2例术后前胸部出现小面积的淡黄色瘀斑。无皮下气肿。结论 :腔镜甲状腺手术是安全可行的。该手术切口隐蔽、颈部无疤痕、美容效果好 ,更符合青年女性的社会心理要求。