Robot-assisted thoracoscopic brachytherapy for lung cancer: comparison of the ZEUS robot, VATS, and manual seed implantation.

OBJECTIVE: Interstitial brachytherapy is becoming an accepted treatment option for lung cancer patients for whom surgery poses a high risk. Robotic surgery has the potential to deliver brachytherapy seeds into tumors while keeping surgeons at a safe distance from the radioactive source. Our aim was to compare the accuracy, number of attempts, and time needed to place seeds next to a target when using a manual technique, video-assisted thoracoscopic surgery (VATS), and the ZEUS robot for minimally invasive surgery (MIS). METHODS: A brachytherapy seed injector was developed and attached to one of the ZEUS robotic arms. Four subjects each inserted inactive dummy brachytherapy seeds into clear agar-gelatin cubes containing a 1.6-mm stainless steel ball target. Two orthogonal radiographs were taken of each agar cube, and the corresponding distances were measured in triplicate using ImageJ processing software. The mean distance between the center of each seed and the corresponding target was calculated using the Pythagorean theorem. Comparisons were made using analysis of variance, t-tests, and Kruskal-Wallis tests, as appropriate. RESULTS: A total of 384 tests (128 for each technique) were performed. The median accuracies for the manual technique, VATS, and ZEUS were 1.8 mm (range: 0.9-6.7 mm), 2.4 mm (range: 1.0-11.3 mm), and 3.6 mm (range: 1.3-16.7 mm), respectively (p < 0.01). The median numbers of attempts for the manual technique, VATS, and ZEUS were 1 (range: 1-5), 4 (range: 1-14), and 3 (range: 1-20), respectively (p < 0.01). The median times for the manual technique, VATS, and ZEUS were 3.0 s (range: 1-43 s), 86.5 s (range: 6-372 s), and 64.5 s (range: 5-356 s), respectively (p < 0.01). CONCLUSIONS: The manual technique is the most accurate, least traumatic, and fastest method of inserting seeds into tumors. The ZEUS robotic platform was able to place seeds beside a target within a clinically acceptable distance, with an acceptable amount of trauma and time required. It achieved results equal to or better than those obtained with VATS.     

An internet survey of 2,596 people with fibromyalgia

Background  

This study explored the feasibility of using an Internet survey of people with fibromyalgia (FM), with a view to providing information on demographics, sources of information, symptoms, functionality, perceived aggravating factors, perceived triggering events, health care utilization, management strategies, and medication use.     

Acute Achilles tendon rupture: minimally invasive surgery versus non operative treatment,with immediate full weight bearing. Design of a randomized controlled trial

Background  

We present the design of an open randomized multi-centre study on surgical versus conservative treatment of acute Achilles tendon ruptures. The study is designed to evaluate the effectiveness of conservative treatment in reducing complications when treating acute Achilles tendon rupture.     

Intraoperative Awareness in a Regional Medical System: A Review of 3 Years' Data

Background: Intraoperative awareness in patients undergoing general anesthesia is an infrequent but well-described adverse outcome. The reported incidence of this phenomenon is between 0.1% and 0.9%.

Methods: With institutional review board approval, the authors reviewed continuous quality improvement data from 3 yr (2002-2004) at the locations where the physician group provided anesthesia. Board-certified anesthesiologists supervising certified registered nurse anesthetists in the anesthesia care team model of practice delivered all anesthetics. Brain function monitors were not used in the operating room setting. Patients were interviewed twice during a 48-h postoperative period and, as part of that process, underwent a modified Brice interview to determine intraoperative awareness. All cases that met the criteria for awareness were examined by the continuous quality improvement committee to modify anesthetic practice and were included in this study.

Results: Data from 211,842 patients undergoing anesthesia were considered. Of these, the continuous quality improvement process followed up 177,468 (83.1%). Cases were not included in the study if the patient was younger than 18 yr, did not have a general anesthetic, or had a terminal event during the hospital course. By these criteria, a total of 87,361 patients followed by the continuous quality improvement process were at risk for awareness. Six patients reported instances of recall.     

The Role of Extended Lymphadenectomy for Adenocarcinoma of the Head of the Pancreas: Strength of the Evidence

With improvements in the safety of Whipple resection in recent decades, surgeons have continued to explore the role of more extensive lymphadenectomy in hope of improving long-term survival. A systematic literature search of level I evidence addressing the role of the extent of lymphadenectomy was undertaken. Only reports of prospective, randomized controlled trials comparing pancreaticoduodenectomy with standard lymphadenectomy to pancreaticoduodenectomy with extended lymphadenectomy where information regarding survival, morbidity, mortality, the number of resected lymph nodes in each group and detailed operative technique were included. Four prospective, randomized trials comprising some 424 patients and one meta-analysis were identified. In aggregate, these studies confirmed that the number of resected lymph nodes was significantly higher in the pancreaticoduodenectomy with extended lymphadenectomy group. Morbidity and mortality rates were comparable. Postoperative diarrhea in the early months after operation was problematic in patients undergoing extended lymphadenectomy. In none of the studies was a benefit in long-term survival demonstrated. Standard pancreaticoduodenectomy continues to be the operation of choice for adenocarcinoma of the head of the pancreas. Presented at The Society for Surgery of the Alimentary Tract Postgraduate Course “Systematic Reviews of Pancreaticobiliary Disease Customized for the Gastroenterologist and Gastrointestinal Surgeon” on May 20, 2007, Washington, D.C.     

Treatment of Hemorrhoids in Day Surgery: Stapled Hemorrhoidopexy vs Milligan–Morgan Hemorrhoidectomy

Background Recently, it has been demonstrated that surgical treatment of hemorrhoids in a day-care basis is possible and safe. The aim of this study was to compare the Longo stapled hemorrhoidopexy (SH) and the Milligan–Morgan hemorrhoidectomy (MMH). Methods One hundred seventy one patients (95 cases in SH group and 76 cases in MMH group) entered the study: 83 cases were III degree hemorrhoids, 88 IV degree. A priori and a post hoc power analysis were performed. Results, prospectively collected, were compared using chi squared test and student t test. Visual analog scale was used for pain evaluation. Postoperative pain, duration of pain, wound secretion, bleeding, resumption of a normal lifestyle, and postoperative complication were evaluated. Results Surgical time was 28.41 ± 10.78 for MMH and 28.30 ± 13.28 min in SH (P = 0.94). Postoperative pain was not different between MMH and SH during the first two postoperative days (4.73 ± 2.91 vs 5.1 ± 3.048; P = 0.4), during the following 6 days, patients treated with SH had less pain (4.63 ± 2.04 in MMH vs 3.60 ± 2.35 in SH; P = 0.006). In the SH group, seven patients needed further hospital stay for complicated course. SH showed higher incidence of anal fissure compared with MMH (6.3% vs 0%; P = 0.025) but no differences in urinary retention, anal stricture, urgency, or anal hemorrhage. Conclusions This study confirms that SH is associated with less postoperative pain and shorter postoperative symptoms, compared with MMH. SH may be a viable addition to the therapy for hemorrhoids with some advantages in early postoperative pain and some disadvantages in postoperative complications and costs.     

Balance algorithm for cluster randomized trials

Background  

Within cluster randomized trials no algorithms exist to generate a full enumeration of a block randomization, balancing for covariates across treatment arms. Furthermore, often for practical reasons multiple blocks are required to fully randomize a study, which may not have been well balanced within blocks.     

Safety evaluation of surgical materials by cytotoxicity testing

The cytotoxicity of three kinds of commercially available absorbable hemostats [oxidized cellulose (Surgicel, gauze and cotton types), microfibrillar collagen (Avitene), and cotton-type collagen (Integran)] and one adhesion barrier [sodium hyaluronate and carboxymethyl-cellulose membrane (Seprafilm)] were comparatively assessed by a colony assay using V79 cells and a minimum essential medium (MEM) elution assay in combination with a neutral red assay using L929 cells. Strong cytotoxicity was detected for Surgicel by both the MEM elution assay and the colony assay. For Avitene, both methods revealed weak cytotoxicity. For Seprafilm, no cytotoxicity was detected by the MEM elution assay, while a moderate degree of cytotoxicity was observed in the colony assay. For Integran cytotoxicity was not detected by either the MEM elution or the colony assay. The results of the different methods showed some inconsistency in terms of the degree of cytotoxicity of the materials. It is proposed that the combination of two or more sensitive cytotoxicity testing methods for the evaluation of biomaterials is necessary to avoid false-negative results for biomaterials at the preclinical stage. Furthermore, investigation of the correlation between the cytotoxicity and the extraction period of the surgical materials is helpful for predicting the effect of prolonged in vivo use of biomaterials on surrounding cells, tissues, and organs.