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A letter to the editor in response to the article "Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial," by Surya Biere, M.I. van Berge Henegouwen, K.W. Maas and colleagues in the May 19, 2012 issue and response made by the authors in reference to the letter are presented.

Unlabelled: Surgical site infections (SSIs) with Staphylococcus aureus are a recognized adverse event of hip and knee replacements. We evaluated the impact of a program to detect S. aureus nasal carriers before surgery with preoperative decolonization (using mupirocin twice daily for 5 days prior to surgery) of carriers. Nasal swab samples were obtained from patients prior to surgery from 8/1/2003 through 2/28/2005. Samples were tested using real-time PCR technology to detect S. aureus. The group that developed S. aureus SSI was compared to a combined concurrent and historical control for one year following the operation. S. aureus caused 71% of SSIs in the combined control groups. Of the 1495 surgical candidates evaluated, 912 (61.0%) were screened for S. aureus; 223 of those screened (24.5%) were positive and then decolonized with mupirocin. Among the 223 positive and decolonized patients, three (1.3%) developed a SSI. Among the 689 screen-negative patients, four (0.6%) developed SSIs for an overall rate of 0.77%. Among the 583 control patients who were not screened or decolonized, 10 (1.7%) developed S. aureus SSIs. SSIs from other organisms were 0.44% and 0.69%, respectively.Level Of Evidence: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Robot-assisted minimally invasive esophagectomy (RAMIE) for esophageal carcinoma has emerged as the contemporary alternative to conventional laparoscopic minimally invasive (LMIE), hybrid (HE) and open (OE) surgical approaches. No single study has compared all four approaches with a view to postoperative outcomes. A systematic search of electronic databases was undertaken. A network meta-analysis was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-network meta-analysis guidelines. Statistical analysis was performed using R and Shiny. Seven randomised controlled trials (RCTs) with 1063 patients were included. Overall, 32.9% of patients underwent OE (350/1063), 11.0% underwent HE (117/1063), 34.0% of patients underwent LMIE (361/1063), and 22.1% of patients underwent RAMIE (235/1063). OE had the lowest anastomotic leak rate 7.7% (27/350), while LMIE had the lowest pulmonary 10.8% (39/361), cardiac 0.56% (1/177) complications, re-intervention rates 5.08% (12/236), 90-day mortality 1.05% (2/191), and shortest length of hospital stay (mean 11.25 days). RAMIE displayed the lowest 30-day mortality rate at 0.80% (2/250). There was a significant increase in pulmonary complications for those undergoing OE (OR 3.63 [95% confidence interval: 1.4-9.77]) when compared to RAMIE. LMIE is a safe and feasible option for esophagectomy when compared to OE and HE. The upcoming RCTs will provide further data to make a more robust interrogation of the surgical outcomes following RAMIE compared to conventional open surgery to determine equipoise or superiority of each approach as the era of minimally invasive esophagectomy continues to evolve (International Prospective Register of Systematic Reviews Registration: CRD42023438790)., (© The Author(s) 2024. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Neoadjuvant cancer treatment (NCT) reduces both physical fitness and physical activity (PA) levels, which can increase the risk of adverse outcomes in cancer patients. This study aims to determine the effect of exercise prehabilitation on PA and sedentary behavior (SB) in patients undergoing NCT and surgery for esophagogastric malignancies. This study is a randomized pragmatic controlled multi-center trial conducted across three Irish hospitals. Participants were aged ≥18 years scheduled for esophagectomy or gastrectomy and were planned for NCT and surgery. Participants were randomized to an exercise prehabilitation group (EX) that commenced following cancer diagnosis, continued to the point of surgery, and resumed following recovery from surgery for 6 weeks or to usual care (UC) who received routine treatment. The primary outcome measures were PA and SB. Between March 2019 and December 2020, 71 participants were recruited: EX (n = 36) or UC (n = 35). No significant differences were found between the EX group and UC group on levels of PA or SBs across all measured timepoints. Significant decreases in moderate-vigorous physical activity levels (MVPAs) were found between baseline and post-surgery (P = 0.028), pre-surgery and post-surgery (P = 0.001) and pre-surgery and 6-week follow-up (P = 0.022) for all participants. Step count also significantly decreased between pre-surgery and post-surgery (P < 0.001). Baseline aerobic fitness was positively associated to PA levels and negatively associated with SB. Esophagogastric cancer patients have lower than recommended levels of PA at the time of diagnosis and this decreased further following completion of NCT. An optional home- or group-based exercise intervention was not effective in improving PA levels or behaviors across the cancer treatment journey., (© The Author(s) 2024. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus.)

There is currently no consensus as to how to manage esophageal anastomotic leaks. Intervention with endoscopic vacuum-assisted closure (EVAC), stenting, reoperation, and conservative management have all been mooted as potential options. To conduct a systematic review and network meta-analysis (NMA) to evaluate the optimal management strategy for esophageal anastomotic leaks. A systematic review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines with extension for NMA. NMA was performed using R packages and Shiny. In total, 12 retrospective studies were included, which included 511 patients. Of the 449 patients for whom data regarding sex was available, 371 (82.6%) were male, 78 (17.4%) were female. The average age of patients was 62.6 years (standard deviation 10.2). The stenting cohort included 245 (47.9%) patients. The EVAC cohort included 123 (24.1%) patients. The conservative cohort included 87 (17.0%) patients. The reoperation cohort included 56 (10.9%) patients. EVAC had a significantly decreased complication rate compared to stenting (odds ratio 0.23 95%, confidence interval [CI] 0.09;0.58). EVAC had a significantly lower mortality rate than stenting (odds ratio 0.43, 95% CI 0.21; 0.87). Reoperation was used in significantly larger leaks than stenting (mean difference 14.66, 95% CI 4.61;24.70). The growing use of EVAC as a first-line intervention in esophageal anastomotic leaks should continue given its proven effectiveness and significant reduction in both complication and mortality rates. Surgical management is often necessary for significantly larger leaks and will likely remain an effective option in uncontained leaks with systemic features., (© The Author(s) 2024. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The knee joint plays a pivotal role in mobility and stability during ambulatory and standing activities of daily living (ADL). Increased incidence of knee joint pathologies and resulting surgeries has led to a growing need to understand the kinematics and kinetics of the knee. In vivo, in silico, and in vitro testing domains provide researchers different avenues to explore the effects of surgical interactions on the knee. Recent hardware and software advancements have increased the flexibility of in vitro testing, opening further opportunities to answer clinical questions. This paper describes best practices for conducting in vitro knee biomechanical testing by providing guidelines for future research. Prior to beginning an in vitro knee study, the clinical question must be identified by the research and clinical teams to determine if in vitro testing is necessary to answer the question and serve as the gold standard for problem resolution. After determining the clinical question, a series of questions ( What surgical or experimental conditions should be varied to answer the clinical question, what measurements are needed for each surgical or experimental condition, what loading conditions will generate the desired measurements, and do the loading conditions require muscle actuation? ) must be discussed to help dictate the type of hardware and software necessary to adequately answer the clinical question. Hardware (type of robot, load cell, actuators, fixtures, motion capture, ancillary sensors) and software (type of coordinate systems used for kinematics and kinetics, type of control) can then be acquired to create a testing system tailored to the desired testing conditions. Study design and verification steps should be decided upon prior to testing to maintain the accuracy of the collected data. Collected data should be reported with any supplementary metrics (RMS error, dynamic statistics) that help illuminate the reported results. An example study comparing two different anterior cruciate ligament reconstruction techniques is provided to demonstrate the application of these guidelines. Adoption of these guidelines may allow for better interlaboratory result comparison to improve clinical outcomes., Competing Interests: R.C., J.L., C.G., and T.N. receive royalties for simVITRO system licensed through Cleveland Clinic Innovations Department., (Thieme. All rights reserved.)

Introduction: Although the benefits of post-operative rehabilitation in cancer surgery are well established, the role of prehabilitation is less defined. Oesophagogastric cancers present a unique opportunity to study the impact of prehabilitation during the neoadjuvant window, whether with chemotherapy or chemoradiotherapy (NCT) in patients who are frequently nutritionally depleted. This trial examines the impact of a community-based exercise program on patient fitness during and after the neoadjuvant window., Methods: A pragmatic, randomized controlled multi-centre trial was undertaken in three centres. Inclusion criteria were patients aged ≥ 18 years planned for NCT and esophagectomy or gastrectomy. Participants were randomized 1:1 to an exercise prehabilitation group (EX) or to usual care (UC). The primary endpoint was cardiorespiratory fitness between baseline and pre-surgery timepoint using the 6-min walk test. Secondary endpoints included hand dynamometer, 10-sec sit to stand, activity behaviour, body mass index, semi-structured interviews, questionnaires assessing quality of life, surgical fear, general self-efficacy and mastery., Results: Between March 2019 and December 2020, 71 participants were recruited: EX (n=36) or UC (n=35). From baseline to pre-surgery, the difference-in-difference for EX showed a significant improvement in 6MWT of 50.7m (P=0.05) compared to UC [mean (SD): 522.1m (+/-104.3) to 582.1m (+/-108) vs. 497.5m (+/-106.3) to 506.0 m (+/-140.4). There was no statistically significant DID for secondary outcome measures., Conclusions: This community exercise prehabilitation program significantly improves physical fitness for surgery, is feasible and provides a standardized framework for prescription of exercise in esophagogastric cancer patients undergoing NCT., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Optimal pain control following esophagectomy remains a topic of contention. The aim was to perform a systematic review and network meta-analysis (NMA) of randomized clinical trials (RCTs) evaluating the analgesia strategies post-esophagectomy. A NMA was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-NMA guidelines. Statistical analysis was performed using Shiny and R. Fourteen RCTs which included 565 patients and assessed nine analgesia techniques were included. Relative to systemic opioids, thoracic epidural analgesia (TEA) significantly reduced static pain scores at 24 hours post-operatively (mean difference (MD): -13.73, 95% Confidence Interval (CI): -27.01-0.45) (n = 424, 12 RCTs). Intrapleural analgesia (IPA) demonstrated the best efficacy for static (MD: -36.2, 95% CI: -61.44-10.96) (n = 569, 15 RCTs) and dynamic (MD: -42.90, 95% CI: -68.42-17.38) (n = 444, 11 RCTs) pain scores at 48 hours. TEA also significantly reduced static (MD: -13.05, 95% CI: -22.74-3.36) and dynamic (MD: -18.08, 95% CI: -31.70-4.40) pain scores at 48 hours post-operatively, as well as reducing opioid consumption at 24 hours (MD: -33.20, 95% CI: -60.57-5.83) and 48 hours (MD: -42.66, 95% CI: -59.45-25.88). Moreover, TEA significantly shortened intensive care unit (ICU) stays (MD: -5.00, 95% CI: -6.82-3.18) and time to extubation (MD: -4.40, 95% CI: -5.91-2.89) while increased post-operative forced vital capacity (MD: 9.89, 95% CI: 0.91-18.87) and forced expiratory volume (MD: 13.87, 95% CI: 0.87-26.87). TEA provides optimal pain control and improved post-operative respiratory function in patients post-esophagectomy, reducing ICU stays, one of the benchmarks of improved post-operative recovery. IPA demonstrates promising results for potential implementation in the future following esophagectomy., (© The Author(s) 2024. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Arborists work in high-risk environments, particularly when climbing trees, where a combination of grip strength and resistance to psychological stress are important attributes for safety. This study investigated the physical and cognitive activities of arborists combined with selected workload factors such as blood pressure, pulse, handgrip strength, and other anthropometric measurements, including manual dexterity and spatial awareness. The sample included 10 participants aged 17-48 years. Blood pressure was negatively correlated with handgrip strength after the activity had been performed. Different types of arborist activities led to various types of physiological feedback, as shown by the analysis of variance. According to our results, there is a difference between physical workloads, associated with activities such as tree felling, tree climbing, or chainsaw maintenance, and cognitive workloads, such as supervision or observation, in relation to blood pressure. Blood pressure was higher for activities that involved a cognitive workload. Before and after any activity, handgrip strength was positively associated with hand size. After any activity, greater changes in handgrip strength of the participant's right hand were associated with needing more time to successfully complete a peg test, which represents a greater cognitive burden. Our results suggest that arborists deal with physical activities such as tree felling, tree climbing, working with a chainsaw, and mental activities (supervising or observing) which were identified as two different groups correlated with hand grip strength, blood pressure, manual dexterity, and spatial awareness. In conclusion, the tree-climbing activity appeared to be the least stressful, and psychological stress appeared to have a greater impact on the health of observers and supervisors in the study group. This can be applied to other professions in many fields, including industries where workers face both physical and cognitive workloads., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Introduction: There is uncertainty regarding the optimal mesh fixation techniques for laparoscopic ventral and incisional hernia repair., Aim: To perform a systematic review and network meta-analysis of randomised control trials (RCTs) to investigate the advantages and disadvantages associated with absorbable tacks, non-absorbable tacks, non-absorbable sutures, non-absorbable staples, absorbable synthetic glue, absorbable sutures and non-absorbable tacks, and non-absorbable sutures and non-absorbable tacks., Methods: A systematic review was performed as per PRISMA-NMA guidelines. Odds ratios (ORs) and mean differences (MDs) were extracted to compare the efficacy of the surgical approaches., Results: Nine RCTs were included with 707 patients. Short-term pain was significantly reduced in non-absorbable staples (MD; -1.56, confidence interval (CI); -2.93 to -0.19) and non-absorbable sutures (MD; -1.00, CI; -1.60 to -0.40) relative to absorbable tacks. Recurrence, length of stay, operative time, conversion to open surgery, seroma and haematoma formation were unaffected by mesh fixation technique., Conclusion: Short-term post-operative pain maybe reduced by the use of non-absorbable sutures and non-absorbable staples. There is clinical equipoise between each modality in relation to recurrence, length of stay, and operative time., Competing Interests: Declaration of competing interest This manuscript has not been published and is not under consideration for publication elsewhere. All authors have declared no conflicts of interest. This research received no external funding. The authors understand that a moderate fee (APC) is payable to cover the costs associated with publication., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background and Objectives: Optimal surgical management for gastric cancer remains controversial. We aimed to perform a network meta-analysis (NMA) of randomized clinical trials (RCTs) comparing outcomes after open gastrectomy (OG), laparoscopic-assisted gastrectomy (LAG), and robotic gastrectomy (RG) for gastric cancer., Methods: A systematic search of electronic databases was undertaken. An NMA was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-NMA guidelines. Statistical analysis was performed using R and Shiny., Results: Twenty-two RCTs including 6890 patients were included. Overall, 49.6% of patients underwent LAG (3420/6890), 46.6% underwent OG (3212/6890), and 3.7% underwent RG (258/6890). At NMA, there was a no significant difference in recurrence rates following LAG (odds ratio [OR] 1.09, 95% confidence interval [CI] 0.77-1.49) compared with OG. Similarly, overall survival (OS) outcomes were identical following OG and LAG (OS: OG, 87.0% [1652/1898] vs. LAG: OG, 87.0% [1650/1896]), with no differences in OS in meta-analysis (OR 1.02, 95% CI 0.77-1.52). Importantly, patients undergoing LAG experienced reduced intraoperative blood loss, surgical incisions, distance from proximal margins, postoperative hospital stays, and morbidity post-resection., Conclusions: LAG was associated with non-inferior oncological and surgical outcomes compared with OG. Surgical outcomes following LAG and RG superseded OG, with similar outcomes observed for both LAG and RG. Given these findings, minimally invasive approaches should be considered for the resection of local gastric cancer, once surgeon and institutional expertise allows., (© 2023. The Author(s).)

Introduction: The emergence of the novel coronavirus Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and the coronavirus disease COVID-19 has impacted enormously on non-COVID-19-related hospital care. Curtailment of intensive care unit (ICU) access threatens complex surgery, particularly impacting on outcomes for time-sensitive cancer surgery. Oesophageal cancer surgery is a good example. This study explored the impact of the pandemic on process and short-term surgical outcomes, comparing the first wave of the pandemic from April to June in 2020 with the same period in 2019., Methods: Data from all four Irish oesophageal cancer centres were reviewed. All patients undergoing resection for oesophageal malignancy from 1 April to 30 June inclusive in 2020 and 2019 were included. Patient, disease, and peri-operative outcomes (including COVID-19 infection) were compared., Results: In 2020, 45 patients underwent oesophagectomy, and 53 in the equivalent period in 2019. There were no differences in patient demographics, co-morbidities, or use of neoadjuvant therapy. The median time to surgery from neoadjuvant therapy was 8 weeks in both 2020 and 2019. There were no significant differences in operative interventions between the two time periods. There was no difference in operative morbidity in 2020 and 2019 (28% vs 40%, p = 0.28). There was no in-hospital mortality in either period. No patient contracted COVID-19 in the perioperative period., Conclusions: Continuing surgical resection for oesophageal cancer was feasible and safe during the COVID-19 pandemic in Ireland. The national response to this threat was therefore successful by these criteria in the curative management of oesophageal cancer., (© 2021. Royal Academy of Medicine in Ireland.)

Background: In early 2020, the COVID-19 pandemic significantly altered management of surgical patients globally. International guidelines recommended that non-operative management be implemented wherever possible (e.g. in proven uncomplicated appendicitis) to reduce pressure on healthcare services and reduce risk of peri-operative viral transmission. We sought to compare our management and outcomes of appendicitis during lockdown vs a non-pandemic period., Methods: All presentations to our department with a clinical diagnosis of acute appendicitis between 12/03/2020 and 30/06/2020 were compared to the same 110-day period in 2019. Quantity and severity of presentations, use of radiological investigations, rate of operative intervention and histopathological findings were variables collected for comparison., Results: There was a reduction in appendicitis presentations (from 74 to 56 cases), and an increase in radiological imaging (from 70.27% to 89.29%) (P = 0.007) from 2019 to 2020. In 2019, 93.24% of patients had appendicectomy, compared to 71.42% in 2020(P < 0.001). This decrease was most pronounced in uncomplicated cases, whose operative rates dropped from 90.32% to 62.5% (P = 0.009). Post-operative histology confirmed appendicitis in 73.9% in 2019, compared to 97.5% in 2020 (P = 0.001). Normal appendiceal pathology was reported for 17 cases (24.64%) in 2019, compared to none in 2020 (P < 0.001) - a 0% negative appendicectomy rate (NAR)., Discussion: The 0% NAR in 2020 is due to a combination of increased CT imaging, a higher threshold to operate, and is impacted by increased disease severity due to delayed patient presentation. This study adds to growing literature promoting routine use of radiological imaging to confirm appendicitis diagnosis. As we enter a second lockdown, patients should be encouraged to avoid late presentations, and surgical departments should continue using radiological imaging more liberally in guiding appendicitis management., Competing Interests: Declaration of competing interest The authors whose names are listed above certify that there are no affiliations with or involvement in any organisation or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript., (Copyright © 2021 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Introduction: Textbook outcome (TBO) is a composite measure of a number of peri-operative and clinical outcomes in oesophagogastric malignancy. It has previously been shown that TBOs are associated with improved overall survival in both oesophageal and gastric cancer. The influence of a minimally invasive approach (MIA) on TBO is not well defined. The purpose of this study is to validate TBO in our population, examine the influence of a MIA on achieving a TBO, and the impact of TBO on long-term survival., Methods: 269 patients undergoing oesophagectomy and 258 patients undergoing subtotal or total gastrectomy were included in this study. Demographic, clinical and pathological differences between patients with and without a TBO were compared using univariable and multivariable analysis. Overall survival for those with and without a TBO was examined. The influence of MIA on overall survival and TBO was determined using Cox proportional hazard models., Results: Patients undergoing oesophagectomy and gastrectomy were significantly more likely to achieve a TBO when MIA was used (p = 0.01 and 0.001 respectively). When MIA is included as an outcome measure patients achieving a TBO show improved overall survival in both oesophageal and gastric cancer. MIA, clear resection margins and no unplanned admission to critical care are the strongest predictors of overall survival from the putative bundle of TBO parameters., Conclusion: Minimally invasive surgery is associated with improved TBO. Completion of a minimally invasive approach should be considered for inclusion as a textbook parameter., Competing Interests: Declaration of competing interest None., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: The Patient-Reported Outcomes Measurement Information System (PROMIS)-Plus-Osteoarthritis of the Knee (OAK) profile integrates universal PROMIS items with knee-specific items across 13 domains. We evaluated the psychometric properties of a subset of six domains associated with quality of life in people with OAK., Study Design and Setting: In a cross-sectional study of OAK patients (n=600), we estimated reliability using Pearson and Spearman correlations with Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores and known-groups validity with PROMIS Global Health. Measure responsiveness was tested via paired t-tests in a longitudinal study (n=238), pre/post total knee replacement., Results: Across the six domains, internal consistency reliability (Cronbach's alpha) was 0.77-0.95 and test-retest reliability (intraclass correlation coefficients) was ≥0.90. Correlations with Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores and PROMIS Global supported convergent and divergent validity. Known-groups validity testing revealed better scores in all domains for high vs. low global status groups, and knee-specific items added value in physical function and pain. All domains reflected (p<0.001) better health status scores at follow up., Conclusion: The six PROMIS-Plus-OAK profile domains demonstrated good psychometric characteristics. The measure integrates universal and knee-specific content to provide enhanced relevance, measurement precision and efficient administration for patient care and clinical research., (Copyright © 2021. Published by Elsevier Inc.)

Background: Obesity and type 2 diabetes mellitus (T2DM) represent significant healthcare burdens. Surgical management is superior to traditional medical therapy. Laparoscopic sleeve gastrectomy (LSG) and gastric bypass (both Roux-en-Y (RYGB) and one anastomosis gastric bypass (OAGB) are the most commonly performed metabolic procedures. It remains unclear which gives the optimal quality-of-life pay-off in the context of T2DM. This study compares LSG, RYGB, and OAGB in the management of T2DM and obesity using modeled decision analysis. Alternative approaches were assessed considering efficacy of interventions, post-operative complications, and quality of life outcomes to determine the optimal approach., Methods: Modeled decision analysis was performed from the patent's perspective comparing best medical management (MM), SG, RYGB, OAGB, and LAGB. The base case is a 40-year-old female with a body mass index (BMI) of 40 and T2DM. Input variables were calculated based on published decision analyses and a literature review. Utilities were based on previous studies. Sensitivity analysis was performed. The payoff was quality-adjusted life years (QALYs) 5 years from intervention. TreeAge Pro modeling software was used for analysis., Results: In 5-years post-procedure, OAGB gave the optimal QALY payoff of 3.65 QALYs (reviewer 2). RYGB gave 3.47, SG gave 3.08, LAGB gave 2.62 and MM 2.45 QALYs. Three input variables proved sensitive. RYGB is optimal if its metabolic improvement rates exceed 86%. It is also optimal if metabolic improvement rates in OAGB drop below 71.8% or if the utility of OAGB drops below 0.759., Conclusion: OAGB gives the optimal QALY payoff in treatment of T2DM. RYGB and SG also improve metabolic outcomes and remain viable options in selected patients.

Background: Obesity is a chronic disease associated with significant morbidity and mortality. Bariatric surgery has been shown to significantly reduce both morbidity and mortality. Numerous surgical strategies exist, but the most frequently used worldwide are adjustable gastric banding, sleeve gastrectomy (SG), and Roux-en-Y gastric bypass (RYGB). It is not clear which of these strategies provides the optimal quality-of-life pay-off., Objective: Modeled decision analysis allows comparison of different treatment interventions allowing for plausible differences in input variables. This facilitates establishment of the optimal intervention under numerous conditions., Setting: University Hospital, Ireland., Methods: Modeled decision analysis was performed from the patient's perspective comparing best medical therapy, adjustable gastric banding, SG, and RYGB. Input variables were calculated based on previously published decision analyses and a systematic search of obesity-related literature. Utilities were based on previously published studies. One-way sensitivity analysis was performed. Sensitive variables underwent 3-way analysis., Results: The optimal treatment strategy in the base case was RYGB with a quality-adjusted life-year payoff (QALY) of 1.53 QALYs at 2 years postprocedure. Sleeve gastrectomy provided 1.49 QALYs. Medical therapy and adjustable gastric banding provided .98 and .96 QALYs, respectively. Rate of complications in RYGB and the utility of SG and RYGB proved sensitive. If complication rates are high, SG becomes the optimal strategy. Sensitive thresholds were established for the utility of SG and RYGB at .804 and .78, respectively., Conclusion: SG and RYGB offer similar outcomes in terms of QALY payoffs. Decision making should be in line with institutional and patient preference., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Despite having considerable influence over resource allocation clinicians possess poor knowledge of healthcare costs. This study evaluated surgeons' cost-awareness with regard to surgical equipment and assessed attitudes towards health economics training using survey format., Materials and Methods: An online survey was distributed to 326 surgeons across a range of specialties in Ireland. Respondents were asked about their surgical expertise, previous training in health economics, and its role in the surgical curriculum. They were also asked to estimate the recommended retail price (RRP) of 17 commonly used items of surgical equipment. Answers within ±25% of the RRP were considered correct., Results: Of 140 respondents, 62 (44.3%) were on a surgical training scheme and 16 (11.4%) were consultants. Overall, surgeons correctly estimated the RRP of only 14.0% of items. There was no difference in accuracy between surgeons in later years of training compared to their junior counterparts (13.1 ± 8.8% versus 15.0 ± 8.8%, p = 0.115). The highest individual score was six out of 17 items correctly estimated. Participants overestimated the cost of low-cost items by 347.7% and underestimated the cost of high-cost items by 35.5%. Only 5.7% of participants had received undergraduate training in health economics but 75.0% felt it should be included in the curriculum. Over two-thirds said their practice would change if they had better knowledge of the cost of surgical equipment., Conclusion: The majority of surgeons receive little training in health economics and have poor knowledge of the cost of surgical equipment. Most would welcome more training at both an undergraduate and postgraduate level. An opportunity exists to promote cost awareness in the operating room, which could lead to a reduction in waste and improved use of resources., (Copyright © 2018 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Enhanced recovery after surgery (ERAS) guidelines, fast-track protocols, and alternative clinical pathways have been widely promoted in a variety of disciplines leading to improved outcomes in post-operative morbidity and length of stay (LOS). This meta-analysis assesses the implications of standardized management protocols in bariatric surgery., Methods: The PRISMA guidelines were adhered to. Databases were searched with the application of pre-defined inclusion and exclusion criteria. Results were reported as mean differences or pooled odds ratios (OR) with 95% confidence intervals (95% CI). Individual protocols and surgical approaches were assessed through subgroup analysis, and sensitivity analysis of methodological quality was performed., Results: A total of 1536 studies were screened; 13 studies were eventually included for meta-analysis involving a total of 6172 patients. Standardized perioperative techniques were associated with a savings of 19.5 min in operative time (p < 0.01), as well as a LOS which was shortened by 1.5 days (p < 0.01). Pooled post-operative morbidity rates also favored enhanced recovery care protocols (OR 0.7%, 95% CI 0.6-0.9%, p < 0.01)., Conclusion: Bariatric surgery involves a complex cohort of patients who require high-quality evidence-based care to improve outcomes. Consensus guidelines on the feasibility of ERAS and alternative clinical pathways are required in the setting of bariatric surgery.

Background: Endoscopic ultrasound-guided gallbladder drainage is a novel method of treating acute cholecystitis in patients deemed too high risk for surgery. It involves endoscopic stent placement between the gallbladder and the alimentary tract to internally drain the infection and is an alternative to percutaneous cholecystostomy (PC). This meta-analysis assesses the clinical outcomes of high-risk patients undergoing endoscopic drainage with an acute cholecystoenterostomy (ACE) compared with PC in acute cholecystitis., Methods: A literature search was performed using the preferred reporting items for systematic reviews and meta-analyses guidelines. Databases were searched for studies reporting outcomes of patients undergoing ACE or PC. Results were reported as mean differences or pooled odds ratios (OR) with 95% confidence intervals (95% CI)., Results: A total of 1593 citations were reviewed; five studies comprising 495 patients were ultimately selected for analysis. There were no differences in technical or clinical success rates between the two groups on pooled meta-analysis. ACE had significantly lower post-procedural pain scores (mean difference - 3.0, 95% CI - 2.3 to - 3.6, p < 0.001, on a 10-point pain scale). There were no statistically significant differences in procedure complications between groups. Re-intervention rates were significantly higher in the PC group (OR 4.3, 95% CI 2.0-9.3, p < 0.001)., Conclusion: ACE is a promising alternative to PC in high-risk patients with acute cholecystitis, with equivalent success rates, improved pain scores and lower re-intervention rates, without the morbidities associated with external drainage.

Study Objective: The use of a double check by 2 nurses has been advocated as a key error-prevention strategy. This study aims to determine how often a double check is used for high-alert medications and whether it increases error detection., Methods: Emergency department and ICU nurses worked in pairs to care for a simulated patient. Nurses were randomized into single- and double-check groups. Errors intentionally introduced into the simulation included weight-based dosage errors and wrong medication vial errors. The evaluator recorded whether a double check was used, whether errors were detected, and observational data about nurse behavior during the simulation., Results: Forty-three pairs of nurses consented to enroll in the study. All nurses randomized to the double-check group used a double check. In the single-check group, 9% of nurses detected the weight-based dosage error compared with 33% of nurses in the double-check group (odds ratio 5.0; 95% confidence interval 0.90 to 27.74). Fifty-four percent of nurses in the single-check group detected the wrong vial error compared with 100% of nurses in the double-check group (odds ratio 19.9; 95% confidence interval 1.0 to 408.5)., Conclusion: Our study demonstrates that nurses use double checks before administering high-alert medications. Use of a double check increases certain error detection rates in some circumstances, but not others. Both techniques missed many errors. In some cases, the second nurse actually dissuaded the first nurse from acting on the error., (Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

The incidence of wrong-site surgery in orthopaedics is unknown. This is due to a lack of data regarding the exact numbers of surgical procedures performed and a lack of a uniform mandatory error reporting infrastructure. Twenty-one percent of hand surgeons, 50% of spinal surgeons, and 8.3% of knee surgeons surveyed have reported performing at least one wrong-site surgery during their career. Every orthopaedic surgeon, no matter his or her orthopaedic subspecialty, is at risk for completing a wrong-site surgery during his or her career. Prevention of wrong-site surgery should remain a priority for the orthopaedic community. Surgeon leadership, commitment, and vigilance are critical to improve patient safety by ensuring that validated safety processes are used in all orthopaedic settings including effective surgical team communication, checklists, and routine collection and analysis of quality and safety data.

Background: Early failure in cemented total knee replacement (TKR) due to aseptic loosening is uncommon. A small number of early failures requiring revision were observed at one hospital due to observed cement-implant fixation failure. The purpose of this case series is to report and identify possible causes for these early failures., Methods: Between May 2005 and December 2010, 3048 primary TKRs were performed over a five-year period of time by six surgeons. Two total knee systems were used during this period of time. Nine early failures were observed in eight patients. High viscosity cement (HVC) was used in all these cases., Results: Aseptic loosening of the tibial component was observed in all nine early total knee failures. The high viscosity bone cement was noted to be non-adherent to the tibial trays at the time of revision surgery. HVC was used in all these cases., Conclusions: Properties of HVC may contribute to make it more susceptible to early failure in a small number of TKRs. HVC in total hip replacement (THR) has been associated with cement micro-fractures, cement debris generation and early implant failure. The mechanical properties of HVC may similarly contribute to early failure at the cement-implant interface in a small percentage TKRs., (Published by Elsevier B.V.)

Background: Perioperative oncologic treatments provide a survival benefit for junctional and gastric adenocarcinoma (JGA) and esophageal cancer (EC). Whether neoadjuvant therapy toxicity (NTT) correlates with increased perioperative risk remains unclear. We aimed to evaluate the impact of grade III/IV NTT on postoperative and oncologic outcomes in resected upper gastrointestinal malignancies., Methods: A multicenter retrospective analysis was performed on consecutive patients who benefited from neoadjuvant chemo(radio)therapy followed by surgery between 1997 and 2010 for JGA (first cohort, n = 653) and for EC (second cohort, n = 640). Data between patients who experienced NTT were compared to those who did not., Results: NTT was associated with higher postoperative mortality after resection of JGA (P = 0.001) and after esophagectomy (P < 0.001), more non-R0 resections (JGA P = 0.019, EC P = 0.024), a decreased administration of adjuvant treatment among the JGA cohort (P = 0.012), and higher surgical morbidity (JGA P = 0.005, EC P = 0.020). Median survival was reduced in patients who experienced NTT in both cohorts (JGA P = 0.018, EC P = 0.037). After adjustment on confounding variables, NTT was independently associated with postoperative mortality in both cohorts (P ≤ 0.007)., Conclusions: NTT is a predictor of postoperative mortality, correlates with higher postoperative morbidity, and negatively affects oncologic outcomes for upper gastrointestinal carcinomas.

Background: Although the signet ring cell histologic subtype (SRC) is an independent predictor of poor prognosis in advanced gastric adenocarcinomas (GA), its prognostic value in early GA remains highly controversial. The aim of the study was to evaluate the prognostic impact of SRC in mucosal and submucosal GAs., Methods: Based on a multicenter cohort of 3,010 patients operated on for GA between January 1997 and January 2010, patients with pTis or pT1 tumors were extracted and analyzed comparatively between the SRC and non-SRC groups. The primary objective was to compare the 5-year survival rate between groups., Results: Among 421 patients with a pTis or pT1 tumor, 104 (25%) were SRC and 317 (75%) were non-SRC. Demographic variables were comparable between groups, except median age, which was less in the SRC group (59.6 vs 68.8 years; P < .001). Submucosal involvement was more frequent in the SRC group (94% vs 85%; P = .043), whereas lymph node involvement and number of invaded nodes were comparable between the 2 groups. When comparing SRC and non-SRC, recurrence rates (6% vs 9%; P = .223) and sites of recurrence were similar. The 5-year overall survival benefit in SRC patients (85% vs 76%, respectively; P = .035), was not evident when considering exclusively disease-specific survival or in multivariable analysis., Conclusion: Contrary to more advanced GA, SRC morphologic subtype is not a negative prognostic factor in early GA. Better survival identified in some reports may be related to the younger age in SRC patients., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Importance: Postoperative mortality after junctional and gastric adenocarcinoma resection remains a significant issue., Objective: To identify factors predictive of mortality within 30 days of junctional and gastric adenocarcinoma resection in a large national multicenter cohort., Design: A retrospective study collecting data from a multicenter database of patients who underwent resection for junctional and gastric adenocarcinoma from January 1, 1997, through January 31, 2010. A stepwise logistic regression model was built to identify, by multivariate analysis, variables independently predictive of 30-day postoperative mortality (POM)., Setting: Nineteen university teaching hospitals in France., Participants: Two thousand six hundred seventy patients with available data., Main Outcome Measures: The primary end point was POM. Secondary end points included (1) late mortality (30-90 days after resection) and (2) postoperative morbidity., Results: One thousand eight hundred ninety-six patients (71.01%) had gastric adenocarcinoma and 774 (28.99%) had junctional tumors. Neoadjuvant treatment was given to 655 patients (24.53%), and 114 patients (4.27%) died within 30 days of surgery. Postoperative mortality was higher in patients who experienced grades III and IV toxic effects during neoadjuvant treatment compared with those who did not (8.7% vs 2.9%, respectively; P = .007). Multivariate analysis revealed metastatic disease at diagnosis (odds ratio, 9.13 [95% CI, 3.29-25.35]; P < .001) and poor tolerance of neoadjuvant treatment (3.33 [1.25-8.85]; P = .02) as being independently predictive of POM. Centers performing at least 10 resections per year were found to be protective against POM (odds ratio, 0.29 [95% CI, 0.12-0.72]; P = .008)., Conclusions and Relevance: This large national cohort study confirms that advanced disease heightens the risk of POM; centralization of junctional and gastric adenocarcinoma resection is warranted. The novel finding that grades III to IV toxic effects during neoadjuvant therapy increase POM has significant implications for decision making in this subgroup of patients., Trial Registration: clinicaltrials.gov Identifier: NCT01249859.

Introduction: Evidence-based medicine continues to have an increasingly important impact on all surgical departments, with the art of publication becoming a skill in its own right and occupying an ever more central role. However, it remains a challenge for any surgeon to publish their work., Purpose: The aims of this educational review are to understand why, what and where surgeons should publish and to provide surgeons with a guide regarding the publication process and the rules to be adhered to., Methodology: This review targets (1) any surgeon beginning their scientific publication activity, (2) more experienced surgeons who wish to optimise their ability to have their work published and finally (3) leaders of research departments who aspire to improve the quality of their publications and their research productivity and profile.

Introduction: The recent introduction of a Surgical Safety Checklist has significantly reduced the morbidity and mortality of surgery. Such a simple measure that can impact so highly on surgical outcomes causes all surgeons to pause for thought. This paper documents the introduction of a 10-step intraoperative surgical checklist (ISC) to standardize performance, decision-making, and training during laparoscopic cholecystectomy (LC). The checklist's impact on conversion rates to open cholecystectomy (OC) is presented., Methods: In 2004, a 10-step ISC was introduced by a single consultant surgeon for the performance of LCs. Data were collected comparing LCs between 1999-2003 (period 1) and 2004-2008 (period 2). Data on sex, age, American Society of Anesthesiology grade, previous abdominal surgery, severity of gallbladder pathology, and conversion to OC were recorded. The chi-squared test with Yates correction was used to compare groups., Results: In total, 637 LCs were performed, 277 during period 1 and 360 during period 2. Risk factors for conversion (gender, age, previous abdominal surgery, and severity of gallbladder pathology) were not significantly different in the two periods studied. The overall conversion rate to OC fell significantly in period 2 (p=0.001). Subgroup analysis also showed a significant reduction in conversion rates in female patients (p=0.002) and patients with grades III and IV gallbladder disease (p=0.001)., Conclusions: The introduction of a 10-step ISC was temporally related to reduced conversion rates to OC. The standardization of a frequently performed operation such as a LC that could potentially lead to an impact as great the one we observed warrants further attention in prospective, appropriately designed studies.

Despite a decline in the overall incidence, gastric adenocarcinoma remains the second most common cause of cancer death worldwide and thus a significant global health problem. Even in early-stage locoregional confined disease the 5-year survival rarely exceeds 25-35 %. Randomized trials have demonstrated a benefit from neoadjuvant and perioperative chemotherapy. However the optimal approach in individual patients is not clear and remains controversial. A consistent finding is that patients who have a histopathological response to neoadjuvant therapy are more likely to receive a survival benefit. These clinical data provide a strong argument for the urgent development of methods to predict histopathological response to neoadjuvant therapies for gastric adenocarcinomas. Published data demonstrate that clinico-pathological features (tumour histology and location), imaging through metabolic response by FDG-PET and tissue/molecular biomarkers may all have a predictive value for neoadjuvant therapies. However it is still uncertain from published data whether or not they will be useful for clinical decision making in individual patients. Existing candidate biomarkers need to be properly qualified and validated and novel biomarkers are required and an optimal approach should involve the combination and integration of clinical, imaging, pathological and molecular biomarkers.

Oesophagectomy is one of the most challenging surgical operations. Potential for morbidity and mortality is high. Minimally invasive techniques have been introduced in an attempt to reduce postoperative complications and recovery times. Debate continues over whether these techniques decrease morbidity and whether the quality of the oncological resection is compromised. Globally, minimally invasive oesophagectomy (MIO) has been shown to be feasible and safe, with outcomes similar to open oesophagectomy. There are no controlled trials comparing the outcomes of MIO with open techniques, just a few comparative studies and many single institution series from which assessments of the current role of MIO have been made. The reported improvements of MIO include reduced blood loss, shortened time in high dependency care and decreased length of hospital stay. In comparative studies there is no clear reduction in respiratory complications, although larger series suggest that MIO may have a benefit. Although MIO approaches report less lymph node retrieval compared with open extended lymphadenectomy, MIO cancer outcomes are comparable. MIO will be a major component of the future oesophageal surgeons' armamentarium, but should continue to be carefully assessed. Randomized trials comparing MIO versus open resection in oesophageal cancer are urgently needed: two phase III trials are recruiting, the TIME and the MIRO trials.

Background: The School Health Policies and Programs Study (SHPPS) 2006 examined 8 components of school health programs: health education, physical education and activity, health services, mental health and social services, nutrition services, healthy and safe school environment, faculty and staff health promotion, and family and community involvement. All 8 components were assessed at the state, district, and school levels. Two components, health education and physical education and activity, also were assessed at the classroom level., Methods: Computer-assisted telephone interviews or self-administered mail questionnaires were completed by state education agency personnel in all 50 states plus the District of Columbia and among a nationally representative sample of school districts (n=538). Computer-assisted personal interviews were conducted with personnel in a nationally representative sample of elementary, middle, and high schools (n=1103), with a nationally representative sample of teachers of required health education classes or courses (n=912), and with a nationally representative sample of teachers of required physical education classes or courses (n=1194)., Results: This article provides a detailed description of the development of the questionnaires; sampling; data collection; and data cleaning, weighting, and analysis., Conclusions: SHPPS 2006 is the largest and most comprehensive study of school health programs ever conducted. Fielding a study of this magnitude provides many challenges, and several recommendations for future studies emerged from the experience.

Family violence, in the form of child abuse, adult domestic violence, and elder abuse, is a major public health problem in the United States. It leads to physical and psychological disability, loss of productivity, and even death. It can perpetuate itself through successive generations and contributes to the escalating costs of health care in this country. Family violence affects a significant proportion of the US population either as direct victims or as witnesses of abuse. As a result, orthopaedic surgeons are undoubtedly treating family violence victims, knowingly or unknowingly in their practices. Therefore, it is important that orthopaedic surgeons understand that victims of family violence often present for orthopaedic care in both emergency department and office or clinic settings. It is equally important that orthopaedic surgeons acquire the skills that are needed for the appropriate evaluation, diagnosis, treatment, and referral of such victims.

The neural correlates of retrieval orientation-the differential processing of retrieval cues according to the form of the sought-for information-and retrieval effort were investigated in a factorial design. ERPs elicited by test words were recorded during four recognition memory tests. Orientation was manipulated by varying study material: The study phases preceding two of the tests employed pictures, whereas the study phases preceding the other two tests employed words. Effort was manipulated by varying difficulty, using a combination of the variables of length of study list and study-test interval. ERPs elicited by correctly classified new test words were sensitive to both the study material and, to a much lesser extent, the difficulty of manipulations. Whereas difficulty effects onset early and were short-lived, the effects of study material onset later, extended for several hundred milliseconds, and did not vary according to difficulty. It was concluded that retrieval orientation exerts a major influence on the processing of recognition memory test items.