Search

Right hemicolectomy with complete mesocolic excision (CME) requires the removal of an intact mesocolic envelope. The study aimed to determine, on the basis of macroscopic and microscopic anatomical studies, the optimal surgical dissection planes for CME to preserve fascial integrity. Unequivocal anatomical nomenclature was applied to describe the retrocolic fascial system and compared to frequently used eponyms (Toldt, Gerota, Fredet, Treitz).Stepwise macroscopic dissections, cross-section studies and histological analysis were performed on body donors to identify the components of the retrocolic fascial system. Based on these anatomical findings, the optimal surgical dissection planes for CME were validated in laparoscopic training courses on body donors and in robot-assisted surgical procedures in patients.The mesocolic tissue and lymphovascular pedicles were enveloped by the ventral and dorsal mesocolic leaf (mesocolic fascia). The mesocolic fascia was attached to the parietal peritoneal fascia ("fascia of Toldt") along the parieto-mesocolic interface, and further cranially to the pre-duodenopancreatic fascia along the mesocolic-duodenopancreatic interface ("space of Fredet"). Dorsally, the parietal peritoneal fascia was separated from the anterior renal fascia ("fascia of Gerota") by the parieto-renal interface. Dissection along this interface in front of the anterior renal fascia followed by incision of the parietal peritoneal fascia at the duodenal border and opening the mesocolic-duodenopancreatic interface yielded the best macroscopic appearance of specimens and was considered optimal for CME.The retrocolic fascial system as well as the surgical dissection planes for CME can be described by clearly defined anatomical terms rather than potentially confusing eponyms.

The following article summarizes technical aspects of how to operate in the mesentery during complete mesocolic excision (CME). Increasingly, CME is being adopted and as such it is important to establish the anatomical basis of the techniques involved. This review thus serves to provide that foundation and explains the surgical techniques built on it.

Background Long-term pouch surveillance outcomes for familial adenomatous polyposis (FAP) are unknown. We aimed to quantify surveillance outcomes and to determine which of selected possible predictive factors are associated with pouch dysplasia. Methods Retrospective analysis of collected data on 249 patients was performed, analyzing potential risk factors for the development of adenomas or advanced lesions ( ≥ 10 mm/high grade dysplasia (HGD)/cancer) in the pouch body and cuff using Cox proportional hazards models. Kaplan–Meier analyses included landmark time-point analyses at 10 years after surgery to predict the future risk of advanced lesions. Results Of 249 patients, 76 % developed at least one pouch body adenoma, with 16 % developing an advanced pouch body lesion; 18 % developed an advanced cuff lesion. Kaplan–Meier analysis showed a 10-year lag before most advanced lesions developed; cumulative incidence of 2.8 % and 6.4 % at 10 years in the pouch body and cuff, respectively. Landmark analysis suggested the presence of adenomas prior to the 10-year point was associated with subsequent development of advanced lesions in the pouch body (hazard ratio [HR] 4.8, 95 %CI 1.6–14.1; P = 0.004) and cuff (HR 6.8, 95 %CI 2.5–18.3; P Conclusions Pouch adenoma progression is slow and most advanced lesions occur after 10 years. HGD and cancer were rare events. Pouch phenotype in the first decade is associated with the future risk of developing advanced lesions and may guide personalized surveillance beyond 10 years.

BACKGROUND: Three-dimensional (3D) modelling technology translates the patient-specific anatomical information derived from two-dimensional radiological images into virtual or physical 3D models, which more closely resemble the complex environment encountered during surgery. It has been successfully applied to surgical planning and navigation, as well as surgical training and patient education in several surgical specialties, but its uptake lags behind in colorectal surgery. Rectal cancer surgery poses specific challenges due to the complex anatomy of the pelvis, which is difficult to comprehend and visualise. AIM: To review the current and emerging applications of the 3D models, both virtual and physical, in rectal cancer surgery. METHODS: Medline/PubMed, Embase and Scopus databases were searched using the keywords "rectal surgery", "colorectal surgery", "three-dimensional", "3D", "modelling", "3D printing", "surgical planning", "surgical navigation", "surgical education", "patient education" to identify the eligible full-text studies published in English between 2001 and 2020. Reference list from each article was manually reviewed to identify additional relevant papers. The conference abstracts, animal and cadaveric studies and studies describing 3D pelvimetry or radiotherapy planning were excluded. Data were extracted from the retrieved manuscripts and summarised in a descriptive way. The manuscript was prepared and revised in accordance with PRISMA 2009 checklist. RESULTS: Sixteen studies, including 9 feasibility studies, were included in the systematic review. The studies were classified into four categories: feasibility of the use of 3D modelling technology in rectal cancer surgery, preoperative planning and intraoperative navigation, surgical education and surgical device design. Thirteen studies used virtual models, one 3D printed model and 2 both types of models. The construction of virtual and physical models depicting the normal pelvic anatomy and rectal cancer, was shown to be feasible. Within the clinical context, 3D models were used to identify vascular anomalies, for surgical planning and navigation in lateral pelvic wall lymph node dissection and in management of recurrent rectal cancer. Both physical and virtual 3D models were found to be valuable in surgical education, with a preference for 3D printed models. The main limitations of the current technology identified in the studies were related to the restrictions of the segmentation process and the lack of 3D printing materials that could mimic the soft and deformable tissues. CONCLUSION: 3D modelling technology has potential to be utilised in multiple aspects of rectal cancer surgery, however, it is still at the experimental stage of application in this setting.

Community health workers (CHWs) are critical to health equity efforts, but sustaining CHW programs is challenging. Understanding stakeholders' knowledge and attitudes about CHWs can inform strategies to advance this important workforce. The authors implemented an online survey of potential CHW employers to learn their perceptions of CHWs' roles, outcomes, and abilities to affect important health outcomes, and of key issues that affect CHW employment. The survey was disseminated statewide to a diverse group of stakeholders working in healthcare in Arkansas. A total of 151 surveys were collected and included in the analysis. The organizations represented by respondents primarily included state and local agencies and clinics, followed by healthcare systems. The main professional roles of survey respondents were administrators and clinicians, followed by healthcare staff. Over 90% of respondents agreed that CHWs have the ability to conduct community outreach, serve as a liaison, navigate health systems, provide coaching support, and participate in care coordination. Over 90% of healthcare administrators, clinicians, and policymakers agreed that standardized training and a clear definition of role and scope of practice are important to CHW employment. However, almost two-thirds of respondents' organizations were not employing CHWs, adding to previous research which has primarily focused on CHW employers' attitudes. Understanding and addressing attitudes of those who lack experience with CHWs can help to identify actions needed to promote and increase adoption of CHWs. The authors share how they are using these data to engage stakeholders in decision-making and adoption of CHWs in their state.

Aim The continent ileostomy allows evacuation of an ileal reservoir at a time convenient to the patient. It is a surgical option for patients with ulcerative colitis (UC) when a restorative option is not suitable or has not succeeded and the patient does not want a conventional end ileostomy. Continent ileostomy types include the Kock pouch, Barnett continent intestinal reservoir and T-pouch. All of the published evidence on the long-term outcome and quality of life after continent ileostomy for UC was systematically reviewed. Methods A systematic review was performed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies published between 1990 and 2020 were included. A descriptive synthesis was used due to the clinical heterogeneity. Results The search returned 1,655 abstracts and after screening of abstracts and full text review, 19 were included in the final review, involving 1,602 patients. Operative mortality is low (0-3.6%) after all types of continent ileostomy but re-operation rates are high (20.8-65%) because of valve mechanism failures. Rates of fistulae (0-25.5%) and stomal stenosis (0-25%) can be relatively high post-operatively. Quality of life scores improve for most patients undergoing continent ileostomy, especially for patients converted from ileal pouch anal anastomosis. Overall, continent ileostomy retention is high in the long-term. Discussion In the long-term patients report high satisfaction and a good quality of life with continent ileostomy, despite high re-operation rates and complications. Newer technologies may reinvigorate interest in the continent ileostomy for this population.

3D modelling has been highlighted as one of the key digital technologies likely to impact surgical practice in the next decade. 3D virtual models are reconstructed using traditional 2D imaging data through either direct volume or indirect surface rendering. One of the principal benefits of 3D visualisation in surgery relates to improved anatomical understanding-particularly in cases involving highly variable complex structures or where precision is required.Workflows begin with imaging segmentation which is a key step in 3D reconstruction and is defined as the process of identifying and delineating structures of interest. Fully automated segmentation will be essential if 3D visualisation is to be feasibly incorporated into routine clinical workflows; however, most algorithmic solutions remain incomplete. 3D models must undergo a range of processing steps prior to visualisation, which typically include smoothing, decimation and colourization. Models used for illustrative purposes may undergo more advanced processing such as UV unwrapping, retopology and PBR texture mapping.Clinical applications are wide ranging and vary significantly between specialities. Beyond pure anatomical visualisation, 3D modelling offers new methods of interacting with imaging data; enabling patient-specific simulations/rehearsal, Computer-Aided Design (CAD) of custom implants/cutting guides and serves as the substrate for augmented reality (AR) enhanced navigation.3D may enable faster, safer surgery with reduced errors and complications, ultimately resulting in improved patient outcomes. However, the relative effectiveness of 3D visualisation remains poorly understood. Future research is needed to not only define the ideal application, specific user and optimal interface/platform for interacting with models but also identify means by which we can systematically evaluate the efficacy of 3D modelling in surgery.

Preoperative planning is a crucial aspect of safe complete mesocolic excision (CME) surgery. 3D models derived from imaging may help improve anatomical understanding of the complex vascular anatomy. Here, we assessed the effect of 3D models on surgeons' anatomical understanding in comparison to a systematic approach for CT scan interpretation (AMIGO).Fifteen cases were included in the study. Two GI radiology consultants reviewed each scan to ascertain the vascular anatomy. Virtual 3D models were produced and displayed on a web-based platform (https://skfb.ly/6OZUZ). A total of 13 surgical trainees were recruited. Candidates were assessed after baseline anatomical training and subsequently using the AMIGO method and 3D models. Five cases were randomly allocated in each round of testing for each participant. The primary outcome measure was an objective vascular anatomy knowledge score. The secondary outcome measure was subjective feedback from participants.Both 3D and AMIGO significantly improved anatomical understanding in comparison to baseline testing. However, 3D was superior to AMIGO (3D [n = 65; median score 8/14] vs. AMIGO [n = 65; median score 6/14; p 0.0001]. For 13/15 patient cases examined, 3D was superior to the AMIGO method. Eleven participants demonstrated better anatomical understanding using 3D models versus AMIGO. Ten participants preferred 3D models in comparison to standard CT imaging.3D models improve anatomical understanding of mesenteric vascular anatomy in a group of colorectal surgical trainees in comparison to a formal CT interpretation method. 3D models may be a useful planning adjunct to 2D imaging for CME surgery.

AIM Delayed closure of ileostomy following an anterior resection for rectal cancer in the UK is common. The aims of this study were (i) to investigate the variation in patient pathways between hospitals, (ii) to identify the key learning points from units with the shortest time to closure and (iii) to develop guidance for a pathway to minimize delay in ileostomy closure. METHOD This was a mixed methods study. Thirty-eight colorectal units in the UK completed a short online survey. Nine colorectal units in Wales filled in an additional, expanded version of the survey. Semi-structured interviews were performed with clinicians from the six best performing units in terms of timely ileostomy closure. The optimal pathway suggested is based on the best evidence available and the Association of Coloproctology of Great Britain and Ireland guidelines. RESULTS Qualitative analysis revealed that 5% of units (n = 2) have a local target time for ileostomy closure. Of all units, 90% (n = 34) would consider implementing a pathway if guidelines were developed. In-depth interviews highlighted the importance of a multidisciplinary approach, a dedicated coordinator to facilitate timely booking, and consensus on whether closure should be performed before or after adjuvant chemotherapy. CONCLUSION There is a lack of national guidance in timing of contrast studies and ileostomy closure. Key aspects to consider are better information at consent regarding stoma closure timing, a dedicated person to track patients and the planning of contrast studies at discharge from initial surgery. With a dedicated approach closure of ileostomy within 10-12 weeks is feasible for most units.

We present a training case in which a 3D model was used to plan and perform a robotic right mesocolectomy on a 40-year-old male patient with a T3 N2 M0 moderately differentiated adenocarcinoma in the ascending colon.

Delay to closure of ileostomy following anterior resection for rectal cancer may impair postoperative bowel function and quality of life. We analysed time to ileostomy closure across the UK and investigated factors delaying closure.For the retrospective cohort we assessed time to closure and incidence of non-closure for patients who underwent anterior resection with defunctioning ileostomy during 2015. Multivariate linear/Cox regression analyses were performed. For the prospective cohort we captured patients undergoing ileostomy closure during a 3-month period in 2018 to validate retrospective findings.The retrospective cohort involved 788 patients of whom 669 (84.9%) had bowel continuity restored, median time to closure 259 days. Recognized factors associated with delay and risk of non-closure included anastomotic leak (hazard ratio [HR] 3.65, 2.61-5.08), chemotherapy (HR 2.62, 2.17-3.15) and cancer progression (HR 2.05, 1.62-2.58). Crucially, specific aspects of the surgical pathway were associated with time to closure; for example, waiting list entry prior to outpatient clinic review/imaging was associated with an estimated 133-day shorter interval to closure (P 0.001). In the prospective cohort 288 patients underwent closure, at a median of 271 days. Chemotherapy use and cancer progression were associated with delay to closure while listing for surgery prior to clinic and imaging was associated with an estimated shorter interval to closure of 168 days (P = 0.008).Delays to closure of ileostomy are common in the UK. Listing patients for surgery only after follow-up outpatient appointment, imaging or chemotherapy delays closure. Findings will inform consensus guidelines towards an optimum treatment pathway to reduce delay and improve post-closure quality of life.

In den deutschen Leitlinien zur Behandlung des kolorektalen Karzinoms (Stand 2019) wird die Sonografie als einzige Bildgebung vor der Operation eines Kolonkarzinoms gefordert. Mit der weiteren Verbreitung der minimalinvasiven kompletten mesokolischen Exzision (CME), insbesondere am rechten Hemikolon, muss dies aber eindeutig infrage gestellt werden, da die Bildgebung heute nicht mehr nur der Metastasensuche gilt, sondern in zunehmendem Mas fur eine praoperative Planung der Operation eingesetzt werden sollte, um die Sicherheit der Prozedur zu gewahrleisten. Insbesondere bei der Hemikolektomie rechts mit CME sollten Operateure in der Lage sein, die wesentlichen Gefasstrukturen praoperativ zu identifizieren und so die Operation zu planen bzw. Schwierigkeiten zu antizipieren. Das dargestellte AMIGO-Prinzip ist hierfur eine sehr hilfreiche Grundlage.

Preoperative planning is a fundamental aspect of safe surgery. Patient-specific 3D virtual and printed models have now been used in a wide variety of preoperative planning applications in the majority of surgical specialties.

The human foot and ankle are uniquely adapted to support the entire weight of the body and provide a platform through which propulsive forces are transmitted to the ground beneath. Far from being passive elements, however, the foot and ankle together represent a dynamic, reactive, and force-generating structure containing a complex arrangement of bones held in inherently unstable configurations by an array of ligaments and muscle tendons. This anatomical complexity, together with the biomechanical demands placed on them, make the foot and ankle particularly susceptible to a variety of injuries and disease processes. This chapter covers the anatomy of the human foot and ankle, including illustrative figures.

Background Small bowel obstruction is a common surgical emergency, and is associated with high levels of morbidity and mortality across the world. The literature provides little information on the conservatively managed group. The aim of this study was to describe the burden of small bowel obstruction in the UK. Methods This prospective cohort study was conducted in 131 acute hospitals in the UK between January and April 2017, delivered by trainee research collaboratives. Adult patients with a diagnosis of mechanical small bowel obstruction were included. The primary outcome was in‐hospital mortality. Secondary outcomes included complications, unplanned intensive care admission and readmission within 30 days of discharge. Practice measures, including use of radiological investigations, water soluble contrast, operative and nutritional interventions, were collected. Results Of 2341 patients identified, 693 (29·6 per cent) underwent immediate surgery (within 24 h of admission), 500 (21·4 per cent) had delayed surgery after initial conservative management, and 1148 (49·0 per cent) were managed non‐operatively. The mortality rate was 6·6 per cent (6·4 per cent for non‐operative management, 6·8 per cent for immediate surgery, 6·8 per cent for delayed surgery; P = 0·911). The major complication rate was 14·4 per cent overall, affecting 19·0 per cent in the immediate surgery, 23·6 per cent in the delayed surgery and 7·7 per cent in the non‐operative management groups (P < 0·001). Cox regression found hernia or malignant aetiology and malnutrition to be associated with higher rates of death. Malignant aetiology, operative intervention, acute kidney injury and malnutrition were associated with increased risk of major complication. Conclusion Small bowel obstruction represents a significant healthcare burden. Patient‐level factors such as timing of surgery, acute kidney injury and nutritional status are factors that might be modified to improve outcomes. © 2019 The Authors. BJS Open published by John Wiley & Sons Ltd on behalf of BJS Society Ltd This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

Since 1980, corporations have spent nearly 50% of their revenue on technology, yet 50% of these new systems fail. The field of technology acceptance modeling posits that user acceptance is a root cause of these failures. Technology acceptance studies endeavor to determine the factors that lead users to adopt or reject a technology, but existing models have multiple weaknesses that impact their effectiveness and applicability. This study used enterprise system engineering principles to analyze and improve existing technology acceptance models, and proposed a new model that could be applied to disadvantaged user populations. The study analyzed information technology survey results from 338 firms across India and used the revised technology acceptance model to identify factors that were correlated to broadband internet use. The study found that relative advantage, process support infrastructure, relative cost, technology accessibility, and relevant knowledge were significantly correlated to broadband interne...

Developing nations are poised to spend billions on ICT innovation in 2020. A study of the historical adoption of ICT in developing nations indicated that their adoption patterns do not follow typical technology innovation adoption models. This study addressed the weaknesses found in existing technology acceptance models and proposed a new technology acceptance modelling approach and conceptual model. The new model integrated the population and technology characteristics factors found in popular technology acceptance models to task and process factors found in other models, consistent with enterprise system engineering principles and the Information Technology Infrastructure Library framework. This study also addressed the weakness in the survey approach by introducing data from publicly-available industry and economic data sources. An experiment was conducted on 42 nations in Sub-Saharan Africa, resulting in validation of the model. This new model and approach should be further validated by future research.