Minimally invasive gastro-oesophageal surgery for cancer: current evidence and practice

Background Since its introduction in the early 1990s, minimally invasive gastro-oesophageal surgery for cancer has been growing in popularity. Despite this, published evidence on this type of technique is weak and its role in the management of gastric and oesophageal cancer remains controversial. Aims The aim of this thesis was to test the hypothesis that: minimally invasive gastro- oesophageal cancer surgery has superior outcomes compared to control studies of conventional open surgery; but current studies are methodologically inadequate to confirm this. Methods The first study (chapter 3) is a systematic review of the literature on minimally invasive gastro-oesophageal cancer surgery, outlining the differences between literature published in Eastern and Western countries. The following 3 chapters outline and use a phase II surgical study to obtain data on minimally invasive gastro-oesophageal cancer (MIGOCS.) The MIGOCS group was set up in 2005 amongst UK surgeons. An online database was developed to enable data collection and comprises 5 sections: demographics; pre-operative staging and assessment; surgical intervention; post-operative course; pathology and clinical outcome. The first study is retrospective collecting data up to December 2006; the second study is prospective with data obtained between December 2006- July 2008 from centres around the UK utilising the MIGOCS database. Chapter 7 involves analysis of the learning curve in laparoscopic gastro-oesophageal cancer surgery using CUSUM (continuous surveillance monitoring) assessment. By studying operative time at each centre, improvement or deterioration in quality were detected. Results The systematic review of minimally invasive gastro-oesophageal surgery consists in the majority of case reports, with no randomised controlled trials of oesophagectomies and 4 (low quality) randomised controlled trials of gastrectomies. It demonstrates a mortality and morbidity of 2.3% and 46.2% respectively for oesophagectomies; 0.1% and 12.7% respectively for gastrectomies. Data from this review suggests that the minimally invasive approach is beneficial compared to open surgery in terms of reduced mortality, respiratory complications, blood loss and quicker return to a good quality of life (but not reduced hospital stay as expected.) There are currently 60 MIGOCS member consultant surgeons from over 40 UK centres. The retrospective study obtained data from 7 UK centres with an overall mortality and morbidity of 6.0% and 57% respectively for oesophagectomies and 7.7% and 13% respectively for gastrectomies. The prospective study collected data from 7 UK centres, comprising a total of 258 minimally invasive oesophagectomies and 33 minimally invasive gastrectomies. Overall mortality and morbidity were 2.5% and 56.6% respectively for oesophagectomies and 10.8% and 27.3% respectively for gastrectomies. CUSUM analysis varied considerably between centres. The two larger volume centres however demonstrated an improvement in their operative time with experience, with a possible pateau at around 30 procedures. Conclusions Published data suggests that the minimally invasive approach to gastro-oesophageal cancer has advantages over conventional open surgery. Data collected in this thesis does not overwhelmingly support published evidence, but does demonstrate that this technique is both safe and feasible even during the early part of a surgeon’s learning curve. It is the first study to provide an insight into outcomes of this type of surgery in a multicentre setting in the UK; and has made progress towards a randomised controlled trial

A systematic review of patient reported outcome measures (PROMs) and quality of life reporting in patients undergoing laparoscopic cholecystectomy

Background Patient Reported Outcome Measures (PROMs) provide a valuable means of measuring outcomes subjectively from a patient's perspective, facilitating the assessment of service quality across healthcare providers, and assisting patients and clinicians in shared decision making. The primary aim of this systematic review was to critically appraise all historic studies evaluating patient reported quality of life, in adult patients undergoing laparoscopic cholecystectomy for symptomatic gallstones. The secondary aim was to perform a quality assessment of cholecystectomy-specific PROM-validation studies. Methods A literature review was performed in PubMed, Google ScholarTM, the Cochrane Library, Medline, CINAHL, EMBASE and PsychINFO databases up to September 2017. Study characteristics, PROM-specific details and a bias assessment were summarised for non-validation studies. A COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) analysis was performed to assess the methodological quality of identified PROM-validation studies. Results Fifty one studies were found to evaluate Health-Related Quality of Life (HRQoL) after laparoscopic cholecystectomy. Although 94.1% of these studies included PROMs as a primary outcome measure

Understanding the influences on successful quality improvement in emergency general surgery: learning from the RCS Chole-QuIC project

Abstract: Background: Acute gallstone disease is the highest volume Emergency General Surgical presentation in the UK. Recent data indicate wide variations in the quality of care provided across the country, with national guidance for care delivery not implemented in most UK hospitals. Against this backdrop, the Royal College of Surgeons of England set up a 13-hospital quality improvement collaborative (Chole-QuIC) to support clinical teams to reduce time to surgery for patients with acute gallstone disease requiring emergency cholecystectomy. Methods: Prospective, mixed-methods process evaluation to answer the following: (1) how was the collaborative delivered by the faculty and received, understood and enacted by the participants; (2) what influenced teams’ ability to improve care for patients requiring emergency cholecystectomy? We collected and analysed a range of data including field notes, ethnographic observations of meetings, and project documentation. Analysis was based on the framework approach, informed by Normalisation Process Theory, and involved the creation of comparative case studies based on hospital performance during the project. Results: Chole-QuIC was delivered as planned and was well received and understood by participants. Four hospitals were identified as highly successful, based upon a substantial increase in the number of patients having surgery in line with national guidance. Conversely, four hospitals were identified as challenged, achieving no significant improvement. The comparative analysis indicate that six inter-related influences appeared most associated with improvement: (1) achieving clarity of purpose amongst site leads and key stakeholders; (2) capacity to lead and effective project support; (3) ideas to action; (4) learning from own and others’ experience; (5) creating additional capacity to do emergency cholecystectomies; and (6) coordinating/managing the patient pathway. Conclusion: Collaborative-based quality improvement is a viable strategy for emergency surgery but success requires the deployment of effective clinical strategies in conjunction with improvement strategies. In particular, achieving clarity of purpose about proposed changes amongst key stakeholders was a vital precursor to improvement, enabling the creation of additional surgical capacity and new pathways to be implemented effectively. Protected time, testing ideas, and the ability to learn quickly from data and experience were associated with greater impact within this cohort

Large expert-curated database for benchmarking document similarity detection in biomedical literature search

Document recommendation systems for locating relevant literature have mostly relied on methods developed a decade ago. This is largely due to the lack of a large offline gold-standard benchmark of relevant documents that cover a variety of research fields such that newly developed literature search techniques can be compared, improved and translated into practice. To overcome this bottleneck, we have established the RElevant LIterature SearcH consortium consisting of more than 1500 scientists from 84 countries, who have collectively annotated the relevance of over 180 000 PubMed-listed articles with regard to their respective seed (input) article/s. The majority of annotations were contributed by highly experienced, original authors of the seed articles. The collected data cover 76% of all unique PubMed Medical Subject Headings descriptors. No systematic biases were observed across different experience levels, research fields or time spent on annotations. More importantly, annotations of the same document pairs contributed by different scientists were highly concordant. We further show that the three representative baseline methods used to generate recommended articles for evaluation (Okapi Best Matching 25, Term Frequency-Inverse Document Frequency and PubMed Related Articles) had similar overall performances. Additionally, we found that these methods each tend to produce distinct collections of recommended articles, suggesting that a hybrid method may be required to completely capture all relevant articles. The established database server located at https://relishdb.ict.griffith.edu.au is freely available for the downloading of annotation data and the blind testing of new methods. We expect that this benchmark will be useful for stimulating the development of new powerful techniques for title and title/abstract-based search engines for relevant articles in biomedical research.Peer reviewe

Outcomes from elective colorectal cancer surgery during the SARS-CoV-2 pandemic

This study aimed to describe the change in surgical practice and the impact of SARS-CoV-2 on mortality after surgical resection of colorectal cancer during the initial phases of the SARS-CoV-2 pandemic

PANC Study (Pancreatitis: A National Cohort Study): national cohort study examining the first 30 days from presentation of acute pancreatitis in the UK

Abstract Background Acute pancreatitis is a common, yet complex, emergency surgical presentation. Multiple guidelines exist and management can vary significantly. The aim of this first UK, multicentre, prospective cohort study was to assess the variation in management of acute pancreatitis to guide resource planning and optimize treatment. Methods All patients aged greater than or equal to 18 years presenting with acute pancreatitis, as per the Atlanta criteria, from March to April 2021 were eligible for inclusion and followed up for 30 days. Anonymized data were uploaded to a secure electronic database in line with local governance approvals. Results A total of 113 hospitals contributed data on 2580 patients, with an equal sex distribution and a mean age of 57 years. The aetiology was gallstones in 50.6 per cent, with idiopathic the next most common (22.4 per cent). In addition to the 7.6 per cent with a diagnosis of chronic pancreatitis, 20.1 per cent of patients had a previous episode of acute pancreatitis. One in 20 patients were classed as having severe pancreatitis, as per the Atlanta criteria. The overall mortality rate was 2.3 per cent at 30 days, but rose to one in three in the severe group. Predictors of death included male sex, increased age, and frailty; previous acute pancreatitis and gallstones as aetiologies were protective. Smoking status and body mass index did not affect death. Conclusion Most patients presenting with acute pancreatitis have a mild, self-limiting disease. Rates of patients with idiopathic pancreatitis are high. Recurrent attacks of pancreatitis are common, but are likely to have reduced risk of death on subsequent admissions. </jats:sec

Minimally invasive gastro-oesophageal surgery for cancer : current evidence and practice

Background Since its introduction in the early 1990s, minimally invasive gastro-oesophageal surgery for cancer has been growing in popularity. Despite this, published evidence on this type of technique is weak and its role in the management of gastric and oesophageal cancer remains controversial. Aims The aim of this thesis was to test the hypothesis that: minimally invasive gastro- oesophageal cancer surgery has superior outcomes compared to control studies of conventional open surgery; but current studies are methodologically inadequate to confirm this. Methods The first study (chapter 3) is a systematic review of the literature on minimally invasive gastro-oesophageal cancer surgery, outlining the differences between literature published in Eastern and Western countries The following 3 chapters outline and use a phase II surgical study to obtain data on minimally invasive gastro-oesophageal cancer (MIGOCS.) The MIGOCS group was set up in 2005 amongst UK surgeons. An online database was developed to enable data collection and comprises 5 sections: demo graphics; pre-operative staging and assessment; surgical intervention; post-operative course; pathology and clinical outcome. The first study is retrospective collecting data up to December 2006; the second study is prospective with data obtained between December 2006- July 2008 from centres around the UK utilising the MIGOCS database. Chapter 7 involves analysis of the learning curve in laparoscopic gastro-oesophageal cancer surgery using CUSUM (continuous surveillance monitoring) assessment. By studying operative time at each centre, improvement or deterioration in quality were detected. Results The systematic review of minimally invasive gastro-oesophageal surgery consists in the majority of case reports, with no randomised controlled trials of oesophagectomies and 4 (low quality) randomised controlled trials of gastrectomies. It demonstrates a mortality and morbidity of 2.3% and 46.2% respectively for oesophagectomies; 0.1 % and 12.7% respectively for gastrectomies. Data from this review suggests that the minimally invasive approach is beneficial compared to open surgery in terms of reduced mortality, respiratory complications, blood loss and quicker return to a good quality of life (but not reduced hospital stay as expected.) There are currently 60 MIGOCS member consultant surgeons from over 40 UK centres. The retrospective study obtained data from 7 UK centres with an overall mortality and morbidity of 6.0% and 57% respectively for oesophagectomies and 7.7% and 13% respectively for gastrectomies. The prospective study collected data from 7 UK centres, comprising a total of 258 minimally invasive oesophagectomies and 33 minimally invasive gastrectomies. Overall mortality and morbidity were 2.5% and 56.6% respectively for oesophagectomies and 10.8% and 27.3% respectively for gastrectomies. CUSUM analysis varied considerably between centres. The two larger volume centres however demonstrated an improvement in their operative time with experience, with a possible pateau at around 30 procedures. Conclusions Published data suggests that the minimally invasive approach to gastro-oesophageal cancer has advantages over conventional open surgery. Data collected in this thesis does not overwhelmingly support published evidence, but does demonstrate that this technique is both safe and feasible even during the early part of a surgeon's learning curve. It is the first study to provide an insight into outcomes of this type of surgery in a multi centre setting in the OK; and has made progress towards a randomised controlled trial. Weaknesses and Intepretation of Findings International literature on the subject of minimally invasive gastro-oesophageal surgery is at present limited and subject to both publication and selection bias. Data presented in this thesis is weakened by the number of operations recorded and centres involved in the studies. This impacts on any interpretation of findings. Further data collection, ideally in the form of a randomised controlled trial is therefore vital.EThOS - Electronic Theses Online ServiceGBUnited Kingdo