An investigation of the detection and treatment of colorectal liver metastases

In the United Kingdom, colorectal cancer creates a significant health burden, with over 34 000 new cases diagnosed each year and over 16 000 deaths per year. Almost 50% of patients with colorectal cancer will develop liver metastases: up to 25% will have liver metastases at time of initial presentation with the remaining 25% developing liver metastases during the course of their disease. Death from hepatic metastases accounts for a large percentage of colorectal cancer mortalities and if left untreated the prognosis is poor, with median survival from 5 to 21 months with almost none alive at 5 years. Surgical resection offers the only potential curative treatment for colorectal liver metastases with the five year survival rate varying in the literature from 25% to 51%. Hepatic surgery was associated with high morbidity and mortality and it is only since the 1990s that an evidence base has been published showing improved long term outcomes. Radiological imaging plays an essential role in the detection and characterisation of colorectal liver metastases. Accurate staging of the disease allows patient selection for hepatic surgery. Despite recent and significant technological advances in radiological imaging, up to 50% of patients that have undergone curative partial hepatectomy will develop hepatic recurrence in the first two years after surgery. Evidence from growth rate studies has shown that colorectal liver metastases are slow growing and that these recurrences were present at the time of initial staging. Therefore, the problem of occult liver metastases remains. This thesis has assessed the potential clinical role of a new imaging modality in the detection of colorectal liver metastases: contrast enhanced ultrasound (CE-US). Initially a prospective trial using percutaneous CE-US with intravenous administration of an ultrasound contrast agent that has been used primarily in cardiac imaging was performed. The results of this study found that CE-US enhanced late phase vascular imaging. This is an important finding as the persistence of a hypoechoic liver lesion in to the late phase of CE-US imaging is typical of a colorectal liver metastasis and an agent that optimises the late phase would allow improved characterisation of colorectal liver metastases. As a result, CE-US was then compared to percutaneous unenhanced ultrasound and found to have improved sensitivity and accuracy in the detection of colorectal liver metastases (sensitivity 100%, accuracy 90.8% versus 64.4% and 64.4% respectively). Furthermore, the optimal late phase imaging was achieved by the lowest dose of agent (0.4mL) that would allow repeated injections if incorporated into routine clinical practice. These findings support the growing evidence base for percutaneous CE-US and it is likely that CE-US will replace unenhanced ultrasound in routine clinical practice. (Abstract shortened by ProQuest.)

Influence of frailty in older patients undergoing emergency laparotomy: a UK-based observational study

Introduction The National Emergency Laparotomy Audit (NELA) has reported that older patients (≥65 years) form a large percentage of emergency high-risk cases with increased postoperative morbidity and mortality. With the population continuing to age rapidly, it is clear that a greater understanding of the factors affecting surgical outcomes in older patients is required. Frailty is a relatively new concept taking into account a variety of factors that increase an individual’s vulnerability to increased dependency and death. Research has suggested that high frailty scores increase postoperative complications, length of stay and mortality but the majority of these studies have been carried out on elective patients. Knowledge of how frailty affects patients in an emergency setting would aid clinicians’ and patients’ decision-making process. Methods and analysis This multicentre study will include consecutive adult patients aged 65 years and over undergoing emergency laparotomies over a 3-month period at 52 National Health Service hospitals across the UK. The primary outcome will be 90-day mortality. Secondary outcomes will include length of hospital stay, 30-day complications, change in level of independence and 30-day readmission. This study has been powered to detect a 10% change in mortality associated with frailty (n=500 patients). Ethics and dissemination This study has been approved by the National Health Service Research Ethics Committee. It has been registered centrally with HRA for English sites, NRSPCC for Scottish sites and Health and Care Research Permissions Service for sites in Wales.Dissemination will be via international and national surgical and geriatric conferences. In addition, manuscripts will be prepared following the close of the project. Trial registration number This study is also registered online at www.clinicaltrials.gov (registration number NCT02952430)

The virtual uncertainty of futility in emergency surgery

No abstract available

Decision-making in COVID-19 and Frailty

Peer reviewedPublisher PD

Contrast-enhanced magnetomotive ultrasound imaging (CE-MMUS) for colorectal cancer staging : assessment of sensitivity and resolution to detect alterations in tissue stiffness

A key challenge in the treatment of colorectal cancer is identification of the sentinel draining lymph node. Magnetomotive ultrasound, MMUS, has identified lymph nodes in rat models: superparamagnetic iron oxide nanoparticles (SPIONs) accumulated in the lymph are forced to oscillate by an external magnetic field; the resulting axial displacement is recovered allowing structure delineation with potential to indicate alterations in tissue stiffness, but it is limited by small vibration amplitudes. We propose CE-MMUS using SPION loaded microbubbles (SPION-MBs) to enhance sensitivity, reduce toxicity, and offer additional diagnostic or perfusion information. Laser doppler vibrometry measurements was performed on SPION containing tissue mimicking material during magnetic excitation. These measurements show a vibration amplitude of 279 ± 113 μm in a material with Young's modulus of 24.3 ± 2.8 kPa, while the displacements were substantially larger, 426 ± 9 μm, in the softer material, with a Young's modulus of 9.6 ± 0.8 kPa. Magnetic field measurement data was used to calibrate finite element modelling of both MMUS and CE-MMUS. SPION-MBs were shown to be capable of inducing larger tissue displacements under a given magnetic field than SPIONs alone, leading to axial displacements of up to 2.3x larger. A doubling in tissue stiffness (as may occur in cancer) reduces the vibration amplitude. Thus, there is potential for CE-MMUS to achieve improved stiffness sensitivity. Our aim is to define the potential contribution of CE-MMUS in colorectal cancer diagnosis and surgical guidance

Poor outcomes in patients with sepsis undergoing emergency laparotomy and laparoscopy are attenuated by faster time to care measures

ACKNOWLEDGEMENTS NE received the University of Aberdeen Innes Will Endowed Research Scholarship 2022 to carry out the research. FUNDING INFORMATION The Emergency Laparotomy and Laparoscopic Scottish Audit (ELLSA) is a Scottish Government initiative supported via the Modernising Patient Pathways Programme (MPPP).Peer reviewedPublisher PD

Exploring shared surgical decision-making from the patient’s perspective : is the personality of the surgeon important?

Open Access via the Jisc Wiley OA agreement Acknowledgements: The authors would like to thank the participating patients who volunteered their time and shared their thoughts on their healthcare experiences and interactions with surgeons. Funding: This work was kindly supported by Bowel and Cancer Research and The Ileostomy and Internal Pouch Association. The funders had no influence in the design, delivery or interpretation of this study.Peer reviewedPublisher PD

A systematic review of the abdominal surgeon’s personality: exploring common traits in western populations

The personality traits commonly seen in abdominal surgeons remains undefined, and its potential influence on decision-making and patient outcomes underexplored. This systematic review identified studies on abdominal surgeons who had undergone validated personality testing, with assessment of decision-making and post-operative patient outcomes. The study protocol was registered on PROSPERO (University of York, UK (CRD42019151375)). MEDLINE, Embase, PsycInfo and Cochrane Library databases were searched using the keywords: surgeon; surgeon personality; outcomes. All study designs were accepted including adult visceral surgeons published in English. Five articles from 3056 abstracts met our inclusion criteria and one article was identified from hand searches with two reviewers screening studies. Bias was assessed using the Newcastle-Ottawa scale. Six studies included 386 surgeons. Studies assessing personality using the Five Factor Model (four studies, 329 surgeons) demonstrated higher levels of conscientiousness (self-discipline, thoughtfulness), extraversion (sociability, emotional expression) and openness (creative, conventional) in surgeons versus population norms. Surgeon characterisation of agreeableness and emotional stability was less clear, with studies reporting mixed results. Post-operative outcomes were reported by only one study. Further exploration of the influence of surgeon personality and its influence on decision-making is necessary to deliver patient-centred care and targeted non-technical skills training for surgeons

Development of Preclinical Ultrasound Imaging Techniques to Identify and Image Sentinel Lymph Nodes in a Cancerous Animal Model

Lymph nodes (LNs) are believed to be the first organs targeted by colorectal cancer cells detached from a primary solid tumor because of their role in draining interstitial fluids. Better detection and assessment of these organs have the potential to help clinicians in stratification and designing optimal design of oncological treatments for each patient. Whilst highly valuable for the detection of primary tumors, CT and MRI remain limited for the characterization of LNs. B-mode ultrasound (US) and contrast-enhanced ultrasound (CEUS) can improve the detection of LNs and could provide critical complementary information to MRI and CT scans; however, the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) guidelines advise that further evidence is required before US or CEUS can be recommended for clinical use. Moreover, knowledge of the lymphatic system and LNs is relatively limited, especially in preclinical models. In this pilot study, we have created a mouse model of metastatic cancer and utilized 3D high-frequency ultrasound to assess the volume, shape, and absence of hilum, along with CEUS to assess the flow dynamics of tumor-free and tumor-bearing LNs in vivo. The aforementioned parameters were used to create a scoring system to predict the likelihood of a disease-involved LN before establishing post-mortem diagnosis with histopathology. Preliminary results suggest that a sum score of parameters may provide a more accurate diagnosis than the LN size, the single parameter currently used to predict the involvement of an LN in disease