Science and industry: can this relationship be controlled?
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Authorship↗
Biomedical subjects
A Cuschieri
Publications and source records attributed to A Cuschieri.
Influence of pathological tumour variables on long-term survival in resectable gastric cancer.
Although tumour stage and nodal status are established prognostic factors for resectable gastric cancer, the relative importance of other pathological characteristics remains unclear. This study reports univariate and multivariate analyses of the prognostic value of various pathological and staging factors based on 324 patients entered into the MRC randomised surgical trial for gastric cancer. In the univariate analysis tumour stage, nodal status, UICC clinical stage, number of involved nodes, WHO predominant type, mixed Lauren type, Ming type, tumour differentiation, lymphocytic and tumour stromal eosinophilic infiltration were all found to have a significant impact on survival (logrank test, 5% level). In the multivariate analysis, UICC clinical stage and eosinophilic infiltration were found to have a significant influence. Risk of death increased for UICC stage II and III patients (Hazard Ratio for stage II compared to stage I=2.0, 95% Confidence Interval (CI) 1.4-2.9; Hazard Ratio for stage III compared to stage I=3.5, 95% CI 2.5-4.8). Patients with numerous eosinophils had a lower risk of death than those with none (Hazard Ratio=0.5, 95% CI 0.3-0.8). This association between survival and eosinophilic infiltration merits further study.
Aged↗
Does chemoradiotherapy after intended curative surgery increase survival of gastric cancer patients?
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Comment↗
Comparison of orthodox versus off-optical axis endoscopic manipulations.
BACKGROUND: During complex laparoscopic operations, the surgeon often has to use both instruments to one side of the telescope (off-optical axis work). This experimental study was undertaken to compare this orthodox versus the off-optical axis endoscopic manipulations regarding the performance parameters and motion analysis and muscle work of the surgeon's dominant upper limb. METHODS: Ten surgeons participated in the study; each sutured 50-mm enterotomy in pig's small bowel in each of three setups: (1) in-optical axis manipulation (one instrument on either side of the laparoscope) (2) off-optical axis manipulation (both instruments on one side of the laparoscope to the dominant hand of the surgeon), and (3) off-optical axis manipulation both instruments on one side of the laparoscope on the nondominant side). The main outcome measures were the placement error score, execution time, leakage pressure, motion analysis, and telemetric electromyography parameters of the surgeon's dominant upper limb. RESULTS: There was no significant difference in all parameters of performance, muscle work, and fatigue between setup 1 and setup 3. However, marked degradation of all parameters of performance with increased muscle work and fatigue was observed with setup 2 compared to setups 1 and 3. The reason for the deterioration with setup 2 is related to the altered "monitor display angle" which are different from the actual physical angles. With this setup, the instrument-to-target physical angle of 30 degrees appears on the screen as ?30 degrees and this disturbs both the manipulation and the azimuth angles obscuring the needle-tissue entry point. In addition, the instrument casts a shadow on its medial side and this tends to obscure the exact relations between instrument, needlepoint, and the tissue. CONCLUSIONS: Off-optical axis work is a good alternative to the orthodox setup provided the instruments are placed to the nondominant hand. The marked degradation in performance encountered during off-optical axis work to the dominant hand of the surgeon is due to the resulting altered monitor display angles. The importance of these monitor display angles in influencing task performance has been previously overlooked.
Animals↗
Ergonomic principles of task alignment, visual display, and direction of execution of laparoscopic bowel suturing.
BACKGROUND: Laparoscopic suturing is technically a demanding skill in laparoscopic surgery. Ergonomic experimental studies provide objective information on the important factors and variables that govern optimal endoscopic suturing. Our objective was to determine the optimum physical alignment, visual display, and direction of intracorporeal laparoscopic bowel suturing using infrared motion analysis and telemetric electromyography (EMG) systems. METHODS: Ten surgeons participated in the study; each sutured 50-mm porcine small bowel enterotomies toward and away from the surgeon in the vertical and horizontal bowel plane with either isoplanar (image display corresponds with actual lie of the bowel) or nonisoplanar (bowel displayed horizontally but mounted vertically in the trainer and vice versa) display. The end points were the placement error score, execution time, leakage pressure, motion analysis, and telemetric EMG parameters of the surgeon's dominant upper limb. RESULTS: Suturing was demonstrably easier in the vertical than in the horizontal plane, resulting in a better task quality (placement error score, p < 0.0001; leakage pressure, p < 0.005) and shorter execution time (p < 0.05). Nonisoplanar display of the surgical anatomy degrades performance in terms of both task efficiency and task quality. On motion analysis, a wider angle of excursion and lower angular velocity were observed during the vertical suturing with isoplaner display. Compared to horizontal suturing, supination at the wrist was significantly greater during vertical than horizontal suturing (p < 0.05). Within each category (vertical vs horizontal suturing), the direction of suturing (toward/away from the surgeon) did not influence the extent of pronation/ supination at the wrist. In line with the degraded performance, significantly more muscle work was expended during horizontal suturing. This affected the forearm flexors (p < 0.05), arm flexors and extensors (p < 0.005 and p < 0.05, respectively), and deltoid muscles (p < 0.005) and was accompanied by significantly more fatigue in the related muscles. Small bowel enterotomies sutured toward the surgeon in both the vertical and the horizontal planes exhibited less placement error score than when sutured away from the surgeon, with no significant difference in the motion analysis and EMG parameters. CONCLUSIONS: Optimal laparoscopic suturing (better task quality and reduced execution time) is achieved with vertical suturing toward the surgeon with isoplanar monitor display of the operative field. The poorer task performance observed during horizontal suturing is accompanied by more muscle work and fatigue, and it is not improved by monitor display of the enterotomy in the vertical plane.
Animals↗
Descriptive epidemiology of isolated anal anomalies: a survey of 4.6 million births in Europe.
The prevalence of anal anomalies among 4,618,840 births recorded in 33 EUROCAT registries between 1980 and 1994 was 4.05 per 10,000 births. Of the 1,846 recorded cases, 672 (36.4%) were isolated anal anomalies while 1,174 (63.6%) occurred together with other anomalies. Only isolated anal anomalies were analyzed in this study: 75.5% were atresias, 10.1% of which were above and 89.9% were below the level of the levator ani muscle. Fistula occurred in 53% of supralevator and 37% of infralevator atresia. Other anal anomalies were ectopic anus (3.4%), congenital anal fistula (14.7%), and persistent cloaca (0.9%). There was a predominance of males in anal atresia without fistula (male to female (M:F) ratio was 6.7 for supralevator and 2.3 for infralevator atresia), but no significant sex difference in atresias with fistula. There was a predominance of females in ectopic anus and congenital anal fistula (M:F = 0.11 and 0.36 respectively). High frequencies of fetal deaths were recorded in supralevator atresia without fistula (8.3%) and in persistent cloaca (11.1%). Mean gestational length and mean birth weights were reduced for persistent cloaca but were within normal limits for other isolated anal anomalies. Odds ratios (ORs) for mothers above 35 years were increased for supralevator atresia without fistula, supralevator atresia with fistula, and congenital anal fistula. ORs for mothers below 30 years were slightly increased for supralevator atresia without fistula and decreased for persistent cloaca. There were marked differences in prevalence and distribution of anal anomalies among the EUROCAT registries. The results indicated that there are epidemiological differences among the various types of anal anomalies which might reflect different embryological origins.
Anal Canal↗
The European Association for Endoscopic Surgery clinical practice guideline on the pneumoperitoneum for laparoscopic surgery.
BACKGROUND: The pneumoperitoneum is the crucial element in laparoscopic surgery. Different clinical problems are associated with this procedure, which has led to various modifications of the technique. The aim of this guideline is to define the scientifically proven standards of the pneumoperitoneum. METHODS: Based on systematic literature searches (Medline, Embase, and Cochrane), an expert panel consensually formulated clinical recommendations, which were graded according to the strength of available literature evidence. RECOMMENDATIONS: Preoperatively, all patients should be assessed for the presence of cardiac, pulmonary, hepatic, renal, or vascular comorbidity. Presupposing appropriate perioperative measures and surgical technique, there is no reason to contraindicate pneumoperitoneum in patients with peritonitis or intraabdominal malignancy. During laparoscopy, monitoring of end tidal CO2 concentration is mandatory. The available data on closed- (Veress needle) and open-access techniques do not allow us to principally favor the use of either technique. Using 2 to 5-mm instead of 5 to 10-mm trocars improves cosmetic result and postoperative pain marginally. It is recommended to use the lowest intraabdominal pressure allowing adequate exposure of the operative field, rather than using a routine pressure. In patients with limited cardiac, pulmonary, or renal function, abdominal wall lifting combined with low-pressure pneumoperitoneum might be an alternative. Abdominal wall lifting devices have no clinically relevant advantages compared to low-pressure (5-7 mmHg) pneumoperitoneum. In patients with cardiopulmonary diseases, intra- and postoperative arterial blood gas monitoring is recommended. The clinical benefits of warmed, humidified insufflation gas are minor and contradictory. Intraoperative sequential intermittent pneumatic compression of the lower extremities is recommended for all prolonged laparoscopic procedures. For the prevention of postoperative pain a wide range of treatment options exists. Although all these options seem to reduce pain, the data currently do not justify a general recommendation.
Contraindications↗
Influence of handle design on the surgeon's upper limb movements, muscle recruitment, and fatigue during endoscopic suturing.
BACKGROUND: Thus far, little has been done to investigate the kinematics (motion analysis) and kinetics (muscle work, muscle fatigue, comfort) of surgeons during laparoscopic surgery. Therefore, we set out to study these ergonomic aspects of task performance in the dominant upper limb of surgeons during endoscopic suturing. METHODS: Three different handles - conventional finger loop, rocker, and ball handle prototype - were compared in a study involving 10 surgeons suturing porcine enterotomies with each of the three instruments. The endpoints were performance parameters, motion analysis and muscle work, and fatigue of the surgeon's dominant upper limb; subjective scores for comfort level and maneuverability were also elicited from the subjects. RESULTS: Task quality and efficiency during endoscopic suturing, were significantly better with the ball and rocker handle needle drivers than with the finger loop instrument, with lower angular velocity at the elbow and shoulder joints, more pronation, and less supination. The integrated muscle work was much lower for both the rocker and the ball handles. Significant muscle fatigue, especially of the arm flexors and deltoid, was observed only with finger loop instruments. Comfort and maneuverability rating scores were higher with both handles than with the conventional finger loop. The ball handle was easier to maneuver, but it was somewhat less comfortable than the rocker system. CONCLUSION: A different pattern of joint movements, a reduction in muscle power exerted during endoscopic suturing, and hence an absence of muscle fatigue were documented with ergonomic needle drivers (rocker and ball) when compared to the conventional finger loop instruments. These differences translate to better and more efficient task performance with enhanced comfort.
Animals↗
Reliability of the Dundee Endoscopic Psychomotor Tester (DEPT) for dominant hand performance.
BACKGROUND: The Dundee Endoscopic Psychomotor Tester (DEPT) was developed as a means of obtaining an objective assessment of endoscopic performance using a single hand. This paper evaluates the reliability of the system. METHODS: Twenty medical students were tested on the DEPT for four runs using the dominant hand. Test-retest reproducibility and coefficient alpha to measure the internal consistency were used as indexes of the reliability of the DEPT system. RESULTS: A positive correlation was found between different runs in all outcome measures of the DEPT. Coefficient a was > 0.7 for all parameters. CONCLUSION: DEPT provides a reliable method for the objective assessment of single-handed endoscopic performance in terms of aiming and force exerted on the target plate.
Clinical Competence↗
Scientific electronic publication: An updated report.
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History, 20th Century↗
Reliability of the Advanced Dundee Endoscopic Psychomotor Tester for bimanual tasks.
OBJECTIVE: To evaluate the reliability of the Advanced Dundee Endoscopic Psychomotor Tester (ADEPT). DESIGN: The Advanced Dundee Endoscopic Psychomotor Tester was developed for objective evaluation of bimanual endoscopic tasks. The system is in several aspects relevant to an actual endoscopic environment, and initial studies showed a strong correlation with clinical competence. Twenty medical students were tested on ADEPT (10 runs in 2 sessions). Their performances for 2 sessions were analyzed by the Spearman rho correlation to examine test-retest reliability. Coefficient alpha was used to indicate the internal consistency of the system. RESULTS: There was no significant improvement in task performance during the 10 runs. A positive correlation on ADEPT performance was found between the 2 test sessions. A coefficient alpha of.98 was observed between the different tasks of ADEPT. CONCLUSION: These findings confirm that ADEPT is a reliable system for assessment of bimanual endoscopic task performance.
Clinical Competence↗
Role of video-laparoscopy in the staging of intra-abdominal lymphomas and gastrointestinal cancer.
There is good category II/III evidence that video-laparoscopic staging is valuable in certain gastrointestinal (gastric, esophageal, pancreatic, and hepatobiliary) and intra-abdominal lymphomas, but no category I evidence (based on prospective randomized trials). The evidence available is all retrospective, but of sufficient consistency to indicate that laparoscopic staging adds to the primary (imaging) staging and often alters the clinical stage of the disease and hence the management of the individual patient. The advent of laparoscopic contact ultrasound (LCU) scanning has improved the staging accuracy for pancreatic and hepatobiliary neoplasms. The laparoscopic approach also offers a means of surgical palliation in certain patient groups. However, there are a number of unresolved issues concerning the use of video-laparoscopy. The most important concerns whether staging laparoscopy should be performed immediately before scheduled surgery or as a separate intervention. The cost-efficacy of these two management options needs to be evaluated in prospective studies. In some centres, laparoscopic staging is being conducted by gastroenterologists and hepatologists. This raises issues of safety and ability to undertake certain procedures that may be necessary during the laparoscopic staging.
Abdominal Neoplasms↗
[New technologies in laparoscopic surgery].
The technology associated with endoscopic surgery continues to evolve as a result of industrial R & D and research within academic surgical departments with interest in surgical endoscopic and remote handling technology. Some of the developments in the last ten years are reviewed. The problem concerning health technology assessment (HTA) in relation to new devices/instrumentation and procedures is discussed. Randomised controlled clinical trials are unsuited for the initial HTA of technology-dependent interventions, and for this reason, an alternative system, controlled stepwise evaluation (CSE) is proposed.
Clinical Trials as Topic↗
Image display technology and image processing.
Significant developments in video imaging have taken place but further progress is needed to provide images with the right characteristics for optimal interpretation by the operator. The nature and location of the image display in relation to the surgeon and operating field are also important in facilitating image-guided surgery/interventions, and several new technologies are being explored. In the diagnostic field, virtual reality surface anatomical and internal luminal rendering has opened a new chapter in diagnosis, screening, and treatment planning, the potential of which is only just being realized.
Diagnostic Imaging↗
The performance of master surgeons on standard aptitude testing.
BACKGROUND: Identification of the desired psychomotor abilities of optimal surgical performance, if possible, would be useful in the selection of surgical trainees. The aim of this study was to determine the level of these abilities among endoscopic consultant surgeons held in high regard by their peers. METHODS: Twenty endoscopic consultant "master" surgeons were tested on three aptitude tests: the Gibson Spiral Maze Test (error score measures eye-hand coordination), the Crawford Small Parts Dexterity Test (execution time indicates manual dexterity), and the Space Relations Test (correct scores reflect visuo-spatial ability). Their performance was compared with that of 20 medical students and the reference norm as provided by the tests' manuals. RESULTS: The median scores of master surgeons fell in the 20th, 24th, and 30th percentiles, whereas the scores of medical students fell in the 50th, 20th, and 65th percentile of norm reference for the Gibson Spiral Maze, Crawford Small Parts Dexterity, and Space Relations tests, respectively. The master surgeons enacted significantly fewer errors (Gibson Spiral Maze), had similar execution times (Crawford Small Parts Dexterity), and lower visuo-spatial scores (Space Relations) than medical students. CONCLUSION: The level of eye-hand coordination and manual dexterity of master surgeons was found to be higher than that of the average norm including medical students, while their visuo-spatial ability was lower.
Aptitude Tests↗
What do master surgeons think of surgical competence and revalidation?
BACKGROUND: There has been on-going debate and public interest in surgical competence in recent years. METHODS: A Delphi reiterative opinion survey was conducted among master surgeons on selection of surgical trainees, methods of assessment of progress of surgical trainees, and revalidation of established consultant surgeons. RESULTS: Selection-the current methods of trainee selection were considered inadequate and in need of revision. The important attributes recognized by group are cognitive factors, innate dexterity, and personality. Important aspects of personality include decision-making ability, insight, team spirit, and emotional stability. Assessment during training-the majority view was that this should be based on clinical judgement/skills, operative skills, and cognitive ability. Assessment of technical ability should be based on standardized checklists. Research within training programs was encouraged but academic achievement does not reflect surgical competence. There was a majority verdict for an exit clinical examination. Revalidation-the group agreed on the need for competence checks during the professional career of surgeons. These should cover knowledge, clinical, operative, and humanistic skills; but expressed concern on the feasibility of a revalidation system that can reliably assess the range of skills needed for surgical competence. There was a majority vote against an internal appraisal system. External assessment by nationally appointed 'assessors' was considered preferable. CONCLUSIONS: Both selection and assessment of surgical trainees require changes and standardization. Although revalidation is necessary, concern was expressed on the reliability and validity of existing and proposed systems.
Clinical Competence↗
Measurements and modelling of the compliance of human and porcine organs.
Stress-strain data obtained from animal and human tissue have several applications including medical diagnosis, assisting in surgical instrument design and the production of realistic computer-based simulators for training in minimal access surgery. Such data may also be useful for corroborating mathematical models of tissue response. This paper presents data obtained from ex-vivo and in-vivo tissue indentation tests using a small indentor that is similar to instruments used in minimal access surgery. In addition, uniform stress tests provide basic material property data, via an exponential stress-strain law, to allow a finite element method to be used to predict the response for the non-uniform stresses produced by the small indentor. Data are obtained from harvested pig liver and spleen using a static compliance probe. Data for human liver are obtained from volunteer patients, undergoing minor open surgery, using a sterile hand-held compliance probe. All the results demonstrate highly non-linear stress-strain behaviour. Pig spleen is shown to be much more compliant than pig liver with mean elastic moduli of 0.11 and 4.0 MPa respectively. The right lobe of human liver had a mean elastic modulus of about 0.27 MPa. However, a single case of a diseased liver had a mean modulus of 0.74 MPa--nearly three times the stiffness. It was found that an exponential stress-strain law could accurately fit uniform stress test data and that subsequent finite element modelling for non-uniform stress around a small indentor matched measured force characteristics.
Animals↗
Central and peripheral adverse hemodynamic changes during laparoscopic surgery and their reversal with a novel intermittent sequential pneumatic compression device.
OBJECTIVE: To study the influence of a novel intermittent sequential pneumatic compression device (Lympha-press) on the adverse cardiac and peripheral hemodynamic changes induced by positive-pressure pneumoperitoneum (PPPn) in laparoscopic surgery. SUMMARY BACKGROUND DATA: Creation of PPPn is known to cause adverse central and peripheral hemodynamic changes. An intrasubject observational study was undertaken to quantitate these adverse changes and to assess the influence of an intermittent sequential pneumatic compression system on these adverse hemodynamic changes during laparoscopic surgery with PPPn. METHODS: The study involved 16 consecutive patients undergoing laparoscopic surgery with PPPn of 12 mmHg and 30 degrees head-up tilt position. The following peripheral hemodynamic recordings were made using Doppler ultrasound: peak systolic velocity (PSV), end diastolic velocity (EDV), and cross-sectional area of the femoral vein. Central monitoring included cardiac output and stroke volume by transesophageal Doppler, blood pressure, and pulse. The hemodynamic state based on these parameters was assessed before induction of PPPn with the anesthetized patient in the supine position, after induction of PPPn and head-up tilt position with Lympha-press off, and during PPPn and head-up tilt position with Lympha-press on, and after desufflation with the patient in the supine position under general anesthesia. RESULTS: Positive-pressure pneumoperitoneum and the head-up tilt position resulted in a 33% reduction in PSV, a 21% reduction in EDV, and a 29% increase in cross-sectional area of the femoral vein. This was associated with a 20% reduction in cardiac output and an 18% reduction in stroke volume. Activation of Lympha-press during PPPn and the head-up tilt position resulted in a 129% increase in PSV and a 55% increase in EDV by 55%. It also increased the cardiac output by 27% and stroke volume by 16%, with no effect on cross-sectional area. Compared with the pre-PPPn stage, there was no difference in cardiac output or stroke volume, but the PSV was higher by 78% and the EDV by 32%. After abdominal desufflation in the supine position, the cardiac output and stroke volume were restored to the pre-PPPn level, but persistent and significant elevations were observed during the period of study in PSV, EDV, and cross-sectional area. CONCLUSIONS: Significant and individually variable central and peripheral hemodynamic changes are encountered during laparoscopic surgery with PPPn and the head-up tilt position. These are reversed by intermittent sequential pneumatic compression using Lympha-press.
Adult↗