Adequate Patient Selection Research Articles

Study Protocol of the ESAP Study: Endoscopic Papillectomy vs. Surgical Ampullectomy vs. Pancreaticoduodenectomy for Ampullary Neoplasm-A Pancreas2000/EPC Study.

Background: Lesions of the Ampulla of Vater are a rare condition and represent <10% of peri-ampullary neoplasms. Nevertheless, ampullary adenomas have the potential for malignant transformation to ampullary carcinomas by an adenoma-to-carcinoma sequence. Thus, adequate patient selection and complete resection (R0) of non-invasive ampullary lesions either by endoscopic papillectomy (EP), surgical ampullectomy (SA), or pancreaticoduodenectomy (PD) is essential. Although PD was traditionally performed, recent studies reported considerable efficacy and fewer complications following EP and SA. Since consistent comparative data are lacking, the Endoscopic Papillectomy vs. Surgical Ampullectomy vs. Pancreaticoduodectomy (ESAP) study will provide evidence for a therapeutic standard and post procedure morbidity in ampullary lesions.Methods: International multicenter retrospective study. Adult patients (>18 years of age) who underwent SA or PD for ampullary neoplasm between 2004 and 2018 or EP between 2007 and 2018 will be evaluated. Main inclusion criteria are ampullary lesions strictly located to the ampulla. This includes adenoma, adenocarcinoma (T1 and T2), neuroendocrine tumors, gastrointestinal stroma tumors and other rare conditions. Exclusion criteria are peri-ampullary lesions, e.g., from the duodenal wall or the head of the pancreas, and interventions for tumor stages higher than T2. The main objective of this study is to analyze rates of complete resection (R0), recurrence and necessity for complementary interventions following EP, SA, and PD. Treatment-quality for each procedure will be defined by morbidity, mortality and complication rates and will be compared between EP, SA, and PD. Secondary objectives include outcome for patients with incomplete resection or initially understated tumors, lesions of the minor papilla, hereditary syndromes, neuroendocrine tumors, mesenchymal lesions, and other rare conditions. Additionally, we will analyze therapy by argon plasma coagulation and radiofrequency ablation. Furthermore, outcome in curative and palliative interventions can be distinguished.Conclusion: The ESAP study will provide evidence for therapeutic algorithms and data for the implementation of guidelines in the treatment of different types of ampullary tumors, including recurrent, or incomplete resected lesions.

Score-based improvement of the indication for surgical treatment ofthyroid lesions.

The prevalence of focal lesions in the thyroid is high in Germany. In 2018 about 70 000 thyroid surgeries were performed, although the malignancy rate of such findings is low. For this reason it is important to conduct an adequate selection of patients for whom surgery is indicated. The aim of our work was to validate the preoperative indication for surgery of thyroid lesions based on an independent, self-developed clinical score. The patient data were evaluated retrospectively over the period 2013 to 2014. A prerequisite for inclusion was that the patients had carried out their complete treatment in domo. The multiparametic score was determined retrospectively and ranges from 3 to 15. The subjective improvement of symptoms (self-disclosure > 6 months postoperatively) and the presence of malignant histology were evaluated as positive outcome parameters. From a collective of 180 patients, 36 patients could be included, in whom all score-relevant parameters had been surveyed. The score distribution was 10 % score 3, 12.5 % score 4, 25 % score 5, 25 % score 6, 12.5 % score 7, 7.5 % score 8, 5 % score 9 and 2.5 % score 10. Using ROC analysis shows an AUC of 0.903, which is a very good differentiation. With a CUT-off score of 7 or higher, 86 % of patients have benefited from surgery. Our score with the parameters clinical complaints, sonographically defined size of the thyroid and the cytological result of a fine needle biopsy can lead to an improvement of the indication for surgical treatment of thyroid nodules.

Feasibility of awake craniotomy in the pediatric population.

Awake craniotomy with direct cortical stimulation and mapping is the gold standard for resection of lesions near eloquent brain areas, as it can maximize the extent of resection while minimizing the risk of neurological damage. In contrast to the adult population, only small series of awake craniotomies have been reported in children. The aim of our study is to establish the feasibility of awake craniotomy in the pediatric population. We performed a retrospective observational study of children undergoing a supratentorial awake craniotomy between January 2009 and April 2019 in a pediatric tertiary care center. Our primary outcome was feasibility of awake craniotomy, defined as the ability to complete the procedure without conversion to general anesthesia. Our secondary outcomes were the incidence of serious intraoperative complications and the mapping completion rate. Thirty procedures were performed in 28 children: 12 females and 16 males. The median age was 14years (range 7-17). The primary diagnosis was tumor (83.3%), epilepsy (13.3%), and arterio-venous malformation (3.3%). The anesthetic techniques were asleep-awake-asleep (96.7%) and conscious sedation (3.3%), all cases supplemented with scalp block and pin-site infiltration. Awake craniotomy was feasible in 29 cases (96.7%), one patient converted to general anesthesia due to agitation. Serious complications occurred in six patients: agitation (6.7%), seizures (3.3%), increased intracranial pressure (3.3%), respiratory depression (3.3%), and bradycardia (3.3%). All complications were quickly resolved and without major consequences. Cortical mapping was completed in 96.6% cases. New neurological deficits occurred in six patients (20%)-moderate in one case and mild in 5-being all absent at 6months of follow-up. Awake craniotomy with intraoperative mapping can be successfully performed in children. Adequate patient selection and close cooperation between neurosurgeons, anesthesiologists, neuropsychologists, and neurophysiologists is paramount. Further studies are needed to determine the best anesthetic technique in this population group.

Prepectoral Two-Stage Implant-Based Breast Reconstruction with and without Acellular Dermal Matrix: Do We See a Difference?

Prepectoral implant-based breast reconstruction has gained popularity because of advantages over the subpectoral technique. Acellular dermal matrix use with implant-based breast reconstruction has become common because of its perceived superior aesthetic outcome. Matrices are expensive, however, and recent evidence has pointed to several potential complications. This article reports a series of prepectoral implant-based breast reconstructions with and without acellular dermal matrix and compared their outcomes. This is a single-surgeon retrospective review of patients who underwent staged prepectoral implant-based breast reconstruction following nipple-sparing mastectomy over two periods. Patients with well-perfused mastectomy skin flaps with a homogeneous thickness underwent reconstruction with acellular dermal matrix initially. On evolution of the practice, it was not used. Patient demographics, operative data, and complications were analyzed. Aesthetic outcome was measured by the BREAST-Q survey and the Aesthetic Item Scale. A cost analysis was also performed. Forty patients were included (acellular dermal matrix group, n = 19; non-acellular dermal matrix group, n = 21). The nonmatrix group had one case (5 percent) of seroma and one case (5 percent) with hematoma; there were none in the acellular dermal matrix group. Average BREAST-Q and Aesthetic Item Scale scores were 82.3 versus 81.6 (p = 0.954) and 20.98 versus 20.43 (p = 0.640) for the matrix and nonmatrix groups, respectively. The direct cost savings for the authors' institution over 1 year if matrix was not used in all cases of implant-based breast reconstruction would be estimated at $3,105,960 to $6,211,920 for unilateral and bilateral cases, respectively, for Medicare reimbursement. With adequate patient selection, acellular dermal matrix is not always required during two-stage prepectoral implant-based breast reconstruction for good aesthetic outcomes. The economic burden on patients and the health care system could be lessened with selective matrix use. Therapeutic, III.

Clinical and radiological assessment of the effect of low level laser therapy on delayed bone fractures healing

Low level laser has been conducted for treatment of bone fracture on animal and had shown positive results. If laser energy is delivered at optimal dose with appropriate parameters, it might get best results however a little research in the literature has conducted on the effect of low level laser on human bone fracture. The aim of the study was to assess the radiological and clinical difference of the effect of low level laser therapy on the delayed bone healing of patients with different bone fractures. This was a prospective study conducted in Benha university hospital on 33 patients with delayed and non-union of bone fractures via low level laser diode laser with a wavelength 905nm. There were 27 male 5 female patients, mean age group ±34.43 range (24 years to 67 years), the mean delayed of union was ± 6,68 range (3 months to 15 months ). At the end of the study, union is achieved in mean period±1,7( 1 month to 4,1 month)which led to success of about 70% improvement of the treated group, union mean number of sessions used ±23,375 (range 15 sessions to 50 sessions), Mean Visual Analog Scale (VAS) ± 1,3 range from (0 to 6). the present study indicate that Low level laser therapy is an effective modality for treatment of delayed bone fracture, can relieve pain and increase range of motion of the associated stiff joints with no adverse effect provided that adequate patient selection has conducted.

Single stage bilateral total hip arthroplasty - 10 years of experience

Background/Aim. Coxarthrosis is a chronic degenerative joint disorder which occurs in approximately 4% of population, and bilateral occurrence is estimated at 42%. Patients with bilateral coxarthrosis can undergo bilateral hip replacement in one or two stage procedure. Aim of this article was to present our experience in simultaneous bilateral hip arthroplasty, and to recommend it in patients with adequate indications. Methods. We processed data for 113 patients of both genders, operated at the Clinic for Orthopedic Surgery and Traumatology of the Military Medical Academy in Belgrade, Serbia from 2005 until 2015 where single stage bilateral hip arthroplasty was performed. Identical operative technique was applied in all patients as well as standard antibiotic and thromboprophylactic treatment. Follow-up period was 30 days postoperatively. Results. Mean age of patients was 56 ? 10.2 years, whereby 45 (39.8%) of them were males and 68 (60.2%) females. Primary coxarthrosis was etiologic factor for the majority of patients, 69 (61.1%). Postoperative hospitalization duration was 10.3 days on average (range from 3 to 34 days). We noticed the following complications: one luxation of the endoprosthesis, one deep infection and one thrombosis of the leg. There was no mortality. Majority of operated patients were grouped as the American Society of Anesthesiologists (ASA) scores 1-3. Mean blood transfusion was 1,275 mL (range from 300 to 2,830 mL). Conclusion. One stage bilateral hip arthroplasty can be performed routinely and safely in facilities with possibility for interdisciplinary approach and adequate selection of patients. Data from our study which indicate significantly increased need for blood substitution, emphasize the need to introduce contemporary perioperative blood loss management principles. The rate of complications observed in our study was within rates published in the literature concerning hip arthroplasty.

Radical surgery in hepatic hydatidosis: analysis of results in an endemic area.

radical surgery in hepatic hydatidosis is associated with less morbidity and recurrence than conservative surgery. a retrospective observational study of patients with liver hydatid cyst surgery was performed. Seventy-one patients with 90 cysts were included between 2007 and 2017, and radical surgery was performed in 69.01 %. there was no difference in morbidity, mortality, biliary leakage or recurrence according to surgery. Complicated cysts were associated with a longer hospital stay and morbidity. decision-making should consider age, comorbidity, cyst characteristics and available resources. Radical surgery should be applied whenever feasible as it achieves better results with an adequate selection of patients.

Major vascular complications after transfemoral arterial closure system implantation: a single-center study.

During the past decades, the use of vascular closure devices (VCDs) has been established due to the increasing number of interventions. Of particular concern is the perceived risk of VCDs for development of implant-induced vascular major complications. Therefore, the aim of this analysis was to report the variety of vascular access side complications after the use of VCDs, and to analyze the referred risk factors. All cases of vascular complications associated with VCD use requiring surgical repair from 2010 to 2016 were retrospectively analyzed in a single center trial. Systemic and local complications, risk factors as pre-existing diseases and their influence on the surgical outcome were evaluated. A total of 46 individuals were included in this study (male/female: 16/30). The total number of interventions in the involved departments of the study center during the same period was 9754 Therefore the complication rate after VCD implantation was 0.47%. The detected complications ranged from symptomatic claudication (N.=24) to acute leg ischemia (N.=19) and major bleeding (N.=3). Surgical reconstruction was performed by direct suture (N.=4), transverse arteriotomy with thrombectomy (N.=2), endarterectomy with patchplasty (N.=35), inguinal graft interposition or bypass (N.=3) and primary major amputation (N.=2). In regard to the risk factors, the study has concluded that atherosclerosis, female gender and diabetes mellitus are correlated with major vascular complications (bleeding and limb ischemia). However, in cases with therapeutic anticoagulation the rate of major bleeding was significantly elevated (P=0.028). Reported complication rates associated with femoral VCD implantation are low. However, in some cases VCD implantation may account for severe complications including limb losses. Therefore, an adequate patient selection is necessary to detect those cases at higher risk for complications.

Nonoperative management of splenic injury in closely monitored patients with reduced consciousness is safe and feasible

BackgroundTreatment of blunt splenic injury has changed over the past decades. Nonoperative management (NOM) is the treatment of choice. Adequate patient selection is a prerequisite for successful NOM. Impaired mental status is considered as a relative contra indication for NOM. However, the impact of altered consciousness in well-equipped trauma institutes is unclear. We hypothesized that impaired mental status does not affect outcome in patients with splenic trauma.MethodsOur prospectively composed trauma database was used and adult patients with blunt splenic injury were included during a 14-year time period. Treatment guidelines remained unaltered over time. Patients were grouped based on the presence (Group GCS: < 14) or absence (Group GCS: 14–15) of impaired mental status. Outcome was compared.ResultsA total of 161 patients were included, of whom 82 were selected for NOM. 36% of patients had a GCS-score < 14 (N = 20). The median GCS-score in patients with reduced consciousness was 9 (range 6–12). Groups were comparable except for significantly higher injury severity scores in the impaired mental status group (19 vs. 17, p = 0.007). Length of stay (28 vs. 9 days, p < 0.001) and ICU-stay (8 vs. 0 days, p = 0.005) were longer in patients with decreased GCS-scores. Failure of NOM, total splenectomy rates, complications and mortality did not differ between both study groups.ConclusionThis study shows that NOM for blunt splenic trauma is a viable treatment modality in well-equipped institutions, regardless of the patients mental status. However, the presence of neurologic impairment is associated with prolonged ICU-stay and hospitalization. We recommend, in institutions with adequate monitoring facilities, to attempt nonoperative management for blunt splenic injury, in all hemodynamically stable patients without hollow organ injuries, also in the case of reduced consciousness.

Clinical pilot study to evaluate the neovaginal PACIENA prosthesis\xae for vaginoplasty without skin grafts in women with vaginal agenesis

BackgroundTo evaluate the feasibility and clinical outcomes of vaginoplasties using a neovaginal polylactic acid prosthesis made with 3-dimensional (3D) printing technology as an intraneovaginal mould.MethodsThis was an interventionist, prospective, and multicentre clinical pilot investigation of a sanitary product (PACIENA prosthesis®) aiming to recruit and operate on 8 patients over 6 months with a follow-up period of 6 months. Only six patients with Rokitansky syndrome and one patient with Morris syndrome (7 patients in total) were operated on in two university hospitals: “La Fe”, Valencia (H1) and “Arrixaca”, Murcia (H2). Interventions: Extensive surgical dissection of a defined space between the urethra and bladder in the front and of the rectum in the back as well as insertion of the PACIENA prosthesis® covered with Interceed® were performed. After 12 days, the prosthesis was changed to the silicone-covered version for daily application.ResultsIn the 6 patients with Rokitansky syndrome (86%), the primary endpoint (satisfactory vaginal outcome in terms of appearance, function, and sensation without relevant additional morbidity) was achieved, although only 2 patients (28%) were sexually active at the end of 6 months of follow-up. The patient with Morris syndrome withdrew from the study after 1 month. Patients without bacterial colonization showed positive Schiller tests at 1 month, and subsequent biopsies showed adequate keratinization and epidermization. Epithelization and iodopositivity were delayed in the patients who developed inflammatory granulomas.ConclusionsGood anatomical and functional results can be achieved with the PACIENA prosthesis® for vaginoplasties without skin grafts. However, adequate patient selection and education, good surgical techniques and haemostasis, postoperative support, and prevention of bacterial colonization are important.Trial registrationThis clinical study was approved by the Ethical Clinical Investigation Committee of San Juan University Hospital on September 27, 2016, to be conducted in the participating centres; it was authorized by the Spanish Agency of Medicines and Health Products (AEMPS) on April 24, 2017 (exp. no. 585/16/EC), to be carried out in that hospitals.

The Differential Impact of SRC Expression on the Prognosis of Patients with Head and Neck Squamous Cell Carcinoma.

Aberrant SRC expression and activation is frequently detected in multiple cancers, and hence, targeting SRC has emerged as a promising therapeutic strategy. Different SRC inhibitors have demonstrated potent anti-tumor activity in preclinical models, although they largely lack clinical efficacy as monotherapy in late-stage solid tumors, including head and neck squamous cell carcinomas (HNSCC). Adequate selection and stratification of patients who may respond to and benefit from anti-SRC therapies is therefore needed to guide clinical trials and treatment efficacy. This study investigates the prognostic significance of active SRC expression in a homogeneous cohort of 122 human papillomavirus (HPV)-negative, surgically treated HNSCC patients. Immunohistochemical evaluation of the active form of SRC by means of anti-SRC Clone 28 monoclonal antibody was specifically performed and subsequently correlated with clinical data. The expression of p-SRC (Tyr419), total SRC, and downstream SRC effectors was also analyzed. Our results uncovered striking differences in the prognostic relevance of SRC expression in HNSCC patients depending on the tumor site. Active SRC expression was found to significantly associate with advanced disease stages, presence of lymph node metastasis, and tumor recurrences in patients with laryngeal tumors, but not in the pharyngeal subgroup. Multivariate Cox analysis further revealed active SRC expression as an independent predictor of cancer-specific mortality in patients with laryngeal carcinomas. Concordantly, expression of p-SRC (Tyr419) and the SRC substrates focal adhesion kinase (FAK) and the Arf GTPase-activating protein ASAP1 also showed specific associations with poor prognosis in the larynx. These findings could have important implications in ongoing Src family kinase (SFK)-based clinical trials, as these new criteria could help to improve patient selection and develop biomarker-stratified trials.

869P - Real-world use of radium-223 for treatment of metastatic castration resistant-prostate cancer (mCRPC): Results from the Dutch CAPRI registry

869P - Real-world use of radium-223 for treatment of metastatic castration resistant-prostate cancer (mCRPC): Results from the Dutch CAPRI registry

P1837HFpEF reverses in more than a quarter of patients after thoracoscopic AF ablation

Abstract Purpose To evaluate the proportion of patients in whom parameters that define the diagnosis of HFpEF and HFmrEF persist versus normalize upon elimination of AF. Background Atrial fibrillation (AF) and heart failure with preserved or mid-range ejection fraction (HFpEF or HFmrEF) concur in many patients. Distinction between these two diagnoses remains challenging as one can cause or exacerbate the other. Adequate patient selection for invasive AF treatment is crucial to improve rhythm outcome. Methods Patients underwent thoracoscopic ablation, consisting of pulmonary vein isolation (PVI) alone or PVI with additional lines in the case of persistent AF. Patients were prospectively followed-up. HFmrEF or HFpEF was defined as left ventricular ejection fraction (LVEF) ≥40% or ≥50% respectively and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels &gt;125 pg/ml. Patients who remained free from AF, or any atrial tachycardia of more than 30 seconds, at 6 months postoperatively, were included in this study. Patients with AF recurrences during this period were excluded. The primary outcome was the change of NT-proBNP at 6 month follow-up. Results From 2008 to 2017, 92 patients undergoing thoracoscopic AF ablation fulfilled the aforementioned criteria and were included. Of these patients, mean age was 61±8 years and 66 (72%) were male. Median NT-proBNP was 366 pg/ml (128–2916) and mean LVEF was 53±7%. Thirty (35%) patients had a LVEF of 40–49%. Six months after elimination of AF, NT-proBNP was &lt;125 pg/ml (Figure 1A: median 87 (50–122) vs 459 (137 – 2916) pg/ml at baseline; p&lt;0.001) in 26 patients (28%), whereas in the remaining patients NT-proBNP was unchanged (Figure 1B: median 298 (126–1568) vs. 318 (128–2387) pg/ml at baseline; p=0.011). Figure 1. NT-proBNP alterations after thoracoscopic AF ablation from baseline to 6 month follow-up. A. Patients with normalization of NT-proBNP. B. Patients with unchanged high levels of NT-proBNP. Conclusion In 28% of patients the diagnostic criteria of HFpEF/HFmrEF are caused by AF and normalize upon elimination of AF with thoracoscopic ablation.

Very low-dose direct oral anticoagulants combined with platelet inhibitors in coronary artery disease: ready for widespread use?

Very low-dose anticoagulation in the form of rivaroxaban twice daily is a welcoming addition to the current antithrombotic arsenal in high-risk patients with acute coronary syndrome or stable coronary artery disease. Adequate patient selection in line with the entry criteria of the approval trials appears to be critical to avoid excessive bleeding.

Rhabdomyolysis and muscle infarcts associated with intra-operative compression

Rhabdomyolysis and muscle infarcts associated with intra-operative compression

Is strict adherence to the nonoperative management protocol associated with better outcome in patients with blunt splenic injuries?: A retrospective comparative cross-sectional study.

The nonoperative management (NOM) protocol with angioembolization (AE) presents a trend in dealing with trauma patients with blunt splenic injury (BSI). This study was designed to explore the adverse events and associated risk factors before and after protocol-based NOM of BSI over a 12-year period. A retrospective study was performed on adult trauma patients with BSI who were admitted from 2005 to 2016. The patients were divided into before cohort (2005-2010) and after cohort (2011-2016). Multivariate logistic regression analysis was performed to identify risk factors associated with the morbidity. The primary outcomes are NOM-related mortality and total number of complications, the secondary outcome is the incidence of each complication. The before cohort was composed of 209 patients, and the after cohort had 190 patients. There was a significant increase in the use of AE (from 18.1% to 47.5%, p < 0.001) with a higher incidence of patients who had a shock episode before AE (from 4.2% to 16.5%, p < 0.001). Regarding the outcomes, there were no significant differences in the incidences of NOM-related mortality between the after than before cohorts. However, there were 190 complications in 71 patients in the before cohort but 289 complications in 73 patients in the after cohort. The incidence of complications was significantly higher in the group of after cohort than the group of before cohort. Regarding the complications, the patients in the after cohort were significantly more likely to have adverse events of coagulopathy, acidosis, hyperbilirubinemia, respiratory failure, and acute kidney injury than those in the before cohort. Strict adherence to the NOM protocol in treating patients with BSI without adequate patient selection increased not only the use of NOM but also the possibility of complications and failed to significantly improve the clinical outcomes.

Minimally invasive mitral valve repair.

Minimally invasive mitral valve (MV) repair is being increasingly performed over the last 2 decades due to the constantly growing patient demand, since it offers a shorter recovery, less restriction and faster return to normal physical activities, reduction in pain, and superior cosmetic results. However, such procedures have to be performed through small incisions which limit visualization and the freedom of movement of the surgeon, in contrast to conventional operations that are performed through a sternotomy. Therefore, special long surgical instruments are required, and visualization is usually enhanced with advanced port-access two-dimensional (2D) or three-dimensional (3D) thoracoscopic cameras. This makes performance of a minimally invasive MV repair more challenging for the surgeon and is thereby associated with a steep learning curve. Nonetheless, the vast majority of patients who require MV repair are usually good candidates for this less invasive technique, though adequate patient selection is of utmost importance for success. Concomitant cardiac procedures such as ablation surgery for atrial fibrillation or right-sided interventions such as tricuspid valve surgery, heart tumor resection, and atrial septal defect closure can easily be performed using this approach. Short- and long-term results after minimally invasive MV repair are excellent and comparable with those achieved through a sternotomy approach. There are few drawbacks associated with minimally invasive MV repair such as the high technical demands of working through a constrained space and development of complications associated with peripheral cannulation and seldom unilateral pulmonary edema. Nonetheless, high-volume centers have been able to achieve similar operating times, postoperative complication rates, and mid-/long-term outcomes to those obtained through conventional sternotomy. Up-to-date evidence is needed in order to improve recommendations supporting minimally invasive MV repair. Future innovations should concentrate on decreasing complexity and improving reproducibility of minimally invasive procedures in low-volume centers.

Prehabilitation before major intra-abdominal cancer surgery: A systematic review of randomised controlled trials.

Although prehabilitation programmes for patients undergoing major intra-abdominal cancer surgery have been shown to improve pre-operative physical fitness, the conclusions regarding any postoperative benefits are inconsistent. The aim of this study was to evaluate the content of and the outcome measures used in studies of prehabilitation programmes for these patients. It was hypothesised that the content of prehabilitation programmes is often therapeutically invalid, and that the postoperative outcomes assessed are inadequate to evaluate the impact of complications. A systematic review of randomised controlled trials. Studies published between January 2009 and January 2019 were retrieved from PubMed, Embase and PEDro. Studies were included when they investigated the effects of prehabilitation in patients undergoing intra-abdominal surgery for cancer, reported pre-operative and/or postoperative outcome measures and were conducted as a randomised controlled trial. Studies for which the full text was not available were excluded, as were studies of patients undergoing nonabdominal cancer surgery. Eight studies (565 patients) were included. Therapeutic validity was low in five studies. Most studies included low-risk surgical patients and considerable variation was observed between prehabilitation programmes in terms of supervision, training context, frequency, intensity, duration and training type. Objective monitoring of training progression was typically not performed, and most trials did not include nutritional or psychological support. Postoperative complications were reported in seven studies, but no study reported the impact of postoperative complications, nor on long-term postoperative outcomes. The content of prehabilitation programmes was heterogeneous. Studies with a high therapeutic validity found unequivocal evidence that prehabilitation had beneficial effects on postoperative outcomes. Future research should focus on adequate selection and inclusion of high-risk surgical patients and provide personalised and probably multimodal (partly) supervised prehabilitation, with objective monitoring of progress. Measuring the incidence and impact of postoperative complications may contribute to demonstrating the clinical value of prehabilitation.

Physician factors in utilizing haemodynamic data in patient care.

To focus on the missing link between accuracy and precision of monitoring devices and effective implementation of therapeutic strategies. Haemodynamic monitoring is generally considered to be an essential part of intensive care medicine. However, randomized controlled trials fail to demonstrate improved outcome unequivocally as a result of hemodynamic monitoring. This absence of solid proof renders doctors to hesitance to apply haemodynamic monitoring in clinical practise. Profound understanding of the underlying mechanisms, adequate patient selection and timing, meaningful representation and software-supported interpretation of data all play an important role. Furthermore, protocol adherence and human behaviour seem to form the often missing link between a solid physiologic principle and clinically relevant outcome. Introduction of haemodynamic monitoring should therefore not be limited to theoretical and practical issues, but also involve integration strategies. By learning from others, we might be able to implement haemodynamic monitoring in such a way that it has potential to modify the course of a disease. The clinical success of haemodynamic monitoring goes far beyond accuracy and precision of monitoring devices. Understanding of the factors influencing the effective implementation of therapeutic strategies plays an important role in the meaningful introduction of haemodynamic monitoring.

Practical guidelines for the use of technetium-99m mebrofenin hepatobiliary scintigraphy in the quantitative assessment of liver function.

Surgical resection remains the most important curative treatment for liver tumors; however, it harbors the risk of developing posthepatectomy liver failure. The principal risk is associated with the quality and quantity of the future remnant liver. Therefore, preoperative assessment of the future remnant liver is essential in patients scheduled for major liver resection. Technetium-99m mebrofenin hepatobiliary scintigraphy (HBS) in combination with single-photon emission computed tomography/computed tomography is increasingly applied for the quantitative assessment of liver function before major liver surgery. This dynamic quantitative liver function test allows assessment of both total and regional liver function, represented by the hepatic mebrofenin uptake rate, thereby assisting in adequate patient selection. Since routine implementation, it has shown to reduce the risk of posthepatectomy liver failure and has proven to be more valuable than volumetric assessment. To ensure optimal and reproducible results that can be compared across different centers, it is crucial to standardize the methodology and ensure practical applicability of this technique, thereby facilitating external validation and multicenter trials. This article provides an overview of the HBS methodology used at some of the largest HBS centers and covers practical details in the application of HBS for the quantitative scintigraphic assessment of liver function.