Current Surgical Guidelines Research Articles

Application of machine learning for predicting lymph node metastasis in T1 colorectal cancer: a systematic review and meta-analysis.

We review and analyze research on the application of machine learning (ML) and deep learning (DL) models to lymph node metastasis (LNM) prediction in patients with T1 colorectal cancer (CRC). Predicting LNM before radical surgery is important in patients with T1 CRC. However, current surgical treatment guidelines are limited. LNM prediction using ML or DL may improve predictive accuracy. The diagnostic accuracy of LNM prediction using ML- and DL-based models for patients with CRC was assessed. We performed a comprehensive search of the PubMed, Embase, and Cochrane databases (inception to April 30th of 2022) for studies that applied ML or DL to LNM prediction in T1 CRC patients specifically to compare with histopathological findings and not related to radiological aspects. 33,199 T1 CRC patients enrolled across seven studies with a retrospective design were included. LNM was observed in 3,173 (9.6%) patients. Overall, the ML- and DL-based model exhibited a sensitivity of 0.944 and specificity of 0.877 for the prediction of LNM in patients with T1 CRC. Six different types of ML and DL models were used across the studies included in this meta-analysis. Therefore, a high degree of heterogeneity was observed. The ML and DL models provided high sensitivity and specificity for predicting LNM in patients with T1 CRC, and the heterogeneity between studies was significant. These results suggest the potential of ML or DL as diagnostic tools. However, more reliable algorithms should be developed for predicting LNM before surgery in patients with T1 CRC.

A Computational Framework for the Administration of 5-Aminovulinic Acid Before Glioblastoma Surgery.

5-Aminolevulinic Acid (5-ALA) is the only fluorophore approved by the FDA as an intraoperative optical imaging agent for fluorescence-guided surgery in patients with glioblastoma. The dosing regimen is based on rodent tests where a maximum signal occurs around 6h after drug administration. Here, we construct a computational framework to simulate the transport of 5-ALA through the stomach, blood, and brain, and the subsequent conversion to the fluorescent agent protoporphyrin IX at the tumor site. The framework combines compartmental models with spatially-resolved partial differential equations, enabling one to address questions regarding quantity and timing of 5-ALA administration before surgery. Numerical tests in two spatial dimensions indicate that, for tumors exceeding the detection threshold, the time to peak fluorescent concentration is 2-7h, broadly consistent with the current surgical guidelines. Moreover, the framework enables one to examine the specific effects of tumor size and location on the required dose and timing of 5-ALA administration before glioblastoma surgery.

Surgical De-Escalation for Re-Excision in Patients with a Margin Less Than 2 mm and a Diagnosis of DCIS.

The current surgical guidelines recommend an optimal margin width of 2 mm for the management of patients diagnosed with ductal carcinoma in situ (DCIS). However, there are still many controversies regarding re-excision when the optimal margin criteria are not met in the first resection. The purpose of this study is to understand the importance of surgical margin width, re-excision, and treatments to avoid additional surgery on locoregional recurrence (LRR). The study is retrospective and analyzed surgical margins, adjuvant treatments, re-excision, and LRR in patients with DCIS who underwent breast-conserving surgery (BCS). A total of 197 patients were enrolled. Re-operation for a close margin rate was 13.5%, and the 3-year recurrence was 7.6%. No difference in the LRR was reported among the patients subjected to BCS regardless of the margin width (p = 0.295). The recurrence rate according to margin status was not significant (p = 0.484). Approximately 36.9% (n: 79) patients had resection margins < 2 mm. A sub-analysis of patients with margins < 2 mm showed no difference in the recurrence between the patients treated with a second surgery and those treated with radiation (p = 0.091). The recurrence rate according to margin status in patients with margins < 2 mm was not significant (p = 0.161). The margin was not a predictive factor of LRR p = 0.999. Surgical re-excision should be avoided in patients with a focally positive margin and no evidence of the disease at post-surgical imaging.

941 A Systematic Review of Surgical Intervention Criteria for Thoracic Aortic Aneurysms

Abstract Aim Elective surgical repair of thoracic aortic aneurysms (TAAs) is the only treatment that prevents dissection or rupture. Current guidelines from the American College of Cardiology/American Heart Association and the European Society of Cardiology, recommend an aortic diameter threshold of 5.5cm for surgical intervention of TAAs. Recent studies have questioned the efficacy of current guidelines as they highlighted that the majority of dissections occur before reaching the threshold. This review aims to determine if an aortic diameter of 5.5cm is an appropriate threshold for prophylactic surgical repair of non-syndromic ascending TAAs. Method A search of Ovid MEDLINE and Pubmed databases was performed. Search terms included “ascending thoracic aortic aneurysm”, “ATAA”, “aortic diameter” and “aortic size paradox”. Non-English papers, animal studies and case reports were excluded. Reference lists from each article were assessed for further literature which met the inclusion criteria. Results 22 studies were included. Four themes emerged from these papers which support lowering the threshold for prophylactic surgery: quantifying the changes in aortic diameter that occur during dissection, the discovery of the aortic size paradox, the identification of a new hinge point, and the improved safety of modern surgery. Regardless of this evidence, it appears to be unjustified to lower the threshold based on relative risk calculations. Conclusions Despite current guidelines, the use of aortic diameter as a risk assessment tool for TAAs is inadequate. Multiple studies have shown the ineffectiveness of a 5.5cm threshold, suggesting revision of current surgical guidelines is warranted.

Enterobacter cloacae infection characteristics and outcomes in battlefield trauma patients.

Enterobacter cloacae is a Gram-negative rod with multidrug-resistant potential due to chromosomally-induced AmpC β-lactamase. We evaluated characteristics, antibiotic utilization, and outcomes associated with battlefield-related E. cloacae infections (2009-2014). Single initial and serial E. cloacae isolates (≥24 hours from initial isolate from any site) associated with a clinical infection were examined. Susceptibility profiles of initial isolates in the serial isolation group were contrasted against last isolate recovered. Characteristics of 112 patients with E. cloacae infections (63 [56%] with single initial isolation; 49 [44%] with serial isolation) were compared to 509 patients with bacterial infections not attributed to E. cloacae. E. cloacae patients sustained more blast trauma (78%) compared to non-E. cloacae infections patients (75%; p<0.001); however, injury severity scores were comparable (median of 34.5 and 33, respectively; p = 0.334). Patients with E. cloacae infections had greater shock indices (median 1.07 vs 0.92; p = 0.005) and required more initial blood products (15 vs. 14 units; p = 0.032) compared to patients with non-E. cloacae infections. Although E. cloacae patients had less intensive care unit admissions (80% vs. 90% with non-E. cloacae infection patients; p = 0.007), they did have more operating room visits (5 vs. 4; p = 0.001), longer duration of antibiotic therapy (43.5 vs. 34 days; p<0.001), and lengthier hospitalizations (57 vs. 44 days; p<0.001). Patients with serial E. cloacae had isolation of infecting isolates sooner than patients with single initial E. cloacae (median of 5 vs. 8 days post-injury; p = 0.046); however, outcomes were not significantly different between the groups. Statistically significant resistance to individual antibiotics did not develop between initial and last isolates in the serial isolation group. Despite current combat care and surgical prophylaxis guidelines recommending upfront provision of AmpC-inducing antibiotics, clinical outcomes did not differ nor did significant antibiotic resistance develop in patients who experienced serial isolation of E. cloacae versus single initial isolation.

Ascending aortic volume: A feasible indicator for ascending aortic aneurysm elective surgery?

Diameter-based criterion have been widely adopted for preventive surgery of ascending thoracic aortic aneurysm (ATAA). However, recent and growing evidence has shown that diameter-based methods may not be sufficient for identifying patients who are at risk of an ATAA. In this study, fluid-structure interaction (FSI) analysis was performed on one-hundred ATAA geometries reconstructed from clinical data to examine the relationship between hemodynamic conditions, ascending aortic volume (AAV), ascending aortic curvature, and aortic ratios measured from the reconstructed 3D models. The simulated hemodynamic and biomechanical parameters were compared among different groups of ATAA geometries classified based on AAV. The ATAAs with enlarged AAV showed significantly compromised hemodynamic conditions and higher mechanical wall stress. The maximum oscillatory shear index (OSI), particle residence time (PRT) and wall stress (WS) were significantly higher in enlarged ATAAs compared with controls (0.498 [0.497, 0.499] vs 0.499 [0.498, 0.499], p = 0.002, 312.847 [207.445, 519.391] vs 996.047 [640.644, 1573.140], p < 0.001, 769.680 [668.745, 879.795] vs 1072.000 [873.060, 1280.000] kPa, p < 0.001, respectively). Values were reported as median with interquartile range (IQR). AAV was also found to be more strongly correlated with these parameters compared to maximum diameter. The correlation coefficient between AAV and average WS was as high as 0.92 (p < 0.004), suggesting that AAV might be a feasible risk identifier for ATAAs. Statement of SignificanceAscending thoracic aortic aneurysm is associated with the risk of dissection or rupture, creating life-threatening conditions. Current surgical intervention guidelines are mostly diameter based. Recently, many studies proposed to incorporate other morphological parameters into the current clinical guidelines to better prevent severe adverse aortic events like rupture or dissection. The purpose of this study is to gain a better understanding of the relationship between morphological parameters and hemodynamic parameters in ascending aortic aneurysms using fluid-solid-interaction analysis on patient-specific geometries. Our results suggest that ascending aortic volume may be a better indicator for surgical intervention as it shows a stronger association with pathogenic hemodynamic conditions.

Patient Safety and organizational Safety Culture in Surgery: A Need of an Hour in the developing countries

Every year, more than 200 million surgeries are performed around the world, and recent statistics show that adverse event rates for surgical pathologies remain unacceptably high, despite several national and global patient safety initiatives over the last decade. Patient safety is diverse and highly complicated in nature, with several critical components. Although concern for patient safety is fundamental in health care practice, its transition into knowledge is comparatively recent, and hence patient safety may be deemed a "new" field. Current surgical safety guidelines and checklists are generic and not adapted to specific patient concerns and risk factors in surgical subspecialties. All surgical practitioners and health care organizations must therefore become better aware of the fundamental context of patient safety, actively participate in endeavors to integrate patient safety measures in daily practice, and foster a patient safety culture. The purpose of this review article is to outline patient safety in surgical techniques that should be adopted and implemented.

The glitz and glamour randomized trial: the effect of fingernail polish on post-caesarean surgical site infection

Current surgical scrub guidelines suggest that fingernail polish should not be worn by healthcare providers despite collective evidence not demonstrating a relationship between fingernail polish and surgical-site infection (SSI). The purpose of this study was to determine the effect of surgical staff wearing nail polish on the incidence of SSI after caesarean delivery. In this calendar block-randomised clinical trial, surgical staff were assigned to wear nail polish or to have unpainted nails for alternating two-week periods. The primary outcome was surgical site infection within 6 weeks of caesarean delivery. There were 372 patients in the nail polish arm and 465 in the polish-free arm. The rate of SSIs was not significantly different between the nail polish arm and the polish-free arm (1.3% vs 2.8% p = .155). We found the rate of SSI following caesarean delivery is not significantly affected by surgical staff wearing fingernail polish. Impact Statement What is already known on this subject? Current surgical scrub guidelines state that fingernail polish should not be worn by healthcare providers even though the collective evidence has not been able to show the relationship between fingernail polish and surgical site infection. Previous studies have only used bacterial colony count after handwashing as a primary endpoint. The evidence they provide for developing scrub guidelines have been contradictory and inconclusive. What do the results of this study add? To better inform surgical scrub guidelines, evidence is needed that evaluates the effect of fingernail polish on clinically significant endpoints. Our study, Glitz & Glamour, examined 885 non-emergent Caesarian sections using a calendar-block schedule to determine if wearing nail polish had an impact on rates of surgical site infection. What are the implications of these findings for clinical practice and/or further research? Results suggested that fingernail polish had no difference on frequency of surgical site infections, and neither condition of the polish (chipped vs. freshly applied) nor the type of polish (gel vs. regular) had any impact either.

Functional Characterization of Neutrophils Allows Source Control Evaluation in a Murine Sepsis Model.

Current surgical guidelines for the treatment of intra-abdominal sepsis recommend interventional source control as the key element of therapy, alongside resuscitation and antibiotic administration. Past trials attempted to predict the success of interventional source control to assess whether further interventional therapy is needed. However, no predictive score could be developed. We utilized an established murine abdominal sepsis model, the cecal ligation and puncture (CLP), and performed a successful surgical source control intervention after full development of sepsis, the CLP-excision (CLP/E). We then sought to evaluate the success of the source control by characterizing circulating neutrophil phenotype and functionality 24h postintervention. We showed a significant relative increase of neutrophils and a significant absolute and relative increase of activated neutrophils in septic mice. Source control with CLP/E restored these numbers back to baseline. Moreover, main neutrophil functions, the acidification of cell compartments, such as lysosomes, and the production of Tumor Necrosis Factor-alpha (TNF-α), were impaired in septic mice but restored after CLP/E intervention. Neutrophil characterization by phenotyping and evaluating their functionality indicates successful source control in septic mice and can serve as a prognostic tool. These findings provide a rationale for the phenotypic and functional characterization of neutrophils in human patients with infection. Further studies will be needed to determine whether a predictive score for the assessment of successful surgical source control can be established.

Aesthetic breast surgery: putting in context-a narrative review.

This review article summarises the latest evidence for commonly undertaken procedures in aesthetic breast surgery with a focus on key principles of breast augmentation, reduction, and mastopexy. The paper also outlines various approaches and controversies as well as complications such as breast implant associated anaplastic large cell lymphoma (BIA-ALCL) and breast implant illness (BII) which are increasingly being recognised and becoming a challenge to manage. Changing trends of aesthetic breast surgery over the decades has warranted a continuous evolution of this field. The ability to deliver safe and appropriate care is dependent upon sound reconstructive principles and proper training. The lack of uniformity in either is a cause of concern. The impact of social media and changing perception of body image can also no longer be overlooked in the field of aesthetics and reconstruction. Review of literature including recent journals, textbook chapters, online databases like PubMed, and current government and surgical society guidelines. Breast reconstruction is based on sound surgical principles and it is imperative to follow these for the practice of this speciality. There are two important issues that revolve around this aspect of surgery. First relates to the urgent need to invest time and effort in improving regulations and outcomes in the cosmetic surgery industry. Second, it is crucial to promote and prioritize the development and training in this field as the principles of aesthetic breast surgery underpins oncoplastic breast surgery for management of cancer.

Prevention of Venous Thromboembolism in Gynecologic Surgery: ACOG Practice Bulletin, Number 232.

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are collectively referred to as "venous thromboembolic events" (VTE). Despite advances in prophylaxis, diagnosis, and treatment, VTE remains a leading cause of cost, disability, and death in postoperative and hospitalized patients (1, 2). Beyond the acute sequelae of leg pain, edema, and respiratory distress, VTE may result in chronic conditions, including postthrombotic syndrome (3), venous insufficiency, and pulmonary hypertension. This Practice Bulletin has been revised to reflect updated literature on the prevention of VTE in patients undergoing gynecologic surgery and the current surgical thromboprophylaxis guidelines from the American College of Chest Physicians (4). Discussion of gynecologic surgery and chronic antithrombotic therapy is beyond the scope of this document.

Knowledge, attitude and experience of episiotomy practice among obstetricians and midwives: a cross-sectional study from China

ObjectiveEpisiotomy is still performed widely by obstetricians and midwives in some Chinese maternity units, but the reasons are unknown. This study aims to determine the knowledge, attitude and experience towards...

Peri-tumoral brain edema associated with glioblastoma correlates with tumor recurrence.

Glioblastoma is the most common malignant tumor of the brain. Despite advances in treatment, the prognosis for the condition has remained poor. Glioblastoma is often associated with peritumoral brain edema (PTBE), which can result in increased intracranial pressure and devastating neurological sequelae if left untreated. Surgery is the main treatment for glioblastoma, however current international surgical guidelines do not specify whether glioblastoma-induced PTBE tissue should be resected. In this study, we analyzed treatment outcomes of PTBE using surgical resection. We performed a retrospective analysis of 255 cases of glioblastoma between 2014 and 2016, and found that a significant proportion of patients had a degree of PTBE. We found that surgical resection led to reduction in midline shift that had resulted from edema, however, postoperative complications and KPS scores were not significantly different in the two conditions. We also observed a delay in glioblastoma recurrence in patients undergoing PTBE tissue resection vs patients without resection of PTBE tissue. Interestingly, there was an abnormal expression of tumor associated genes in PTBE, which has not been previously been found. Taken together, this study indicates that glioblastoma-induced PTBE should be investigated further particularly as the tumor microenvironment is a known therapeutic target and therefore interactions between the microenvironment and PTBE should be explored. This study also highlights the importance of resection of PTBE tissue to not only reduce the mechanical obstruction associated with edema but also to delay recurrence of glioblastoma.

Outcomes After Decompressive Craniectomy for Ischemic Stroke: A Volumetric Analysis

Decompressive hemicraniectomy (DHC) is a treatment of space-occupying hemispheric infarct. Current surgical guidelines use criteria of age <60 years and surgery within 48 hours of stroke onset. The purpose of this study was to evaluate the neurologic outcome after DHC and evaluate the relationship of stroke volume and outcomes. A retrospective review was performed of patients undergoing DHC for cerebral infarct from 2016 to 2019. Unfavorable outcome was defined as modified Rankin Scale (mRS) score >3. Patients with precraniectomy magnetic resonance imaging were selected as a subset for volumetric stroke volume analysis using RAPID software (iSchemaView, Redwood City, California), with stroke volume defined as apparent diffusion coefficient <620 on diffusion-weighted imaging. Fifty-two patients met the inclusion criteria. At 90 days, favorable outcome was achieved in 11 patients (21.2%), and 41 patients (78.8%) had unfavorable outcomes (15 [29%] died). Surgery after 48 hours, age >60 years, and multivessel distribution did not significantly affect 90-day mRS score (P= 0.091, 0.111, and 0.664, respectively). In volumetric subset analysis, 10 patients of 41 (31.3%) achieved favorable outcomes, and no patients with volume of infarct >280 mL had a favorable outcome. There was a trend of lower volumes associated with favorable outcomes, but this did not meet significance (favorable 207 ± 68.7 vs. unfavorable 262 ± 117.1; P= 0.163). Outcomes after DHC for malignant hemispheric infarct were not affected by current accepted guidelines. Volume of infarct may have an effect on outcome after DHC. Further research to aid in predicting which patients benefit from decompressive craniectomy is warranted.

A new randomized controlled trial on abdominal aortic aneurysm repair is needed

Guidelines from societies are based on selected literature and scientific evidence preferably derived from randomized controlled trials (RCTs). Recent Society for Vascular Surgery guidelines 1 Chaikof E.L. Dalman R.L. Eskandari M.K. Jackson B. Lee W.A. Mansour A. et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg. 2018; 67: 2-77.e2 Abstract Full Text Full Text PDF PubMed Scopus (957) Google Scholar on the care of patients with abdominal aortic aneurysm (AAA) recommend an assessment of operative risk and life expectancy in contemplating open repair or endovascular aneurysm repair (EVAR) using the patients' Vascular Quality Initiative perioperative mortality risk score (level 2, evidence C). The European Society for Vascular Surgery guidelines 2 Wanhainen A. Verzini F. Van Herzeele I. Allaire E. Bown M. Cohnert T. et al. European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. Eur J Vasc Endovasc Surg. 2019; 57 ([published correction appears in Eur J Vasc Endovasc Surg 2020;59:494]): 8-93 Abstract Full Text Full Text PDF PubMed Scopus (957) Google Scholar recommend that in most patients with suitable anatomy and reasonable life expectancy, EVAR should be considered the preferred treatment modality (recommendation 60, class IIa; evidence level B). However, in patients with long life expectancy, these guidelines recommend that open surgical repair (OSR) of AAA should be considered the preferred treatment modality (recommendation 61, class IIa, evidence level B). These recommendations are based on previous RCTs comparing OSR with EVAR for AAA. 3 EVAR Trial ParticipantsEndovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet. 2005; 365: 2179-2186 Abstract Full Text Full Text PDF PubMed Scopus (1314) Google Scholar , 4 Prinssen M. Verhoeven E.L. Buth J. Cuypers P.W. van Sambeek M.R. Balm R. et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med. 2004; 351: 1607-1618 Crossref PubMed Scopus (1634) Google Scholar , 5 Becquemin J.P. The ACE trial: a randomized comparison of open versus endovascular repair in good risk patients with abdominal aortic aneurysm. J Vasc Surg. 2009; 50: 222-224 Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar , 6 Lederle F.A. Freischlag J.A. Kyriakides T.C. Padberg Jr., F.T. Matsumura J.S. Kohler T.R. et al. Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial. JAMA. 2009; 302: 1535-1542 Crossref PubMed Scopus (837) Google Scholar New randomized controlled trials for abdominal aortic aneurysm treatment should focus on younger, good-risk patientsJournal of Vascular SurgeryVol. 73Issue 6PreviewIn their editorial, Spanos et al1 concluded that new randomized controlled trials (RCTs) are needed to compare endovascular aneurysm repair (EVAR) with open surgical repair (OSR). They observed that current surgical society guidelines depend on outdated RCTs showing perioperative superiority for EVAR that is lost during the long-term follow-up period. The shortcomings of those trials included the learning curve in the early days of EVAR, evolving approaches to reintervention, and advances in technology leading to improvements in EVAR durability. Full-Text PDF

602 Managing Hypothermia in the Surgical Burn Patient

Abstract Introduction It is known, hypothermia, core body temperature at or below 36oC/96.8oF, can lead to dangerous complications for burn patients. Due to loss of their protective thermoregulation, burn patients are at an increased risk of hypothermia during surgery. Findings from a Quality Assurance audit revealed burn patients were returning from surgery hypothermic and hemodynamically unstable. There was little evidence of intra-operative temperature management in the electronic medical record (EMR) or reported to the nurse upon the patients’ return from the operating room (OR). Only 73% of patients had temperatures recorded during their surgery and of those, 40% had a drop of temperature &amp;gt;2 degrees from their baseline. The purpose of this collaborative evidence-based quality assurance project was to improve temperature management in the operating room and prevent hypothermia in the intra and post operative periods. Our aim was to develop warming methods pre-operatively that would establish a goal for keeping the patients’s temperature within 2 degrees of their baseline preoperative temperature during surgery. Methods A literature search obtained from CINAHL, Cochrane, EMBASE, and MEDLINE from 2010–2018, provided current surgical guidelines and evidence-based practices for managing surgical hypothermia in burn patients (levels of evidence I, III, V, &amp; VI). Recommendations from the burn unit staff for preoperative warming initiatives were listed and shared with the OR staff. Hemodynamic documentation, including core temperature, estimated blood loss, and intra-operative warming methods were monitored for twelve months after the Burn Unit Warming Protocol was implemented. Progress was reported quarterly in our Burn and Trauma Quality Committees. Results After implementing the Burn Unit Warming Protocol, temperature management of the burn patient improved. Intra-operative warming methods were initiated. Patients began returning from surgery warmer with improved hemodynamics. 96% of the patients had their temperatures recorded and managed intra-operatively. Of those patients, only 2.6% had a drop in temperature &amp;gt; 2 degrees from their pre-operative baseline. Conclusions Implementing a nurse-driven warming protocol from the pre-operative stage through surgery can aid in reducing post-operative hypothermia in burn patients. Applicability of Research to Practice Managing hypothermia will help reduce complications that can lead to increase morbidity and mortality in burn patients.

Evaluating the implementability of Antibiotic Surgical Prophylaxis guidelines.

Current Australian data highlight guideline noncompliant prescribing of antimicrobials for surgical prophylaxis. The study aim was to evaluate the implementability of the Australian national surgical prophylaxis (SAP) guidelines to identify facilitators for and barriers to compliance. Key stakeholders appraised the surgical prophylaxis guidelines using the GuideLine Implementability Appraisal (GLIA) tool. Questions with 100% agreement for the response 'Yes' were identified as facilitators and those with 100% agreement for 'No', a barrier. Questions that did not receive 100% agreement, but had a majority (40-60%) 'Yes' or 'No' consensus were considered as borderline facilitators and barriers respectively. Ten appraisals were completed. Guideline recommendations were rated as easily identifiable and concise and were thus facilitators for implementation. The ability to measure guideline adherence and outcomes, and recommendations that were consistent with guideline user abilities and beliefs were also identified as facilitators. Borderline facilitators related to the clarity of the recommendations and whether they were explicit in what to do and in what circumstances. Evidence quality underpinning recommendations (validity), inflexibility of recommendations (flexibility) and the lack of patient data at the point of use (computability) were identified as borderline barriers to implementation. No recommendation reached agreement as being a barrier. The GLIA appraisal demonstrated overall implementability of the current Australian national surgical prophylaxis guidelines. Facilitators (i.e., measurability) and borderline facilitators highlight strengths of the current guideline. Borderline barriers (i.e., validity, flexibility and computability) may negatively impact upon implementability. Guideline developers should consider these dimensions to optimise guideline uptake and consequently patient care.

Impact of non-compliance with guidelines in early type 1 endometrial cancers management, study from FRANCOGYN group.

5587 Background: To standardize surgical practices, ESMO-ESGO-ESTRO consensus conference published in 2016 new guidelines on the management of endometrial cancer. The main objective of this study was to evaluate the impact of non-compliance with current surgical guidelines on disease-free survival and overall survival. Methods: 852 patients with presumptive stage I and II type 1 endometrial cancer were included in a multicenter retrospective study, conducted between January 2000 and November 2015. The main objective of this study was to evaluate the impact of non-compliance with current surgical recommendations on overall survival and disease-free survival. Results: Our study shows that 34.3% of patients (n = 292) did not benefit from optimal surgical treatment. These patients did not have a lombo-aortic lymphadenectomy (LAL) and were at high risk of recurrence. There is a significant difference in disease-free survival in favor of patients undergoing surgery according to the recommendations, (Hazard Ratio (HR): 0.37 (Confidence interval (95% CI): 0.26-0.54), p &lt; 0.001). In multivariate analysis, optimal surgical procedure performance is an independent factor for disease-free survival with HR at 2.04 (95% CI: 1.14-3.68), p = 0.01. There is a significant difference in overall survival in favor of patients undergoing surgery according to the recommendations, (HR: 0.31 (95% CI): 0.19-0.49), p &lt; 0.001. In multivariate analysis, there is a trend toward significance with HR: 2.24 (95% CI: 1-5.05), p = 0.05. Older patients, patients with a larger BMI, patients with no indication of LAL at the preoperative ESMO classification, and no node involvement in are factors contributing to the decision of not to perform a LAL: p &lt; 0.001, p = 0.03, p &lt; 0.001 and p &lt; 0.001 respectively. Conclusions: This study shows that patients with early type 1 endometrial cancer have improved recurrence-free survival and a statistical trend for an increased overall survival when recommended surgery is performed. Despite the current context of therapeutic de-escalation, we must strive to achieve the recommended optimal surgery, even if it requires secondary surgical revision, to avoid underestimation of patients with a poorer prognosis. To improve endometrial cancers management, amelioration of the preoperative assessment by increasing the sensitivity of emboli detection should be considered.

Metastatic patterns and surgical methods for lymph nodes No. 5 and No. 6 in proximal gastric cancer.

ObjectiveThe current surgical treatment guidelines for early proximal gastric cancer (PGC) still lack agreement. Lymphadenectomy of lymph nodes No. 5 and No. 6 is the major difference between total and proximal gastrectomy. We elucidated the appropriate surgical procedure for PGC by investigating the pathological characteristics and prognostic significance of lymph nodes No. 5 and No. 6.MethodsIn total, 333 PGC patients who underwent total gastrectomy were enrolled in this study. We investigated their clinicopathological characteristics and the metastatic patterns of the lymph nodes. Patients with metastasis in lymph nodes No. 5 and No. 6 were combined into one group and we compared the difference in survival between those with and without metastasis in lymph nodes No. 5, 6 (lymph nodes No. 5 and No. 6 in any group of metastasis) for different subgroups.ResultsThe metastatic rates for lymph nodes No. 5 and No. 6 in PGC were 9.91% and 16.11%, respectively. The metastatic rate for both lymph nodes No. 5, 6 was 20.42%. Multivariate analysis showed that positive metastasis in lymph node No. 4, depth of invasion, and tumor size were independently correlated with the presence of metastasis in lymph nodes No. 5, 6.ConclusionsWhen lymph node No. 4 is positive (intraoperative pathology) or tumor size ≥5 cm or T4 stage, lymphadenectomy should be performed for lymph nodes No. 5 and No. 6, and total gastrectomy is recommended.

Robotic transanal microsurgery for high early rectal neoplasia (T0-T1, N0 lesions), case series of 10 patients.

In 2017, an estimated 39910 people will receive a new diagnosis of rectal cancer. Current surgical guidelines limit transanal excision of early rectal neoplasia to 8cm from the anal verge. We report that R0 resection of higher rectal cancers is possible using transanal robotic microsurgery. Ten cases of robotic assisted transanal surgery for early stage disease (T0-T1, N0) between 2013 and 2016 were reviewed. All cases were diagnosed preoperatively with colonoscopy, and the average distance from the anal verge was 11.1cm. The average operative time was 167minutes, and the average blood loss was 37.5cc. Four cases required intraoperative conversion; one conversion required robotic abdominal access to repair a proctotomy. All margins were histologically negative, and 6-month follow-up showed no recurrences. Transanal robotic surgery may provide the colorectal surgeon a method to address rectal lesions farther from the anal verge.