Differentiating Surgical Instruments.epub
Rapheal Charlton
Materials and methods: The Global Evaluative Assessment of Robotic Skills is a tool developed by deconstructing the fundamental elements of robotic surgical procedures in consultation with expert robotic surgeons. Surgical performance was assessed during robot-assisted laparoscopic prostatectomy on a 5-point anchored Likert scale across 6 domains. An overall performance score was derived by summing the ratings in each domain. Expert surgeons and postgraduate year 4 to 6 urology residents were evaluated to determine construct validity. Assessments were completed by the attending surgeon, a trained observer and the operator.
Conclusions: The Global Evaluative Assessment of Robotic Skills is simple to administer and able to differentiate levels of robotic surgical expertise. This standardized assessment tool shows excellent consistency, reliability and validity. Further study is warranted to evaluate its usefulness for surgical education and the establishment of competency in robotic surgery.
The term theranostics is the combination of a diagnostic tool that helps to define the right therapeutic tool for specific disease. It signifies the "we know which sites require treatment (diagnostic scan) and confirm that those sites have been treated (post-therapy scan)" demonstrating the achievable tumor dose concept. This term was first used by John Funkhouser at the beginning of the 90s, at the same time the concept of personalized medicine appeared. In nuclear medicine, theranostics is easy to apply and understand because of an easy switch from diagnosis to therapy with the same vector. It helps in maximizing tumor dose and sparing normal tissue with high specific and rapid uptake in metastasis. The oldest application of this concept is radioactive iodine I-131 (RAI). The first treatment based on the theranostic concept was performed on thyroid cancer patients with RAI in 1946. From then on management of differentiated thyroid cancer (DTC) has evolved on the multimodality concept. We now use the term "our" patient instead of "my" patient to signify this. However, the initial surgical management followed by RAI as per the theranostics has remained the mainstay in achieving a cure in most of DTC patients. The normal thyroid cells metabolise iodine, the principle of which is utilized in imaging of the thyroid gland with isotopes of iodine. RAI treatment of DTC is based on the principle of sodium iodide symporter (NIS) expressing thyroid cells with DTC cells having the ability of trapping circulating RAI successfully helping in treatment of residual and metastatic disease. NIS is usually negative in poorly differentiated cells and is inversely proportional to Glucose transporter receptor Type 1 expression. Both positive and negative NIS are the key components of the theranostic approach in treatment of DTC. Presence or absence of NIS is documented by either whole body iodine scintigraphy (WBS) or 2-deoxy-2(18F) fludeoxyglucose (FDG) positron emission tomography computed tomography (PET-CT). Currently, single photon emission CT and CT (SPECT-CT) has significantly improved the precision and sensitivity of whole body iodine scintigraphy with its capability of accurate localization of disease foci whether iodine avid or non-avid. This has helped in a more personalized approach in treatment. This review will give an overview of the role of NIS in the theranostic approach to management with RAI, its current status and also the molecular approach to treatment in RAI refractory disease.
Purpose: General surgical procedures are among the most commonly performed operations in the United States. Despite advances in surgical and anesthetic techniques and perioperative care, complications after general surgery in older adults remain a significant cause of increased morbidity, mortality, and health care costs. Frailty, a geriatric syndrome characterized by multisystem physiologic decline and increased vulnerability to stressors and adverse clinical outcomes, has emerged as a plausible predictor of adverse outcomes after surgery in older patients. Thus, the goal of this topical review is to evaluate the evidence on the association between preoperative frailty and clinical outcomes after general surgery and whether frailty evaluation may have a role in surgical risk-stratification in vulnerable older patients.
Findings: The available evidence from meta-analyses and cohort studies suggest that preoperative frailty is significantly associated with adverse clinical outcomes after emergent or nonemergent general surgery in older patients. Although these studies are limited by a high degree of heterogeneity of frailty assessments, types of surgery, and primary outcomes, baseline frailty appears to increase risk of postoperative complications and morbidity, hospital length of stay, 30-day mortality, and long-term mortality after general surgical procedures in older adults.
Implications: Evidence supports the further development of preoperative frailty evaluation as a risk-stratification tool in older adults undergoing general surgery. Research is urgently needed to quantify and differentiate the predictive ability of validated frailty instruments in the context of different general surgical procedures and medical acuity and in conjunction with existing surgical risk indices widely used in clinical practice. Practical applicability of frailty instrument as well as geriatrics-centered outcomes need to be incorporated in future studies in this line of research. Furthermore, clinical care pathways that integrate frailty assessment, geriatric medicine focused perioperative and postoperative management, and patient-centered interdisciplinary care models should be investigated as a comprehensive intervention approach in older adults undergoing general surgery. Finally, early implementation of palliative care should occur at the outset of hospital encounter in frail older patients who present with indications for emergent general surgery.
Conditions that can be manifested by acute AP vary in incidence with age and sex. Classification of acute AP based on age is one adapted approach to narrow the differential diagnosis, which can guide selection of appropriate diagnostic tests, imaging, and definitive treatment. The five most prevalent nonsurgical diagnoses have been reported to be upper respiratory tract infection alone or complicated by otitis media or sinusitis (23.7%), AP of uncertain etiology (15.4%), gastroenteritis (15.4%), constipation (9.4%), and urinary tract infection (8%).3
While most of the emergency visits presenting with acute abdominal pain are self-limited and benign medical diagnoses, a surgical etiology may be present in up to 20%.3 In nontraumatic cases of an acute abdomen below 1 year of age, the most common surgical etiology was reported to be incarcerated inguinal hernia (45.1%), followed by intussusception (41.9%). These etiologies were uncommon in school-age and adolescent children. In children above 1 year of age, the most common causes of acute surgical diagnoses have been reported to be acute appendicitis (64.0%), incarcerated hernia (7.5%), trauma (16.3%), intussusception (6.3%), intestinal obstruction (1.3%), and ovarian torsion (1.3%).4 Based on pathology reports of resected specimens, 15.6% of patients with appendicitis present with early appendicitis, 64.1% with suppurative or gangrenous changes, and 20.3% with perforated appendicitis.4
The history is directed toward three components: the pain itself, associated symptoms, and predisposing conditions. Key points regarding AP should include pain location, radiation, intensity and nature of pain, previous episodes of AP, and the intensity or progression of the pain, as well as associated symptoms. Patients with midline pain, those without any increase in pain and without vomiting, and those with weak or moderate pain tend to have more nonspecific benign AP.11,12 In the acute surgical abdomen, pain generally precedes vomiting, while the reverse is true with medical causes.13 Acute-onset severe and colicky, localized AP suggests an intra-abdominal surgical etiology such as intussusception.14 However, only one third of patients with intussusception present with the classical presentation (bloody mucousy stool, colicky AP, and rectal or abdominal mass), so the provider must consider the diagnosis based on age in the absence of classical findings.15 An intra-abdominal inflammatory process is suggested when a child has fever and abdominal tenderness in conjunction with bilious vomiting (bowel obstruction) and bloody stool (bowel ischemia). Having progressive pain preceding vomiting, nausea, lack of appetite, diarrhea, and fever with AP suggest acute appendicitis in children.13 Quality and radiation of pain is not a strong predictor of acute appendicitis, and the classical presentation is usually lacking.13 Similarly, evidence indicates that a weak or absent inflammatory response, female sex, long duration of symptoms, and absence of vomiting (rather than relying on pain quality or severity of tenderness) are predictors of negative surgical explorations in patients with suspected appendicitis.16
For a patient who appears critically ill, the initial concern is to immediately rule out surgical diagnoses particularly those associated with obstruction or ischemia as in Table 1. A more urgent surgical diagnosis is likely if there is distension, peritoneal signs, and abnormal bowel sounds.12,13 A provider must keep in mind that abdominal distension may be absent in patients with gastric outlet or proximal small bowel obstructions which can be seen, for example, in cases of proximal intussusceptions in patients with HSP.23 This is particularly true in patients who have recently vomited as they may decompress the gastrointestinal tract proximal to the obstruction such that abdominal distension may be absent and some imaging studies (eg, abdominal radiograph or ultrasound [US]) may be normal.
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