Myths and methodologies: Assessing glycaemic control and associated regulatory mechanisms in human physiology research.

Accurate measurements of glycaemic control and the underpinning regulatory mechanisms are vital in human physiology research. Glycaemic control is the maintenance of blood glucose concentrations within optimal levels and is governed by physiological variables including insulin sensitivity, glucose tolerance and ß-cell function. These can be measured with a plethora of methods, all with their own benefits and limitations. Deciding on the best method to use is challenging and depends on the specific research question(s). This review therefore discusses the theory and procedure, validity and reliability and any special considerations of a range common methods used to measure glycaemic control, insulin sensitivity, glucose tolerance and ß-cell function. Methods reviewed include glycosylated haemoglobin, continuous glucose monitors, the oral glucose tolerance test, mixed meal tolerance test, hyperinsulinaemic euglycaemic clamp, hyperglycaemic clamp, intravenous glucose tolerance test and indices derived from both fasting concentrations and the oral glucose tolerance test. This review aims to help direct understanding, assessment and decisions regarding which method to use based on specific physiology-related research questions.

Comparing proficiency of obstetrics and gynaecology trainees with general surgery trainees using simulated laparoscopic tasks in Health Education England, North-West: a prospective observational study.

BACKGROUND: Training programmes for obstetrics and gynaecology (O&G) and general surgery (GS) vary significantly, but both require proficiency in laparoscopic skills. We sought to determine performance in each specialty. DESIGN: Prospective, observational study. SETTING: Health Education England North-West, UK. PARTICIPANTS: 47 surgical trainees (24 O&G and 23 GS) were subdivided into four groups: 11 junior O&G, 13 senior O&G, 11 junior GS and 12 senior GS trainees. OBJECTIVES: Trainees were tested on four simulated laparoscopic tasks: laparoscopic camera navigation (LCN), hand-eye coordination (HEC), bimanual coordination (BMC) and suturing with intracorporeal knot tying (suturing). RESULTS: O&G trainees completed LCN (p<0.001), HEC (p<0.001) and BMC (p<0.001) significantly slower than GS trainees. Furthermore, O&G found fewer number of targets in LCN (p=0.001) and dropped a greater number of pins than the GS trainees in BMC (p=0.04). In all three tasks, there were significant differences between O&G and GS trainees but no difference between the junior and senior groups within each specialty. Performance in suturing also varied by specialty; senior O&G trainees scored significantly lower than senior GS trainees (O&G 11.4±4.4 vs GS 16.8±2.1, p=0.03). Whilst suturing scores improved with seniority among O&G trainees, there was no difference between the junior and senior GS trainees (senior O&G 11.4±4.4 vs junior O&G 3.6±2.1, p=0.004). DISCUSSION: GS trainees performed better than O&G trainees in core laparoscopic skills, and the structure of O&G training may require modification. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT05116332).

Surgical stress: the muscle and cognitive demands of robotic and laparoscopic surgery.

Introduction: Surgeons are among the most at-risk professionals for work-related musculoskeletal decline and experience high mental demands. This study examined the electromyographic (EMG) and electroencephalographic (EEG) activities of surgeons during surgery. Methods: Surgeons who performed live laparoscopic (LS) and robotic (RS) surgeries underwent EMG and EEG measurements. Wireless EMG was used to measure muscle activation in four muscle groups bilaterally (biceps brachii, deltoid, upper trapezius, and latissimus dorsi), and an 8-channel wireless EEG device was used to measure cognitive demand. EMG and EEG recordings were completed simultaneously during (i) noncritical bowel dissection, (ii) critical vessel dissection, and (iii) dissection after vessel control. Robust ANOVA was used to compare the %MVCRMS and alpha power between LS and RS. Results: Thirteen male surgeons performed 26 laparoscopic surgeries (LS) and 28 robotic surgeries (RS). Muscle activation was significantly higher in the right deltoid (p = 0.006), upper trapezius (left, p = 0.041; right, p = 0.032), and latissimus dorsi (left, p = 0.003; right, p = 0.014) muscles in the LS group. There was greater muscle activation in the right biceps than in the left biceps in both surgical modalities (both p = 0.0001). There was a significant effect of the time of surgery on the EEG activity (p <0.0001). A significantly greater cognitive demand was observed in the RS than in the LS with alpha, beta, theta, delta, and gamma (p = 0.002 - p <0.0001). Conclusion: These data suggest greater muscle demands in laparoscopic surgery, but greater cognitive demands in robotic surgery.

Should All Minimal Access Surgery Be Robot-Assisted? A Systematic Review into the Musculoskeletal and Cognitive Demands of Laparoscopic and Robot-Assisted Laparoscopic Surgery.

BACKGROUND: Surgeons are among the most at risk of work-related musculoskeletal health decline because of the physical demands of surgery, which is also associated with cognitive fatigue. Minimally invasive surgery offers excellent benefits to patients but the impact of robotic or laparoscopic surgery on surgeon well-being is less well understood. This work examined the musculoskeletal and cognitive demands of robot-assisted versus standard laparoscopic surgery. METHODS: Medline, Embase and Cochrane databases were systematically searched for 'Muscle strain' AND 'musculoskeletal fatigue' AND 'occupational diseases' OR 'cognitive fatigue' AND 'mental fatigue' OR 'standard laparoscopic surgery' AND 'robot-assisted laparoscopic surgery'. Primary outcomes measured were electromyographic (EMG) activity for musculoskeletal fatigue and questionnaires (NASA-TLX, SMEQ, or Borg CR-10) for cognitive fatigue. A systematic review was conducted in accordance with the Synthesis Without Meta-analysis (SWiM) Guidelines. The study was preregistered on Prospero ID: CRD42020184881. RESULTS: Two hundred and ninety-eight original titles were identified. Ten studies that were all observational studies were included in the systematic review. EMG activity was consistently lower in robotic than in laparoscopic surgery in the erector spinae and flexor digitorum muscles but higher in the trapezius muscle. This was associated with significantly lower cognitive load in robotic than laparoscopic surgery in 7 of 10 studies. CONCLUSIONS: Evidence suggests a reduction in musculoskeletal demands during robotic surgery in muscles excluding the trapezius, and this is associated with most studies reporting a reduced cognitive load. Robotic surgery appears to have less negative cognitive and musculoskeletal impact on surgeons compared to laparoscopic surgery.

The feasibility of disposable video-bronchoscopes, Ambu aScope3, for exploration of the common bile duct and extraction of stones.

Introduction: The aim of this study was to assess and evaluate the feasibility of using the Ambu aScope3 (aScope) for common bile duct (CBD) explorations, stone detection and extraction, as well as to assess feasibility of its use through the laparoscopic ports in a low-volume centre. Methods: This is a dual centre prospective study, conducted between February 2015 and August 2019, of patients undergoing laparoscopic cholecystectomy and common bile duct exploration. Ethical approval was obtained from the North West - Greater Manchester South Research Ethics Committee. All patients were counselled on the use of the aScope in clinic, prior to surgery. The Primary endpoints were the ability of the aScope to identify CBD stones, perform a cholangiogram through the available channel, retrieve the stones using a Dormia basket and to visualise second generation biliary radicles satisfactorily. The secondary endpoint was the use of the aScope, via a laparoscopic port without a gas leak. The data collected included patient demographics, need for a CBD exploration, intraoperative confirmation of CBD stones and their safe extraction using an aScope. Results: A total of nine patients were recruited. The aScope provided satisfactory views in eight of nine patients and enabled the safe extraction of CBD stones in six of nine cases. One patient had a bile leak, and another had a transected CBD prior to the use of the aScope. Conclusion: We found that the aScope is a safe, feasible alternative to a choledochoscope, and in a low-volume centre, it provides a financially viable option.

Bio-Degradable Stents: Primary Experience in a Tertiary Hepatopancreaticobiliary Center in the United Kingdom.

BACKGROUND: Management of benign biliary strictures (BBS) post bilioenteric anastomoses requires a multidisciplinary approach including surgical, radiological, and/or endoscopic input. Patients often need multiple hospital visits for treatment with the long-term possibility of restenosis. Conventionally BBS have been treated with serial percutaneous transhepatic biliary dilatations necessitating repeat procedures for drain exchange or removal. Surgery may become necessary in refractory strictures. In the last decade, there have been increasing reports of the use of biodegradable stents (BDS) in treating biliary strictures mainly to address the need for repeated procedures for drain exchange. AIM:  This study aimed to report the early outcomes in patients with BBS treated with BDS. METHODS: Retrospective analysis of prospectively collected data was performed in patients who had a bilioenteric anastomosis presenting with an anastomotic stricture and were intended to be treated with BDS. The primary endpoints reported were technical success (defined as a successful resolution of stricture on repeat cholangiogram) and clinical success (defined as the absence of repeated cholangitis). Clavien-Dindo (CD) grade of complication was reported. RESULTS: Twelve patients presented with BBS and nine patients had BDS. Three patients were not considered suitable for BDS due to a non-traversable stricture and had surgery. The male-female ratio was 1:2. There was 100% technical and clinical success with one patient having stent migration not needing intervention. The procedure took an average of 45 min. In seven (77.7%) patients, it was safely performed under local anesthesia with sedation. Two patients preferred general anesthesia. There was no restenosis noted at a median follow-up of 11 months. CONCLUSION: The use of BDS in the treatment of BBS is a safe and effective procedure. Longer-term follow-up with multi-institutional reporting on a national database is needed to assess its long-term benefits.

The Impact of Prehabilitation on Patient Outcomes in Hepatobiliary, Colorectal, and Upper Gastrointestinal Cancer Surgery: A PRISMA-Accordant Meta-analysis.

OBJECTIVE: To determine the impact of prehabilitation on hospital length of stay, functional capacity, complications, and mortality after surgery in patients with hepatobiliary, colorectal, and upper gastrointestinal cancer. BACKGROUND: "Prehabilitation" encompasses exercise, nutrition, and psychosocial interventions to optimize health before surgery. The benefits of prehabilitation are ill-defined. METHODS: Medline, Embase and Cochrane Databases were searched systematically for the terms "prehabilitation AND exercise," "perioperative care AND cancer surgery," and "colorectal AND hepatobiliary AND hepatopancreatobiliary AND esophagogastric AND recovery AND outcomes." Primary outcomes analyzed were hospital length of stay, functional capacity, significant postoperative complications (Clavien Dindo ≥ III), and mortality. A meta-analysis was conducted on the effect of all-modality prehabilitation for patients with colorectal, hepatopancreatobiliary and upper gastrointestinal cancer surgery using the raw mean difference, risk difference, and a random-effects model. RESULTS: Three hundred and seventy seven original titles were identified. Fifteen studies (randomized controlled trials; n = 9 and uncontrolled trials; n = 6) were included in the meta-analysis. Prehabilitation reduced hospital length of stay by 1.78 days versus standard care (95% CI: -3.36, -0.20, P < 0.05). There was no significant difference in functional capacity with prehabilitation determined using the 6-minute walk test (P = 0.816) and no significant reduction in postoperative complications (P = 0.378) or mortality rates (P = 0.114). CONCLUSIONS: Prehabilitation was associated with reduced hospital length of stay but had no effect on functional capacity, postoperative complications, or mortality rates. Thus, prehabilitation should be recommended to accelerate recovery from cancer surgery, demonstrated by reduced hospital length of stay.

Is the Use of a Robotic Camera Holder Economically Viable? A Cost Comparison of Surgical Assistant Versus the Use of a Robotic Camera Holder in Laparoscopic Liver Resections.

The laparoscopic approach has gained acceptance in the field of hepatopancreaticobiliary surgery. It offers several advantages including reduced blood loss, reduced postoperative pain, and shorter length of stay. However, long operating times can be associated with surgeon and assistant fatigue and image tremor. Robotic camera holders have been designed to overcome these drawbacks but may come with significant costs. The aim of this study was to economically evaluate their use compared with standard assistants using a single surgeon consecutive series of laparoscopic liver resections from January 2014 to May 2015. Only use of nurse assistants with no advanced training and postgraduate year 2 doctors were cheaper than utilization of the device. We suggest the use of a robotic camera holder is cost-beneficial and may have wider service and educational benefits.

Cryoablation for liver tumors - is there clinical utility?

The large majority of liver tumors are metastatic, of which colorectal deposits are the most common. Resection is the preferable mode of treatment because it offers the possibility of prolonged survival, but this strategy is only viable in about 25% of patients. This is due to either the proximity of the disease to the portal structures or to the number of metastases. Other treatment options are therefore required for liver tumors, such as chemotherapy, radiofrequency ablation, laser photocoagulation, chemoembolization, and cryotherapy. This article focuses on cryotherapy as a method of treating unresectable hepatic tumors.