Risk factors for recurrent disease after resection of solitary fibrous tumor: a systematic review.

Introduction: Solitary fibrous tumor (SFT) is a rare soft tissue tumor found at any site of the body. The treatment of choice is surgical resection, though 10%-30% of patients experience recurrent disease. Multiple risk factors and risk stratification systems have been investigated to predict which patients are at risk of recurrence. The main goal of this systematic review is to create an up-to-date systematic overview of risk factors and risk stratification systems predicting recurrence for patients with surgically resected SFT within torso and extremities. Method: We prepared the review following the updated Prisma guidelines for systematic reviews (PRISMA-P). Pubmed, Embase, Cochrane Library, WHO international trial registry platform and ClinicalTrials.gov were systematically searched up to December 2022. All English studies describing risk factors for recurrence after resected SFT were included. We excluded SFT in the central nervous system and the oto-rhino-laryngology region. Results: Eighty-one retrospective studies were identified. Different risk factors including age, symptoms, sex, resection margins, anatomic location, mitotic index, pleomorphism, hypercellularity, necrosis, size, dedifferentiation, CD-34 expression, Ki67 index and TP53-expression, APAF1-inactivation, TERT promoter mutation and NAB2::STAT6 fusion variants were investigated in a narrative manner. We found that high mitotic index, Ki67 index and presence of necrosis increased the risk of recurrence after surgically resected SFT, whereas other factors had more varying prognostic value. We also summarized the currently available different risk stratification systems, and found eight different systems with a varying degree of ability to stratify patients into low, intermediate or high recurrence risk. Conclusion: Mitotic index, necrosis and Ki67 index are the most solid risk factors for recurrence. TERT promoter mutation seems a promising component in future risk stratification models. The Demicco risk stratification system is the most validated and widely used, however the G-score model may appear to be superior due to longer follow-up time. Systematic Review Registration: CRD42023421358.

Transvaginal resection of gastrointestinal stromal tumor in the rectum.

A gastrointestinal stromal tumour (GIST) can occur anywhere in the gastrointestinal tract, though rectal GIST is rare. The primary treatment of GIST is surgical resection. Neoadjuvant imatinib treatment may cause tumor reduction and allow local resection. This is a case report of a 70-year-old woman with a high level of comorbidity who was diagnosed with a low rectal GIST. She was successfully treated with imatinib followed by complete GIST resection using a transvaginal technique.

Increasing Incidence of Pelvic Sepsis Following Ileal Pouch-Anal Anastomosis for Ulcerative Colitis in Denmark: A Nationwide Cohort Study.

BACKGROUND: The risk of pelvic sepsis following IPAA for ulcerative colitis may have changed with changes in medical and surgical treatment, but data are scarce. OBJECTIVES: This study aims to examine temporal changes in the risk of pelvic sepsis following IPAA for ulcerative colitis and to ascertain risk factors associated with pelvic sepsis. DESIGN: This is a nationwide cohort study. SETTING: This study was conducted in Denmark from 1996 to 2013. PATIENTS: Patients were operated on with an IPAA for ulcerative colitis. MAIN OUTCOME MEASURES: Pelvic sepsis was defined and validated as the occurrence of anastomotic leakage, pelvic abscesses or fistulas, or an operation for these conditions, recorded in a nationwide registry. Cumulative risks were calculated by using death as a competing risk. Multivariate Cox regression was used to examine the effects of calendar periods (1996-1999, 2000-2004, 2005-2009, and 2010-2013) on hazards ratios for pelvic sepsis, adjusting for age, sex, comorbidity, annual hospital volume, pelvic sepsis in the 12 months preceding surgery, operative stage (1-, 2-, modified 2-, or 3-stage), laparoscopy, and preoperative treatment with biological medicine within 12 weeks before surgery. RESULTS: Of 1456 patients, 244 (16.8%) experienced pelvic sepsis. The 1-year risk increased by calendar period (1996-1999: 2.5%, 2000-2004: 4.5%, 2005-2009: 7.4%, and 2010-2013: 9.6%). The adjusted hazard ratio for pelvic sepsis increased by an average 4.4% (95% CI, 1.3-7.6) per year in the study period. In general, patients were older and had more comorbidities at IPAA in recent years than in earlier years, and more had experienced pelvic sepsis in the 12 months preceding the operation. LIMITATIONS: This study was register based. There were no data on important clinical variables to determine the causes of an increased risk over calendar periods. CONCLUSION: In this nationwide cohort study, the 1-year risk of pelvic sepsis following primary IPAA for ulcerative colitis increased 4-fold from 1996 to 2013. See Video Abstract at http://links.lww.com/DCR/A956.

Effect of hospital-admission volume on outcomes following acute non-variceal upper gastrointestinal bleeding.

INTRODUCTION: Treatment-requiring acute non-variceal upper gastrointestinal bleeding (NVUGIB) is a common, potentially life-threatening emergency. This study investigated whether hospital admittance volume of patients with NVUGIB was associated with reduced mortality, reduced lasting failure of haemostatic procedures defined as rate of re-endoscopy with repeated haemostasis intervention (ReWHI), transfusion requirements and conversion to surgery. METHODS: Data on Danish nationwide admissions of patients with acute NVUGIB from 2011-2013 were analysed to estimate 30-day mortality, re-bleeding (ReWHI), transfusion rates and rates of conversion to surgery. Data were analysed by regression modelling while controlling for confounders including age, admission haemoglobin, the American College of Anesthesiologists score, comorbidities and the Forrest classification. RESULTS: A total of 3,537 patients with acute non-variceal upper gastrointestinal bleeding were included in the study. The hospital admission volume of patients with NVUGIB was positively associated with a significant increase in ReWHI with an odds ratio of 1.27; p = 1.91 × 10-6. There was no significant association between admission volume and conversion to surgery, 30-day mortality or transfusion rates. CONCLUSIONS: A positive association between admission volumes of patients with NVUGIB and ReWHI was identified. No association between admission volumes and 30-day mortality or other failure of haemostasis events could be identified. FUNDING: none. TRIAL REGISTRATION: not applicable.

An automatic measure of progression during colonoscopy correlates to patient experienced pain.

BACKGROUND: Colonoscopy screening and surveillance programs depend on patient's tolerable experience, which is associated with competence of the endoscopist. The Colonoscopy Progression Score (CoPS) is an automated tool based on recording of the Magnetic Scope Imager (MEI) picture in order to track progression. CoPS deliver a numeric score and a graphic map. A high score expresses a rapid and smooth progression. Aims of study were to explore the correlation between CoPS and patient experienced pain and to identity locations associated with pain. METHODS AND MATERIALS: Patients listed for colonoscopy were included and asked to reply to pain by pressing a rubber ball. The signal was recorded simultaneous to CoPS. Patients evaluated the experience on a Visual Analogue Scale (VAS). CoPS and recorded pain events were used to create a pain sensitive CoPS-map (S-CoPS map). RESULTS: A total of 58 complete recordings were used for evaluation. We demonstrated a moderate correlation between CoPS and patient experienced pain, Pearson's r = -0.47 (p < .001). A low CoPS was associated with a painful colonoscopy and a high CoPS excluded severe pain. Sensitivity and specificity was 0.79 and 0.60 and AUC was 0.61 Passage of the sigmoid colon, right and left flexures were associated with pain for 51%, 33% and 25% of the patients, respectively. CONCLUSION: A moderate correlation between CoPS and patient experienced pain suggest that CoPS measure inserting skills but might also be a measure of a gentle performance. The graphic S-CoPS-map can be used to point-out painful passages and aid planning of future colonoscopies.

Methods for certification in colonoscopy - a systematic review.

INTRODUCTION: Reliable, valid, and feasible assessment tools are essential to ensure competence in colonoscopy. This study aims to provide an overview of the existing assessment methods and the validity evidence that supports them. METHODS: A systematic search was conducted in October 2016. Pubmed, EMBASE, and PsycINFO were searched for studies evaluating assessment methods to ensure competency in colonoscopy. Outcome variables were described and evidence of validity was explored using a contemporary framework. RESULTS: Twenty-five observational studies were included in the systematic review. Most studies were based on small sample sizes. The studies were categorized after outcome measures into five groups: Clinical process related outcome metrics (n = 2), direct observational colonoscopy assessment (n = 8), simulator based metrics (n = 11), automatic computerized metrics (n = 2), and self-assessment (n = 1). Validity score varied among the studies and only five studies presented sufficient evidence to recommend the tool for clinical assessment. CONCLUSIONS: The objectives vary throughout the presented tools. Some tools are global tools where others focus on procedural technical skill assessment or even part-task skills. There is a tendency in the most recent studies towards more specific assessment of technical skills. The majority of assessment methods lack sufficient validity evidence.

Combining different methods improves assessment of competence in colonoscopy.

OBJECTIVES: To develop a reliable method of assessing competence in colonoscopy based on multiple sources. MATERIALS AND METHODS: Physicians with varying degrees of experience in colonoscopy performed two colonoscopies each in a standardized simulated environment. Their performances were assessed under direct observation by an expert rater and by automatic computerized analysis of operator movements and scope movements, respectively. Reliability (Cronbach's alpha) for subjective assessment, time to cecum, analysis of operator movement and analysis of scope movements were calculated. Composite score calculations were used to explore different combinations of the measures. RESULTS: Twenty physicians were included in the study. The reliability (Cronbach's alpha) were 0.92, 0.57, 0.87 and 0.55 for the subjective score assessed under direct observation, time to cecum, distance between operator's hands and colonoscopy progression score, respectively. Equal weight (=25%) to all four methods resulted in a reliability of 0.91 and optimal weighting of the methods (55%, 10%, 25% and 10%, respectively) resulted in a maximum reliability of 0.95. CONCLUSION: Combining subjective expert ratings with automated objective assessments results in a less biased and more reliable assessment of competence in colonoscopy.

Increased Risk of Gallstone Disease Following Colectomy for Ulcerative Colitis.

OBJECTIVES: Biochemical studies suggest that patients who have had a colectomy or restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) are at an increased risk of developing gallstone disease, but epidemiological studies are lacking. We evaluated the risk of gallstone disease following colectomy and IPAA. METHODS: Individuals who had a colectomy were identified from a national cohort of patients with ulcerative colitis (UC), and controls without colectomy were sampled from within the same cohort, matching on gender, calendar year, and year of birth. We used Cox regression to examine the effect of colectomy on the hazard rates of gallstone disease and cholecystectomy, adjusting for alcoholism, stroke, chronic obstructive pulmonary disease, cancer, cardiac disease, diabetes mellitus, hypothyroidism, hyperlipidemia, cirrhosis, obesity, renal failure, and transient ischemic attacks. The effect of an IPAA was determined for patients who had colectomy by including the procedure as a time-dependent variable. RESULTS: We identified 4548 patients and matched these to 44 372 controls without colectomy. During a median follow-up of 11.9 years, 1963 patients were hospitalized for gallstone disease. Patients who had a colectomy were at an increased risk (adjusted hazard ratio (HR)=1.63 (1.39-1.91)), and sensitivity analyses of the risk of undergoing cholecystectomy revealed a similar association (adjusted HR=1.55 (1.22-1.98)). An IPAA did not affect the risk of developing gallstones among patients who had a colectomy (adjusted HR=1.03 (0.77-1.37)). CONCLUSION: The risk of gallstone disease increases following colectomy for UC.

Automatic and unbiased assessment of competence in colonoscopy: exploring validity of the Colonoscopy Progression Score (CoPS).

Background and aims: Colonoscopy is a difficult procedure to master. Increasing demands for colonoscopy, due to screening and surveillance programs, have highlighted the need for competent performers. Valid methods for assessing technical skills are pivotal for training and assessment. This study is the first clinical descriptive report of a novel colonoscopy assessment tool based on Magnetic Endoscopic Imaging (MEI) data and the aim was to gather validity evidence based on the data collected using the "Colonoscopy Progression Score" (CoPS). Methods: We recorded 137 colonoscopy procedures performed by 31 endoscopists at three university hospitals. The participants performed more than two procedures each (range 2 - 12) and had an experience of 0 - 10 000 colonoscopies. The CoPS was calculated for each recording and validity was explored using a widely accepted contemporary framework. The following sources of validity evidence were explored: response process (data collection), internal structure (reliability), relationship to other variables (i. e. operator experience), and consequences of testing (pass/fail). Results: Identical set-ups at all three locations ensured uniform data collection. The Generalizability coefficient (G-coefficient) was 0.80, and a Decision-study (D-study) revealed that four recordings were sufficient to ensure a G-coefficient above 0.80. We showed a positive correlation between CoPS and experience with Pearson's r of 0.61 (P < 0.001). A pass/fail standard of 107 points was established using the contrasting group method to explore the consequences of testing. Conclusion: This study provides evidence supporting the validity of the CoPS for use in assessing technical colonoscopy performance in the clinical setting. STUDY REGISTRATION: NCT01997177.

Three-dimensional motion tracking correlates with skill level in upper gastrointestinal endoscopy.

BACKGROUND AND STUDY AIM: Feedback is an essential part of training in upper gastrointestinal endoscopy. Virtual reality simulators provide limited feedback, focusing only on visual recognition with no feedback on the procedural part of training. Motion tracking identifies patterns of movement, and this study aimed to explore the correlation between skill level and operator movement using an objective automated tool. METHODS: In this medical education study, 37 operators (12 senior doctors who performed endoscopic retrograde cholangiopancreatography, 13 doctors with varying levels of experience, and 12 untrained medical students) were tested using a virtual reality simulator. A motion sensor was used to collect data regarding the distance between the hands, and height and movement of the scope hand. Test characteristics between groups were explored using Kruskal-Wallis H and Man-Whitney U exact tests. RESULTS: All motion-tracking metrics showed discriminative ability primarily between experts and novices in specific sequences. CONCLUSION: Motion tracking can discriminate between operators with different experience levels in upper gastrointestinal endoscopy. Motion tracking can be used to provide feedback regarding posture and movement during endoscopy training.

Simulation-based training for colonoscopy: establishing criteria for competency.

The aim of this study was to create simulation-based tests with credible pass/fail standards for 2 different fidelities of colonoscopy models. Only competent practitioners should perform colonoscopy. Reliable and valid simulation-based tests could be used to establish basic competency in colonoscopy before practicing on patients. Twenty-five physicians (10 consultants with endoscopic experience and 15 fellows with very little endoscopic experience) were tested on 2 different simulator models: a virtual-reality simulator and a physical model. Tests were repeated twice on each simulator model. Metrics with discriminatory ability were identified for both modalities and reliability was determined. The contrasting-groups method was used to create pass/fail standards and the consequences of these were explored. The consultants significantly performed faster and scored higher than the fellows on both the models (P < 0.001). Reliability analysis showed Cronbach α = 0.80 and 0.87 for the virtual-reality and the physical model, respectively. The established pass/fail standards failed one of the consultants (virtual-reality simulator) and allowed one fellow to pass (physical model). The 2 tested simulations-based modalities provided reliable and valid assessments of competence in colonoscopy and credible pass/fail standards were established for both the tests. We propose to use these standards in simulation-based training programs before proceeding to supervised training on patients.

Assessment of colonoscopy by use of magnetic endoscopic imaging: design and validation of an automated tool.

BACKGROUND: Yield and safety of colonoscopy are highly dependent on operator competence. Existing tools for assessing competence is time-consuming and based on direct observation, making them prone for bias. There is a need for an easily accessible, reliable, and valid measure of endoscopic performance. OBJECTIVE: The aim of this study was to develop and explore the validity of an automated, unbiased assessment tool. DESIGN: We tested 10 experienced endoscopists and 11 trainees in colonoscopy on a physical simulator (Kagaku Colonoscope Training Model). Participants were tested with an easy and a difficult case. SETTING: Center for Clinical Education, Capital Region of Denmark. MAIN OUTCOME MEASUREMENTS: By using magnetic endoscopic imaging, we developed a colonoscopy progression score (CoPS). A pass/fail score was established by using the contrast-group method. RESULTS: We found significant differences in performance between the 2 groups using the CoPS in both case scenarios (easy: P < .001, difficult: P < .01). LIMITATIONS: Small sample sizes. The heterogeneity of the experienced group resulted in a high passing score for the difficult case, which led to the failing of the less experienced in the group. The CoPS does not consider polyp detection rate, tissue damage, or patient discomfort. CONCLUSIONS: We developed a score of progression in colonoscopy, based on magnetic endoscopic imaging. With the same tool, a map of progression in colonoscopy can be provided. The CoPS and map of progression in colonoscopy could, with further development, be a valuable tool in colonoscopy training, providing live feedback and aid in unbiased certification.

Using motion capture to assess colonoscopy experience level.

AIM: To study technical skills of colonoscopists using a Microsoft Kinect™ for motion analysis to develop a tool to guide colonoscopy education. RESULTS: Ten experienced endoscopists (gastroenterologists, n = 2; colorectal surgeons, n = 8) and 11 novices participated in the study. A Microsoft Kinect™ recorded the movements of the participants during the insertion of the colonoscope. We used a modified script from Microsoft to record skeletal data. Data were saved and later transferred to MatLab for analysis and the calculation of statistics. The test was performed on a physical model, specifically the "Kagaku Colonoscope Training Model" (Kyoto Kagaku Co. Ltd, Kyoto, Japan). After the introduction to the scope and colonoscopy model, the test was performed. Seven metrics were analyzed to find discriminative motion patterns between the novice and experienced endoscopists: hand distance from gurney, number of times the right hand was used to control the small wheel of the colonoscope, angulation of elbows, position of hands in relation to body posture, angulation of body posture in relation to the anus, mean distance between the hands and percentage of time the hands were approximated to each other. RESULTS: Four of the seven metrics showed discriminatory ability: mean distance between hands [45 cm for experienced endoscopists (SD 2) vs 37 cm for novice endoscopists (SD 6)], percentage of time in which the two hands were within 25 cm of each other [5% for experienced endoscopists (SD 4) vs 12% for novice endoscopists (SD 9)], the level of the right hand below the sighting line (z-axis) (25 cm for experienced endoscopists vs 36 cm for novice endoscopists, P < 0.05) and the level of the left hand below the z-axis (6 cm for experienced endoscopists vs 15 cm for novice endoscopists, P < 0.05). By plotting the distributions of the percentages for each group, we determined the best discriminatory value between the groups. A pass score was set at the intersection of the distributions, and the consequences of the standard were explored for each test. By using the contrasting group method, we showed a discriminatory value of Z = 1.51 to be the pass/fail value of the data showing discriminatory ability. The pass score allowed all ten experienced endoscopists as well as five novice endoscopists to pass the test. CONCLUSION: Identified metrics can be used to discriminate between experienced and novice endoscopists and to provide non-biased feedback. Whether it is possible to use this tool to train novices in a clinical setting requires further study.

Differences in the pattern of anastomotic leakage after oesophagectomy in two high-volume centres.

INTRODUCTION: Complications to oesophageal and junctional cancer surgery are common and have not diminished much during the past ten years. An unusually high occurrence of anastomotic dehiscence occurred in Denmark in 2009 and 2010 as seen in the national database for oesophagus, cardiac and gastric (ECV) cancer. MATERIAL AND METHODS: In accordance with national guidelines, all patients resected for oesophageal and junctional cancer in Denmark from 2003 were prospectively entered into a national database. Data concerning anaesthesia, peri- and post-operative course, complications, re-operations and time spent in intensive care unit were obtained retrospectively from hospital records. An in-depth analysis of data from two high-volume centres performing ECV cancer surgery according to national guidelines was performed. RESULTS: A total of 881 patients (Centre 1: 438; Centre 2: 443) were resected for oesophageal and junctional cancer. A total of 79 patients with anastomotic insufficiency (AI) were detected (Centre 1: 36; Centre 2: 43). By using a grading system, it was shown that AI was more severe and occurred earlier in one centre than in the other. Possible factors of influence are discussed, including neoadjuvant oncological therapy, use of thoracoscopically performed anastomosis and perioperative inotrophic drugs. CONCLUSION: Thanks to the establishment of a nationwide database in pursuance of national guidelines, it was possible to detect variations in quality of surgery over time, evaluate serious complications early and undertake an in-depth analysis of possible aetiological factors. Particularly, comparison was facilitated by the use of a standardised grading system for complications. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.