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1.  Transanal endoscopic microsurgery versus endoscopic mucosal resection for large rectal adenomas (TREND-study) 
BMC Surgery  2009;9:4.
Background
Recent non-randomized studies suggest that extended endoscopic mucosal resection (EMR) is equally effective in removing large rectal adenomas as transanal endoscopic microsurgery (TEM). If equally effective, EMR might be a more cost-effective approach as this strategy does not require expensive equipment, general anesthesia and hospital admission. Furthermore, EMR appears to be associated with fewer complications.
The aim of this study is to compare the cost-effectiveness and cost-utility of TEM and EMR for the resection of large rectal adenomas.
Methods/design
Multicenter randomized trial among 15 hospitals in the Netherlands. Patients with a rectal adenoma ≥ 3 cm, located between 1–15 cm ab ano, will be randomized to a TEM- or EMR-treatment strategy. For TEM, patients will be treated under general anesthesia, adenomas will be dissected en-bloc by a full-thickness excision, and patients will be admitted to the hospital. For EMR, no or conscious sedation is used, lesions will be resected through the submucosal plane in a piecemeal fashion, and patients will be discharged from the hospital. Residual adenoma that is visible during the first surveillance endoscopy at 3 months will be removed endoscopically in both treatment strategies and is considered as part of the primary treatment.
Primary outcome measure is the proportion of patients with recurrence after 3 months. Secondary outcome measures are: 2) number of days not spent in hospital from initial treatment until 2 years afterwards; 3) major and minor morbidity; 4) disease specific and general quality of life; 5) anorectal function; 6) health care utilization and costs. A cost-effectiveness and cost-utility analysis of EMR against TEM for large rectal adenomas will be performed from a societal perspective with respectively the costs per recurrence free patient and the cost per quality adjusted life year as outcome measures.
Based on comparable recurrence rates for TEM and EMR of 3.3% and considering an upper-limit of 10% for EMR to be non-inferior (beta-error 0.2 and one-sided alpha-error 0.05), 89 patients are needed per group.
Discussion
The TREND study is the first randomized trial evaluating whether TEM or EMR is more cost-effective for the treatment of large rectal adenomas.
Trial registration number
(trialregister.nl) NTR1422
doi:10.1186/1471-2482-9-4
PMCID: PMC2664790  PMID: 19284647
2.  Transluminal endoscopic step-up approach versus minimally invasive surgical step-up approach in patients with infected necrotising pancreatitis (TENSION trial): design and rationale of a randomised controlled multicenter trial [ISRCTN09186711] 
BMC Gastroenterology  2013;13:161.
Background
Infected necrotising pancreatitis is a potentially lethal disease that nearly always requires intervention. Traditionally, primary open necrosectomy has been the treatment of choice. In recent years, the surgical step-up approach, consisting of percutaneous catheter drainage followed, if necessary, by (minimally invasive) surgical necrosectomy has become the standard of care. A promising minimally invasive alternative is the endoscopic transluminal step-up approach. This approach consists of endoscopic transluminal drainage followed, if necessary, by endoscopic transluminal necrosectomy. We hypothesise that the less invasive endoscopic step-up approach is superior to the surgical step-up approach in terms of clinical and economic outcomes.
Methods/Design
The TENSION trial is a randomised controlled, parallel-group superiority multicenter trial. Patients with (suspected) infected necrotising pancreatitis with an indication for intervention and in whom both treatment modalities are deemed possible, will be randomised to either an endoscopic transluminal or a surgical step-up approach. During a 4 year study period, 98 patients will be enrolled from 24 hospitals of the Dutch Pancreatitis Study Group. The primary endpoint is a composite of death and major complications within 6 months following randomisation. Secondary endpoints include complications such as pancreaticocutaneous fistula, exocrine or endocrine pancreatic insufficiency, need for additional radiological, endoscopic or surgical intervention, the need for necrosectomy after drainage, the number of (re-)interventions, quality of life, and total direct and indirect costs.
Discussion
The TENSION trial will answer the question whether an endoscopic step-up approach reduces the combined primary endpoint of death and major complications, as well as hospital stay and related costs compared with a surgical step-up approach in patients with infected necrotising pancreatitis.
doi:10.1186/1471-230X-13-161
PMCID: PMC4222267  PMID: 24274589
Acute pancreatitis; Necrotising; Treatment; Drainage; Trial; Endoscopy; Minimally invasive; Surgery; Necrosectomy; Pancreas
3.  Do Basic Psychomotor Skills Transfer Between Different Image-based Procedures? 
World Journal of Surgery  2010;34(5):933-940.
Background
Surgical techniques that draw from multiple types of image-based procedures (IBP) are increasing, such as Natural Orifice Transluminal Endoscopic Surgery, fusing laparoscopy and flexible endoscopy. However, little is known about the relation between psychomotor skills for performing different types of IBP. For example, do basic psychomotor colonoscopy and laparoscopy skills interact?
Methods
Following a cross-over study design, 29 naïve endoscopists were trained on the Simbionix GI Mentor and the SimSurgery SEP simulators. Group C (n = 15) commenced with a laparoscopy session, followed by four colonoscopy sessions and a second laparoscopy session. Group L (n = 14) started with a colonoscopy session, followed by four laparoscopy sessions and a second colonoscopy session.
Results
No significant differences were found between the performances of group L and group C in their first training sessions on either technique. With additional colonoscopy training, group C outperformed group L in the second laparoscopy training session on the camera navigation task.
Conclusions
Overall, training in the basic colonoscopy tasks does not affect performance of basic laparoscopy tasks (and vice versa). However, to limited extent, training of basic psychomotor skills for colonoscopy do appear to contribute to the performance of angled laparoscope navigation tasks. Thus, training and assessment of IBP type-specific skills should focus on each type of tasks independently. Future research should further investigate the influence of psychometric abilities on the performance of IBP and the transfer of skills for physicians who are experienced in one IBP type and would like to become proficient in another type of IBP.
doi:10.1007/s00268-010-0432-5
PMCID: PMC2848730  PMID: 20151134
4.  Expert and construct validity of the Simbionix GI Mentor II endoscopy simulator for colonoscopy 
Surgical Endoscopy  2007;22(1):158-162.
Objectives
The main objectives of this study were to establish expert validity (a convincing realistic representation of colonoscopy according to experts) and construct validity (the ability to discriminate between different levels of expertise) of the Simbionix GI Mentor II virtual reality (VR) simulator for colonoscopy tasks, and to assess the didactic value of the simulator, as judged by experts.
Methods
Four groups were selected to perform one hand–eye coordination task (EndoBubble level 1) and two virtual colonoscopy simulations on the simulator; the levels were: novices (no endoscopy experience), intermediate experienced (<200 colonoscopies performed before), experienced (200–1,000 colonoscopies performed before), and experts (>1,000 colonoscopies performed before). All participants filled out a questionnaire about previous experience in flexible endoscopy and appreciation of the realism of the colonoscopy simulations. The average time to reach the cecum was defined as one of the main test parameters as well as the number of times view of the lumen was lost.
Results
Novices (N = 35) reached the cecum in an average time of 29:57 (min:sec), intermediate experienced (N = 15) in 5:45, experienced (N = 20) in 4:19 and experts (N = 35) in 4:56. Novices lost view of the lumen significantly more often compared to the other groups, and the EndoBubble task was also completed significantly faster with increasing experience (Kruskal Wallis Test, p < 0.001). The group of expert endoscopists rated the colonoscopy simulation as 2.95 on a four-point scale for overall realism. Expert opinion was that the GI Mentor II simulator should be included in the training of novice endoscopists (3.51).
Conclusion
In this study we have demonstrated that the GI Mentor II simulator offers a convincing realistic representation of colonoscopy according to experts (expert validity) and that the simulator can discriminate between different levels of expertise (construct validity) in colonoscopy. According to experts the simulator should be implemented in the training programme of novice endoscopists.
doi:10.1007/s00464-007-9394-6
PMCID: PMC2169271  PMID: 17516114
Endoscopy; Simulator; Training; Colonoscopy; Validation

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