Evaluation of the ScopeControl endoscope test system in six hospitals in The Netherlands

As rigid endoscopes are re-used after minimal invasive surgery, they degrade over time. To guarantee the optical quality of a rigid endoscope, the ScopeControl has been developed to measure key optical parameters such as, light transmission (LT), color correctness (CC), focus (FC), fiber transmission (FT), viewing angle (VA) and field of view (FV). To evaluate the performance of the ScopeControl, five ScopeControls SV (study version) have been tested in six hospitals in the Netherlands. Aspects such as robustness, precision, usability of the measured data, acceptation criteria and ergonomic aspects have been assessed. The ScopeControl maintains its stability over time and can measure LT, CC and FC with 5% precision, VA and FV with 2% accuracy and FT with 10% precision. The final thresholds above which an endoscope could still be considered to be in good condition, appeared to be: VA at 75%, CC, FC and FV at 70%, LT at 65% and FT at 35% of that of the best endoscope of that type ever found. The ScopeControl SV fits the workflow of the sterilization department as it is easy to use and can easily be cleaned. The time to perform a measurement is 2–3 min (one minute is spent to select the correct endoscope). The ScopeControl PV (launched in November 2013), has been used clinically from April to November 2014. It proves to be more stable, well accepted by personnel from the sterilization department and be of large value of preventing defect endoscopes on the surgery table.     

Genomic Epidemiology of an Endoscope-Associated Outbreak of Klebsiella pneumoniae Carbapenemase (KPC)-Producing K. pneumoniae

Increased incidence of infections due to Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae (KPC-Kp) was noted among patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) at a single hospital. An epidemiologic investigation identified KPC-Kp and non-KPC-producing, extended-spectrum β-lactamase (ESBL)-producing Kp in cultures from 2 endoscopes. Genotyping was performed on patient and endoscope isolates to characterize the microbial genomics of the outbreak. Genetic similarity of 51 Kp isolates from 37 patients and 3 endoscopes was assessed by pulsed-field gel electrophoresis (PFGE) and multi-locus sequence typing (MLST). Five patient and 2 endoscope isolates underwent whole genome sequencing (WGS). Two KPC-encoding plasmids were characterized by single molecule, real-time sequencing. Plasmid diversity was assessed by endonuclease digestion. Genomic and epidemiologic data were used in conjunction to investigate the outbreak source. Two clusters of Kp patient isolates were genetically related to endoscope isolates by PFGE. A subset of patient isolates were collected post-ERCP, suggesting ERCP endoscopes as a possible source. A phylogeny of 7 Kp genomes from patient and endoscope isolates supported ERCP as a potential source of transmission. Differences in gene content defined 5 ST258 subclades and identified 2 of the subclades as outbreak-associated. A novel KPC-encoding plasmid, pKp28 helped define and track one endoscope-associated ST258 subclade. WGS demonstrated high genetic relatedness of patient and ERCP endoscope isolates suggesting ERCP-associated transmission of ST258 KPC-Kp. Gene and plasmid content discriminated the outbreak from endemic ST258 populations and assisted with the molecular epidemiologic investigation of an extended KPC-Kp outbreak.     

Evaluation of a dual-function pH and PCO2 in vivo sensor.

A newly developed, dual-function pH and PCO2 sensor was evaluated in this study. The sensors were placed in the femoral arteries of dogs anesthetized with sodium pentobarbital. Comparisons were made between systemic arterial pH and PCO2 measured using the sensor and those measured from blood samples drawn at 15-min intervals over a 7-h period using a bench instrument. The mean pH of the bench instrument measurements was 7.43. The mean difference of the sensor measurements from the bench instrument measurements for 207 comparisons was 0.0003 pH +/- 0.061 SD. The mean PCO2 of the bench instrument measurements was 40 mmHg. The mean difference of the sensor measurements from those of the bench instrument for 212 comparisons was -1.43 mmHg +/- 5.17 SD. The sensors performed equally well in the presence of metabolic or respiratory acidosis and alkalosis. The dual-function sensors evaluated in this study are useful for trend monitoring of pH and PCO2 over at least a 7-h period without recalibration. With improvement in the consistency of sensor construction, these sensors will be reliable in vivo sensing devices for blood pH and PCO2 and thus valuable research and clinical instruments.     

Automated method for determination of glutardialdehyde residues in flexible endoscopes after disinfection

Glutardialdehyde (GDA) is the most commonly used disinfectant for flexible endoscopes. After inappropriate rinsing of endoscopes residual GDA in the narrow endoscope channels may lead to toxic effects in patients. Common methods for determination of aldehydes in water involve derivatization with 2,4-dinitrophenylhydrazine (DNPH), liquid-liquid or solid-phase extraction and HPLC determination. Since derivatization and extraction is both time-consuming and labor-intensive only a small number of samples can be measured. Thus, we developed a fully automated method which includes a conventional HPLC system, a programmable autosampler, and UV detection. After GDA derivatization using DNPH the samples remain in the aqueous phase and no preconcentration of the analyte is necessary. The samples are automatically derivatized through the autosampler. While derivatization in one sample takes place the previous sample is injected and measured by HPLC. Our method is well suited for screening residual GDA in endoscopes as it is both time- and labor-saving.     

Efficacy of Conventional Endoscopic Disinfection and Sterilization Methods Against Helicobacter pylori Contamination

Background. Iatrogenic transmission of Helicobacter pylori via contaminated endoscopic devices is well documented. Despite the prevalence of this infectious agent, few controlled studies have investigated the major factors that impact on reprocessing of endoscopes contaminated with H. pylori. Materials and Methods. An endoscope (Pentax) was contaminated with 10⁸ cfu/ml of H. pylori in 5% bovine calf serum as standardized inoculum. The endoscope then was passed through one of eight arms (five repetitions per arm = 40 total runs), as follows: 1, recovery control (no cleaning or disinfection); 2, manual cleaning alone; 3–5, manual precleaning followed by either 10-, 20-, or 45-minute exposure to 2% glutaraldehyde and ethanol (ETOH) drying; 6, manual cleaning followed by automated reprocessing by STERIS System; 7 and 8, automated reprocessing by STERIS with and without active peracetic acid sterilant (wash-off control). Suction-biopsy channels and air-water channels were harvested for microbiological culture. Results. Control runs recovered more than 1 × 10⁶ cfu per site, confirming the viability of the test organism and the adequacy of the biological burden for challenge. When instruments underwent manual cleaning alone (without subsequent disinfection), test organisms remained in 40% of runs at the air-water site. Manual cleaning followed by 10-, 20-, or 45-minute glutaraldehyde exposure and ETOH drying removed all test organisms from all sites in all runs (i.e., 100% disinfection). The automated STERIS system with or without active peracetic acid sterilant also removed all test organisms from all sites in all runs, as did manual cleaning followed by STERIS use. Conclusion. Manual cleaning alone does not effectively remove H. pylori from an endoscope. Current joint association recommendations for minimal disinfection (manual cleaning followed by at least 20 minutes of immersion in glutaraldehyde and ETOH drying) are effective in preventing cross-transmission of H. pylori. Reprocessing using the automated STERIS system according to manufacturer's recommendations also is highly effective in sterilizing endoscopes contaminated with H. pylori.     

Endoscopic optical coherence tomography angiography using a forward imaging piezo scanner probe

A forward imaging endoscope for optical coherence tomography angiography (OCTA) featuring a piezoelectric fiber scanner is presented. Imaging is performed with an optical coherence tomography (OCT) system incorporating an akinetic light source with a center wavelength of 1300 nm, bandwidth of 90 nm and A‐line rate of 173 kHz. The endoscope operates in contact mode to avoid motion artifacts, in particular, beneficial for OCTA measurements, and achieves a transversal resolution of 12 μm in air at a rigid probe size of 4 mm in diameter and 11.3 mm in length. A spiral scan pattern is generated at a scanning frequency of 360 Hz to sample a maximum field of view of 1.3 mm. OCT images of a human finger as well as visualization of microvasculature of the human palm are presented both in two and three dimensions. The combination of morphological tissue contrast with qualitative dynamic blood flow information within this endoscopic imaging approach potentially enables improved early diagnostic capabilities of internal organs for diseases such as bladder cancer.      

Implantable self‐aligning fiber‐optic optomechanical devices for in vivo intraocular pressure‐sensing in artificial cornea

Artificial cornea is an effective treatment of corneal blindness. Yet, intraocular pressure (IOP) measurements for glaucoma monitoring remain an urgent unmet need. Here, we present the integration of a fiber‐optic Fabry‐Perot pressure sensor with an FDA‐approved keratoprosthesis for real‐time IOP measurements using a novel strategy based on optical‐path self‐alignment with micromagnets. Additionally, an alternative noncontact sensor‐interrogation approach is demonstrated using a bench‐top optical coherence tomography system. We show stable pressure readings with low baseline drift (<2.8 mm Hg) for >4.5 years in vitro and efficacy in IOP interrogation in vivo using fiber‐optic self‐alignment, with good initial agreement with the actual IOP. Subsequently, IOP drift in vivo was due to retroprosthetic membrane (RPM) formation on the sensor secondary to surgical inflammation (more severe in the current pro‐fibrotic rabbit model). This study paves the way for clinical adaptation of optical pressure sensors with ocular implants, highlighting the importance of controlling RPM in clinical adaptation.     

An update on gastrointestinal endoscopy-associated infections and their contributing factors

Introduction

During clinical use, gastrointestinal endoscopes are grossly contaminated with patient’s native flora. These endoscopes undergo reprocessing to prevent infectious transmission upon future use. Endoscopy-associated infections and outbreaks have been reported, with a recent focus on the transmission of multi-drug resistant organisms. This review aims to provide an update on endoscopy-associated infections, and the factors contributing to their occurrence.

Methods

PubMed, ScienceDirect, and CINAHL were searched for articles describing gastrointestinal endoscopy-associated infections and outbreaks published from 2008 to 2018. Factors contributing to their occurrence, and the outcomes of each outbreak were also examined.

Results

This review found 18 articles, 16 of which described duodenoscope-associated infections, and the remaining two described colonoscope- and gastroscope-associated infection respectively. Outbreaks were reported from the United States, France, China, Germany, the Netherlands and the United Kingdom. The causative organisms reported were Klebsiella pneumoniae, Pseudomonas aeruginosa, Escherichia coli and Salmonella enteritidis.

Conclusions

A number of factors, including lapses in reprocessing, biofilm formation, endoscope design issues and endoscope damage, contribute to gastrointestinal endoscopy associated infection. Methods of improving endoscope reprocessing, screening for contamination and evaluating endoscope damage may be vital to preventing future infections and outbreaks.

     

Design and application of a versatile triple-laser cell and chromosome sorter

A high-resolution triple-laser sorter was designed and constructed to provide flexible switchover and high-resolution sorting of cells or chromosomes with any combination of one, two, or three lasers. These features provide a central facility instrument that currently serves multiple users and analyzes different stain combinations with minimal switchover effort between experiments. Improved optics and mounts that focus the three laser beams independently are able to resolve beads and chromosomes better than our previously reported dual-laser sorter. An improved signal collection unit with electronically controlled reference positions can be focused more quickly and precisely for any signal combination. A removable dye laser extends the range of usable fluorochrome labels. A rapid sheath switchover permits sorting of sterile cells and sterile chromosomes sequentially without additional sterilization or reservoir sheath change. Improved dual-laser chromosome resolution is at least as good, analyzing 8,000 chromosomes/s, compared to the previous dual-laser bench at 2,000/s. Stimulated and unstimulated peripheral blood lymphocytes were analyzed according to simultaneous measurements of cell surface receptors labeled with a fluoresceinated neuropeptide and a Texas red-labeled antibody as well as DNA content during the cell cycle. These results demonstrate the broad range of potential applications of this triple-laser system.     

Reproducibility of Structural,Resting-State BOLD and DTI Data between Identical Scanners

Increasingly, clinical trials based on brain imaging are adopting multiple sites/centers to increase their subject pool and to expedite the studies, and more longitudinal studies are using multiple imaging methods to assess structural and functional changes. Careful investigation of the test-retest reliability and image quality of inter- or intra- scanner neuroimaging measurements are critical in the design, statistical analysis and interpretation of results. We propose a framework and specific metrics to quantify the reproducibility and image quality for neuroimaging studies (structural, BOLD and Diffusion Tensor Imaging) collected across identical scanners and following a major hardware repair (gradient coil replacement). We achieved consistent measures for the proposed metrics: structural (mean volume in specific regions and stretch factor), functional (temporal Signal-to-Noise ratio), diffusion (mean Fractional Anisotropy and Mean Diffusivity in multiple regions). The proposed frame work of imaging metrics should be used to perform daily quality assurance testing and incorporated into multi-center studies.     

Heart valve tissue engineering: quo vadis?

Surgical replacement of diseased heart valves by mechanical and tissue valve substitutes is now commonplace and generally enhances survival and quality of life. However, a fundamental problem inherent to the use of existing mechanical and biological prostheses in the pediatric population is their failure to grow, repair, and remodel. A tissue engineered heart valve could, in principle, accommodate these requirements, especially somatic growth. This review provides a brief overview of the field of heart valve tissue engineering, with emphasis on recent studies and evolving concepts, especially those that establish design criteria and key hurdles that must be surmounted before clinical implementation.     

Random Postoperative Day-3 Cortisol Concentration as a Predictor of Hypothalamic-Pituitary-Adrenal Axis Integrity after Transsphenoidal Surgery

ObjectiveTo determine whether a random postoperative day-3 cortisol value of 10 μg/dL or greater is predictive of adrenal sufficiency 3 to 10 weeks after transsphenoidal surgery (TSS) and during long-term clinical follow-up.MethodsWe retrospectively reviewed the case records of patients who underwent TSS at our institution between 1991 and 2008. Inclusion criteria were as follows: random cortisol measured on the morning of postoperative day 3, adrenal dynamic testing performed 3 to 10 weeks after TSS, and clinical assessment of the hypothalamicpituitary-adrenal (HPA) axis at least 6 months after TSS.ResultsA total of 466 patients underwent TSS at our institution during the study period. Eighty-three patients met study inclusion criteria. Sensitivity of a random postoperative day-3 serum cortisol value of 10 μg/dL or greater for the prediction of adrenal sufficiency at a median follow-up of 42 days was 64.81% (95% confidence interval, 50.6%-77.32%), with an odds ratio of 3.1 (95% confidence interval, 1.08-8.58). Specificity was 62.1% (95% confidence interval, 42.3%-79.3%). At a median follow-up of 500 days, only 2 patients with a postoperative day-3 cortisol value of 10 μg/dL or greater required hydrocortisone replacement, both of whom had multiple anterior pituitary hormone deficiencies and evidence of pituitary dysfunction during the perioperative period.ConclusionsIn the appropriate clinical context, a postoperative day-3 cortisol value of 10 μg/dL or greater accurately predicts the integrity of the HPA axis. The final decision regarding corticosteroid replacement should be personalized, considering the postoperative day-3 cortisol level, the clinical context in which the measurement was obtained, and any evidence of concomitant pituitary dysfunction in the perioperative period. (Endocr Pract. 2011;17:717-726)     

Elimination of Toxicity from Polyvinyl Trays After Sterilization with Ethylene Oxide

Ethylene oxide (ETO) sterilization of polyvinyl trays used in an antiviral screening program was initiated to overcome seasonal outbreaks of bacterial and mycotic contamination of tissue culture cells. Trays sterilized by 100% ETO for 5 hr after 48 hr of prehumidification, or by 12% ETO plus 88% Freon 12 for 1, 3, 5 or 18 hr, followed by various methods of aeration, were seeded with several types of tissue culture cells and examined for contamination, toxicity, and monolayer quality. A 1-hr exposure in 12% ETO plus 88% Freon 12 was adequate for sterilization, although residual toxicity for tissue cultures remained. A 7-day aeration period at 37 C was sufficient to eliminate toxicity and allow the growth of good monolayers of WI-38, HEp-2 and primary bovine kidney cells. Sterilization with 100% ETO required 14 days of aeration at 37 C to eliminate cytotoxicity. Increased residual toxicity resulting from longer ETO sterilization periods required longer aeration times at 37 C or higher aeration temperatures for detoxification.     

Probe-based Confocal Laser Endomicroscopy of the Urinary Tract: The Technique

Probe-based confocal laser endomicroscopy (CLE) is an emerging optical imaging technology that enables real-time in vivo microscopy of mucosal surfaces during standard endoscopy. With applications currently in the respiratory¹ and gastrointestinal tracts,^2-6 CLE has also been explored in the urinary tract for bladder cancer diagnosis.^7-10 Cellular morphology and tissue microarchitecture can be resolved with micron scale resolution in real time, in addition to dynamic imaging of the normal and pathological vasculature.⁷The probe-based CLE system (Cellvizio, Mauna Kea Technologies, France) consists of a reusable fiberoptic imaging probe coupled to a 488 nm laser scanning unit. The imaging probe is inserted in the working channels of standard flexible and rigid endoscopes. An endoscope-based CLE system (Optiscan, Australia), in which the confocal endomicroscopy functionality is integrated onto the endoscope, is also used in the gastrointestinal tract. Given the larger scope diameter, however, application in the urinary tract is currently limited to ex vivo use.¹¹ Confocal image acquisition is done through direct contact of the imaging probe with the target tissue and recorded as video sequences. As in the gastrointestinal tract, endomicroscopy of the urinary tract requires an exogenenous contrast agent—most commonly fluorescein, which can be administered intravenously or intravesically. Intravesical administration is a well-established method to introduce pharmacological agents locally with minimal systemic toxicity that is unique to the urinary tract. Fluorescein rapidly stains the extracellular matrix and has an established safety profile.¹² Imaging probes of various diameters enable compatibility with different caliber endoscopes. To date, 1.4 and 2.6 mm probes have been evaluated with flexible and rigid cystoscopy.¹⁰ Recent availability of a < 1 mm imaging probe¹³ opens up the possibility of CLE in the upper urinary tract during ureteroscopy. Fluorescence cystoscopy (i.e. photodynamic diagnosis) and narrow band imaging are additional endoscope-based optical imaging modalities¹⁴ that can be combined with CLE to achieve multimodal imaging of the urinary tract. In the future, CLE may be coupled with molecular contrast agents such as fluorescently labeled peptides¹⁵ and antibodies for endoscopic imaging of disease processes with molecular specificity.     

Delivering on the promise of bone morphogenetic proteins.

The advent of bone growth factors has been widely anticipated since their successful production using recombinant DNA technology. Bone morphogenetic proteins (BMPs) are an important class of bone growth factors and will be the focus of this article. In the near future these therapeutics might revolutionize how clinicians treat such diverse orthopedic applications as the healing of broken bones, increasing bone density lost through aging, and strengthening the spine. These potent proteins require application directly at the site of repair via a delivery system. The choice of delivery system has a profound effect on the clinical outcome. In the past decade, researchers have focused on developing efficient delivery systems and advancing these factors from the bench to the clinic.     

Sterilization with electron beam irradiation influences the biomechanical properties and the early remodeling of tendon allografts for reconstruction of the anterior cruciate ligament (ACL)

Although allografts for anterior cruciate ligament (ACL) replacement have shown advantages compared to autografts, their use is limited due to the risk of disease transmission and the limitations of available sterilization methods. Gamma sterilization has shown detrimental effects on graft properties at the high doses required for sufficient pathogen inactivation. In our previous in vitro study on human patellar tendon allografts, Electron beam (Ebeam) irradiation showed less detrimental effects compared to gamma sterilization (Hoburg et al. in Am J Sports Med 38(6):1134-1140, 2010). To investigate the biological healing and restoration of the mechanical properties of a 34?kGy Ebeam treated tendon allograft twenty-four sheep underwent ACL replacement with either a 34?kGy Ebeam treated allograft or a non-sterilized fresh frozen allograft. Biomechanical testing of stiffness, ultimate failure load and AP-laxity as well as histological analysis to investigate cell, vessel and myofibroblast-density were performed after 6 and 12?weeks. Native sheep ACL and hamstring tendons (HAT, each n?=?9) served as controls. The results of a previous study analyzing the remodeling of fresh frozen allografts (n?=?12) and autografts (Auto, n?=?18) with the same study design were also included in the analysis. Statistics were performed using Mann-Whitney U test followed by Bonferroni-Holm correction. Results showed significantly decreased biomechanical properties during the early remodeling period in Ebeam treated grafts and this was accompanied with an increased remodeling activity. There was no recovery of biomechanical function from 6 to 12?weeks in this group in contrast to the results observed in fresh frozen allografts and autografts. Therefore, high dose Ebeam irradiation investigated in this paper cannot be recommended for soft tissue allograft sterilization.     

Methods for magnetically labeling stem and other cells for detection by in vivo magnetic resonance imaging

Superparamagnetic iron oxide (SPIO) nanoparticles are being used for intracellular magnetic labeling of stem cells and other cells in order to monitor cell trafficking by magnetic resonance imaging (MRI) as part of cellular-based repair, replacement and treatment strategies. This review focuses on the various methods for magnetic labeling of stem cells and other mammalian cells and on how to translate experimental results from bench to bedside.     

Passive autofocusing for digital endoscopic imaging systems.

An autofocus is a desirable feature of an endoscope, because it relieves the user from performing a task which can be automated and thereby prevents unnecessary interruptions in the work to be performed. Autofocusing is in general best achieved by an active system, i.e., on the basis of a distance measurement. Yet, in handheld medical endoscopes such a method is unsuited because of the added weight associated with the necessary electromechanical components. Autofocusing should rather be performed passively, furthermore, in applications which are particularly critical with respect to safety, e.g., in the eye, a stable and reliable operation in real time and without interruption is necessary. Passive autofocus strategies applied to date and known to the authors lead however to algorithms which are either too slow for a real time implementation and/or are influenced by the structure of the object which is to be brought into focus. Accordingly, a new autofocus procedure has been developed which exhibits a stable and reliable operation in real time under all circumstances of interest. It is based on the squared differences of the intensity of adjacent points in both dimensions of a plane image (Square Plane Sum Modulus Difference, SPSMD) and as such particularly suitable for digital camera systems and real-time needs (typically, 30 evaluations per second on an image of 1024 x 1024 pixels). The SPSMD criterion is more sensitive, has a larger SNR than other focus criteria known to the authors and exhibits in particular no secondary extrema which could adversely affect proper focusing. As it includes intensity differences in both (perpendicular) directions in the image plane, it is essentially independent of image structures.     

Low levels of DNA excision repair in undamaged bovine lymphocytes

Quiescent and concanavalin A-stimulated bovine lymphocytes were subjected to a buoyant density analysis used in excision repair studies. Despite neutral and alkaline rebands to remove replicative contamination, the CsCl gradient profiles of DNA isolated from unstimulated lymphocytes given a 6-h labelling period revealed a small amount of radioactivity in the normal-density region which is indicative of an excision repair process. It amounted to the incorporation of 8,000-20,000 molecules of thymidine per lymphocyte. In a 12-h labelling period the extent of repair incorporation was twice that measured in a 6-h period. The extent of this repair incorporation was not altered significantly during the initial 6 or 12 h of lectin stimulation when DNA-strand breaks normally present in the unstimulated cells are repaired. The same amount of repair activity was found whether the measurements were made on the same day that the lymphocytes were isolated or on the next day following an overnight incubation of the cells in culture medium. These observations indicate that lymphocytes display a spontaneous excision repair activity that proceeds continuously and at a constant rate.     

Surgical treatment of osteoarthritis of the carpometacarpal joint of the thumb: a systematic review

In most cases of basal joint osteoarthritis, surgery becomes an option at stages II, III, and IV, as classified by Eaton. Controversy exists regarding which technique achieves the best outcome. This systematic review was undertaken to address the question of which technique, if any, offers the best outcome to patients with osteoarthritis of the first carpometacarpal joint greater than stage II. A thorough search of the electronic databases Cochrane, Cinahl, Healthstar, and MEDLINE/PubMed was undertaken to identify reviews and articles on primary comparative studies of the different surgical options. The methodological quality of the retrieved articles was assessed on the basis of specific criteria. Inclusion criteria were applied to 44 of 254 possibly relevant articles. Eight reviews and 18 comparative studies met the criteria and were reviewed. Each of the techniques, arthrodesis, trapeziectomy with or without biological/synthetic interposition, osteotomy, and joint replacement, was associated with unique benefits and risks. There was great variability in outcome measurements. The majority of retrieved review articles claim that ligamentous reconstruction and tendon interposition may represent the best option; however, validity assessment of these studies revealed methodological flaws. Furthermore, results from the articles on comparative studies indicate that ligamentous reconstruction and tendon interposition may provide no additional benefit when compared with arthrodesis and trapeziectomy alone or with tendon interposition. There is no consensus as to which clinical outcomes are most important in thumb basal joint surgery and how these should be measured. This renders the appraisal and comparison of such studies a challenging task. Until large randomized controlled trials that compare techniques in similar populations with respect to staging and prognostic factors are undertaken and the clinical outcomes are clearly defined, surgeons will continue to claim superiority of one technique over another without supporting evidence.