Featured Articles in Jul 2018

Consensus on Training and Implementation of Enhanced Recovery After Surgery: A Delphi Study

 

Author list: Nader K. Francis, Thomas Walker, Fiona Carter, Martin Hubner, Angela Balfour, Dorthe Hjort Jakobsen, Jennie Burch, Tracy Wasylak, Nicolas Demartines, Dileep N. Lobo, Valerie Addor, Olle Ljungqvist 

 

Abstract:

Background

Enhanced Recovery After Surgery (ERAS) is widely accepted in current surgical practice due to its positive impact on patient outcomes. The successful implementation of ERAS is challenging and compliance with protocols varies widely. Continual staff education is essential for successful ERAS programmes. Teaching modalities exist, but there remains no agreement regarding the optimal training curriculum or how its effectiveness is assessed. We aimed to draw consensus from an expert panel regarding the successful training and implementation of ERAS.

 

Methods

A modified Delphi technique was used; three rounds of questionnaires were sent to 58 selected international experts from 11 countries across multiple ERAS specialities and multidisciplinary teams (MDT) between January 2016 and February 2017. We interrogated opinion regarding four topics: (1) the components of a training curriculum and the structure of training courses; (2) the optimal framework for successful implementation and audit of ERAS including a guide for data collection; (3) a framework to assess the effectiveness of training; (4) criteria to define ERAS training centres of excellence.

 

Results

An ERAS training course must cover the evidence-based principles of ERAS with team-oriented training. Successful implementation requires strong leadership, an ERAS facilitator and an effective MDT. Effectiveness of training can be measured by improved compliance. A training centre of excellence should show a willingness to teach and demonstrable team working.

 

Conclusion

We propose an international expert consensus providing an ERAS training curriculum, a framework for successful implementation, methods for assessing effectiveness of training and a definition of ERAS training centres of excellence.

 

URL: https://rdcu.be/RD2a

 


Emergency-to-Elective Surgery Ratio: A Global Indicator of Access to Surgical Care

 

Author list: Meghan Prin, Jean Guglielminotti, Onias Mtalimanja, Guohua Li, Anthony Charles

 

Abstract:

Background

Surgical care is essential to health systems but remains a challenge for low- and middle-income countries (LMICs). Current metrics to assess access and delivery of surgical care focus on the structural components of surgery and are not readily applicable to all settings. This study assesses a new metric for surgical care access and delivery, the ratio of emergent surgery to elective surgery (Ee ratio), which represents the number of emergency surgeries performed for every 100 elective surgeries.

 

Methods

A systematic search of PubMed and Medline was conducted for studies describing surgical volume and acuity published between 2006 and 2016. The relationship between Ee ratio and three national indicators (gross domestic product, per capital healthcare spending, and physician density) was analyzed using weighted Pearson correlation coefficients (r w) and linear regression models.

 

Results

A total of 29 studies with 33 datasets were included for analyses. The median Ee ratio was 14.6 (IQR 5.5–62.6), with a range from 1.6 to 557.4. For countries in sub-Saharan Africa the median value was 62.6 (IQR 17.8–111.0), compared to 9.4 (IQR 3.4–13.4) for the United States and 5.5 (IQR 4.4–10.1) for European countries. In multivariable linear regression, the per capita healthcare spending was inversely associated with the Ee ratio, with a 63-point decrease in the Ee ratio for each 1 point increase in the log of the per capita healthcare spending (regression coefficient β = −63.2; 95% CI −119.6 to −6.9; P = 0.036).

 

Conclusion

The Ee ratio appears to be a simple and valid indicator of access to available surgical care. Global health efforts may focus on investment in low-resource settings to improve access to available surgical care.

 

URL: https://rdcu.be/RD4T

 


American College of Surgeons Member Involvement in Global Surgery: Results from the 2015 Operation Giving Back Survey

 

Author list: Marissa A. Boeck, Laura F. Goodman, Yihan Lin, Brittanie Wilczak, Girma Tefera

 

Abstract:

Background

Five billion people worldwide lack access to safe surgery. American College of Surgeons (ACS) members have a strong history of humanitarian and volunteer work. Since its founding in 2004, Operation Giving Back (OGB) has served as a volunteer resource portal. This study sought to understand current activities, needs, and barriers to ACS member volunteerism, and to re-assess the role of OGB.

 

Methods

A 25-question electronic survey was sent to ACS members in August 2015. Utilizing branching logic, those who were involved or interested in volunteerism completed the full survey. Data were assessed using univariable analysis methods.

 

Results

Three percent (n = 1764) of those e-mailed answered the survey. Respondents were mostly men (82%), ≥50 years of age (61%), and general surgeons (70%). Fifty-three percent (n = 937) reported current or past volunteer activities, and 76.5% (n = 1349) were interested in activities within three years. Approximately 84% were interested in international volunteerism and 55% in domestic volunteerism. Few (5.7%) had both training and experience in emergency and disaster response, and only 17% had institutional salary support. Eighty-two percent wished to work with OGB, and 418 indicated organizations with whom they are involved could benefit from OGB collaboration.

 

Conclusion

Interest in surgical volunteerism among ACS member survey respondents is high. OGB has the opportunity to meet member needs by developing programmatic activities, identifying volunteer prospects, facilitating multi-institutional consortia, and leading pre-deployment training. By maximizing volunteer efforts, OGB has the potential to foster sustainable and scalable ethical practices to improve basic access to surgical care globally.

 

URL: https://rdcu.be/RD7A

 


Risk Factors for Mortality and Morbidity in Elderly Patients Presenting with Digestive Surgical Emergencies

 

Author list: Hassen Hentati, Chady Salloum, Philippe Caillet, Eylon Lahat, Mara Disabato, Eric Levesque, Philippe Compagnon, Chetana Lim, Daniel Azoulay

 

Abstract:

Background

Emergency digestive surgery is being increasingly performed in elderly patients. The aim of the present study was to identify the predictors of mortality and morbidity following emergency digestive surgery in patients aged 80 years and older.

 

Methods

A single-center retrospective review was performed of consecutive patients aged ≥65 years operated for a digestive surgical emergency between January 2011 and December 2013. Two groups were compared: group A (aged 65–79 years) and group B (aged ≥80 years).

 

Results

The study population included 185 patients: 76 patients in group A and 109 in group B. The mean age was 79.9 years (65–104 years). The overall 90-day mortality rate was 23.2 and 31.9% at 1 year, which was similar between groups. The overall morbidity was 28.6%. No differences were noted between the two groups in overall, minor (Dindo I–II) or major (Dindo III–IV) morbidity rates. Multivariate analysis identified pulmonary disease (odds ratio, OR = 6.43, p = 0.02), bowel ischemia (OR = 11.41, p = 0.01), postoperative ICU stay (OR = 7.37, p < 0.0001) and the occurrence of postoperative complications (OR = 2.66, p = 0.03) as predictors of 90-day mortality. Predictors of in-hospital morbidity were preoperative hemoglobin <12 g/dL (OR = 2.49, p = 0.02) and postoperative intensive care unit (ICU) stay (OR = 6.69, p < 0.0001). An age ≥80 year was not associated with mortality or morbidity in this study.

 

Conclusions

The decision to perform abdominal surgery in the emergency setting should be based on physiological status, which accounts for a patient’s comorbidities and health status, rather than on chronological age per se.

 

URL: https://rdcu.be/REbR

 


Factors Predicting the Recovery of Unilateral Vocal Fold Paralysis After Thyroidectomy

 

Author list: Yong-Sug Choi, Young-Hoon Joo, Young-Hak Park, Sang-Yeon Kim, Dong-Il Sun

 

Abstract:

Background

We used voice analysis and clinicopathological factors to explore the prognosis of unilateral vocal fold paralysis after thyroid surgery.

 

Methods

The medical records of 63 females who developed unilateral vocal fold paralysis after thyroidectomy were reviewed. All patients were divided into two groups: those who recovered from vocal fold paralysis and those who did not. We analyzed clinical parameters and voice analysis results in a search for correlations with recovery from paralysis.

 

Results

Of the 63 patients, 37 (58%) recovered from paralysis. A small tumor size, incomplete paralysis, the absence of arytenoid tilting, no compensatory movement of the normal side, lower postoperative shimmer, a higher postoperative maximum phonation time (MPT), and lower postoperative subglottic pressure correlated significantly with recovery from vocal fold paralysis. Multivariate analysis confirmed that the absence of compensatory movement of the normal side on videostroboscopy was independently prognostic. A postoperative MPT of 6.86 appeared to be optimal for prediction of recovery. Most patients recovered within 6 months, but those with incomplete paralysis recovered about 3 months earlier. At the 12-month follow-up, the thyroidectomy-related voice questionnaire scores had returned to preoperative values in only 12 patients (19.0%); 51 patients (81.0%) did not fully recover.

 

Conclusion

Compensatory movement of the normal side evident on videostroboscopy was a poor prognostic factor. Voice analysis can be helpful in counseling vocal fold paralysis patients after thyroidectomy, and early intervention may be considered in patients who are expected to have a poor prognosis.

 

URL: https://rdcu.be/REew

 


Antireflux Surgery in the USA: Influence of Surgical Volume on Perioperative Outcomes and Costs—Time for Centralization?

 

Author list: Francisco Schlottmann, Paula D. Strassle, Marco G. Patti

 

Abstract:

Background

Few studies have analyzed the relationship between surgical volume and outcomes after antireflux procedures. The aim of this study was to determine the effect of surgical volume on postoperative results and costs for patients undergoing surgery for gastroesophageal reflux disease.

 

Methods

We analyzed the National Inpatient Sample (period 2000–2013). Adult patients (≥18 years old) with gastroesophageal reflux disease who underwent fundoplication were included. Hospital surgical volume was determined using the 30th and 60th percentile cut points using weighted discharges and categorized as low (<10 operations/year), intermediate (10–25 operations/year), or high (>25 operations/year). We performed multivariable logistic regression models to assess the effect of surgical volume on patient outcomes.

 

Results

The studied cohort comprised 75,544 patients who had antireflux surgery. When operations performed at low-volume hospitals, postoperative bleeding, cardiac failure, renal failure, respiratory failure, and inpatient mortality were more common. In intermediate-volume hospitals, patients were more likely to have postoperative infection, esophageal perforation, bleeding, cardiac failure, renal failure, and respiratory failure. The length of hospital stay was longer at low- and intermediate-volume hospitals (1.08 and 0.55 days longer, respectively). There was an increase in charges of 5120 dollars per patient at low-volume centers, and 4010 dollars per patient at intermediate-volume centers.

 

Conclusions

When antireflux surgery is performed at high-volume hospitals, morbidity is lower, length of hospital stay is shorter, and costs for the healthcare system are decreased.

 

URL: https://rdcu.be/REhp

 


Depression Induced by Total Mastectomy, Breast Conserving Surgery and Breast Reconstruction: A Systematic Review and Meta-analysis

 

Author list: Chengjiao Zhang, Guangfu Hu, Ewelina Biskup, Xiaochun Qiu, Hongwei Zhang, Haiyin Zhang

 

Abstract:

Background

To carry out a systematic review and meta-analysis of the literature to determine whether different type of surgery induces different depression occurrence in female breast cancer at mean time more than 1-year term postoperatively.

 

Methods

A systematic literature search of PubMed, Web of Science, EMBASE, OvidSP, EBSCO and PsycARTICLES was conducted. Observational clinical studies that compared the depression incidence in different surgery groups and presented empirical findings were selected.

 

Results

Sixteen studies met the inclusion criteria, including 5, 4, 2 and 5 studies compared depression between total mastectomy (TM) and breast conserving therapy (BCS), TM and breast reconstruction (BR), BCS and BR, or among all three groups (TM, BCS and BR), respectively. Only 1 of 5 studies, which subjected to multivariate analysis of depression in female breast cancer, reported a statistically significant effect of type of surgery on depression occurrence. Our meta-analysis showed no significant differences among the three types of surgery, with BCS patients versus TM patients (relative risk [RR] = 0.89, 95% confidence interval [CI] 0.78–1.01; P = 0.06), BR patients versus TM patients (RR = 0.87, 95% CI 0.71–1.06; P = 0.16) and BCS patients versus BR patients (RR = 1.10; 95% CI 0.89–1.35; P = 0.37), respectively.

 

Conclusions

Our study showed that there were no statistically significant differences concerning the occurrence of depressive symptoms in breast cancer patients as a consequence of TM, BCS or BR at mean time more than 1-year term postoperatively.

 

URL: https://rdcu.be/REkH

 


 

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