Patient Blood Management: Improving Outcomes for Millions While Saving Billions. What Is Holding It Up?

Patient blood management (PBM) offers significantly improved outcomes for almost all medical and surgical patient populations, pregnant women, and individuals with micronutrient deficiencies, anemia, or bleeding. It holds enormous financial benefits for hospitals and payers, improves performance of health care providers, and supports public authorities to improve population health. Despite this extraordinary combination of benefits, PBM has hardly been noticed in the world of health care. In response, the World Health Organization (WHO) called for its 194 member states, in its recent Policy Brief, to act quickly and decidedly to adopt national PBM policies. To further support the WHO's call to action, this article addresses 3 aspects in more detail. The first is the urgency from a health economic perspective. For many years, growth in health care spending has outpaced overall economic growth, particularly in aging societies. Due to competing economic needs, the continuation of disproportionate growth in health care spending is unsustainable. Therefore, the imperative for health care leaders and policy makers is not only to curb the current spending rate relative to the gross domestic product (GDP) but also to simultaneously improve productivity, quality, safety of patient care, and the health status of populations. Second, while PBM meets these requirements on an exceptional scale, uptake remains slow. Thus, it is vital to identify and understand the impediments to broad implementation. This includes systemic challenges such as the so-called "waste domains" of failure of care delivery caused by malfunctions of health care systems, failure of care coordination, overtreatment, and low-value care. Other impediments more specific to PBM are the misperception of PBM and deeply rooted cultural patterns. Third, understanding how the 3Es-evidence, economics, and ethics-can effectively be used to motivate relevant stakeholders to take on their respective roles and responsibilities and follow the urgent call to implement PBM as a standard of care.

Investigation of a method for long-term preservation of the vascular allograft.

BACKGROUND/OBJECTIVE: During multiple organ procurement, blood vessels are routinely retrieved and stored in University of Wisconsin solution and then discarded after two weeks, if not used at organ transplantation owing to lack of a method for long-term preservation. Therefore, the aim of this study is to investigate a method for long-term preservation of vascular allografts in ethanol. METHODS: Aorta and vena cava allografts were retrieved and stored in 75% ethanol solution for 12 months at 4°C. Four pigs were divided into two groups. A segment of aorta was excised and replaced by insertion of preserved aorta graft (Group A) or vena cava graft (Group V). The pigs were observed for six weeks. A laparotomy was performed and the vascular graft was harvested for histopathology followed by euthanasia at the end of study. RESULTS: Three pigs recovered uneventfully, while one pig died from venous graft rupture in the third week after surgery. There was no aneurysmal formation or thrombosis in the grafts. Some calcification was seen over aorta allograft. On histopathology, the elastic pattern was almost normal, although the endothelial cells degenerated after preservation. After implantation, the formation of the endothelium cell-like layer was seen in both aorta and vena cava allografts. CONCLUSION: Vascular allografts were functional after preservation for 12 months. The vena cava grafts had much less wall calcification than the aorta grafts. Further studies are necessary to investigate vascular graft remodelling with a longer observation period after implantation.

Associations of a Preoperative Anemia and Suboptimal Iron Stores Screening and Management Clinic in Colorectal Surgery With Hospital Cost, Reimbursement, and Length of Stay: A Net Cost Analysis.

BACKGROUND: In 2016, a preoperative clinic was implemented to screen, evaluate, and manage anemia and suboptimal iron stores at a major tertiary care medical center in Western Australia. Few studies compare the costs and reimbursements associated with preoperative anemia and suboptimal iron stores management. The objective of our study was to conduct a net cost analysis associated with the implementation of this clinic. METHODS: We designed a retrospective cohort study involving elective colorectal surgical admissions over a 3-year period. The baseline year selected was the 2015-2016 financial year, with outcomes in the 2016-2017 and 2017-2018 year compared to baseline. The study perspective was the Western Australian Health System. Hospital costs were extracted from the health service clinical costing system, which captures costs at the admission level. The primary outcome was net cost, defined as gross cost minus reimbursement (or funding) received. RESULTS: Our 3-year study included 544 admissions for elective colorectal surgery. After the implementation of the preoperative clinic, 73.4% (n = 257) of admissions were screened for anemia and suboptimal iron stores, and 31.4% (n = 110) received intravenous iron. In our adjusted analysis, when comparing the final year (2017-2018) with baseline (2015-2016), the units of red blood cells transfused per admission decreased 53% (142 vs 303 units per 1000 discharges; P = .006), and mean hospital length of stay decreased 15% (7.7 vs 9.1 days; P = .008). When comparing the final year with baseline, rectal resection admissions were associated with a mean decrease in the net cost of Australian dollar (A$) 7619 (95% confidence interval, 4230-11,008; P < .001) between 2015-2016 and 2017-2018. For small and large bowel procedures, there was a mean decrease of A$6744 (95% confidence interval, 2430-11,057; P = .002). CONCLUSIONS: The implementation of a preoperative anemia and suboptimal iron stores screening and management clinic in elective colorectal surgery was associated with reductions in red cell transfusions, length of stay, and net costs.

TLR9 is up-regulated in human and murine NASH: pivotal role in inflammatory recruitment and cell survival.

Background and aims: TLR9 deletion protects against steatohepatitis due to choline-amino acid depletion and high-fat diet. We measured TLR9 in human non-alcoholic steatohepatitis (NASH) livers, and tested whether TLR9 mediates inflammatory recruitment in three murine models of non-alcoholic fatty liver disease (NAFLD). Methods: We assayed TLR mRNA in liver biopsies from bariatric surgery patients. Wild-type (Wt), appetite-dysregulated Alms1 mutant (foz/foz), Tlr9-/-, and Tlr9-/-foz/foz C57BL6/J mice and bone marrow (BM) chimeras were fed 0.2% cholesterol, high-fat, high sucrose (atherogenic[Ath]) diet or chow, and NAFLD activity score (NAS)/NASH pathology, macrophage/neutrophil infiltration, cytokines/chemokines, and cell death markers measured in livers. Results: Hepatic TLR9 and TLR4 mRNA were increased in human NASH but not simple steatosis, and in Ath-fed foz/foz mice with metabolic syndrome-related NASH. Ath-fed Tlr9-/- mice showed simple steatosis and less Th1 cytokines than Wt. Tlr9-/-foz/foz mice were obese and diabetic, but necroinflammatory changes were less severe than Tlr9+/+.foz/foz mice. TLR9-expressing myeloid cells were critical for Th1 cytokine production in BM chimeras. BM macrophages from Tlr9-/- mice showed M2 polarization, were resistant to M1 activation by necrotic hepatocytes/other pro-inflammatory triggers, and provoked less neutrophil chemotaxis than Wt Livers from Ath-fed Tlr9-/- mice appeared to exhibit more markers of necroptosis [receptor interacting protein kinase (RIP)-1, RIP-3, and mixed lineage kinase domain-like protein (MLKL)] than Wt, and ∼25% showed portal foci of mononuclear cells unrelated to NASH pathology. CONCLUSION: Our novel clinical data and studies in overnutrition models, including those with diabetes and metabolic syndrome, clarify TLR9 as a pro-inflammatory trigger in NASH. This response is mediated via M1-macrophages and neutrophil chemotaxis.

Association between liver-specific gene polymorphisms and their expression levels with nonalcoholic fatty liver disease.

UNLABELLED: Genetic factors account for a significant proportion of the phenotypic variance of nonalcoholic fatty liver disease (NAFLD); however, very few predisposing genes have been identified. We aimed to (1) identify novel genetic associations with NAFLD by performing a genome-wide association study (GWAS), and (2) examine the biological expression of the strongest genetic associations in a separate cohort. We performed GWAS of a population-based cohort (Raine Study) of 928 adolescents assessed for NAFLD by ultrasound at age 17. Expression of genes with single nucleotide polymorphisms (SNPs) that were associated with NAFLD at a significance level of P < 10(-5) was examined in adults with NAFLD and controls by quantifying hepatic messenger RNA (mRNA) expression and serum levels of protein. After adjustment for sex and degree of adiposity, SNPs in two genes expressed in liver were associated with NAFLD adolescents: group-specific component (GC) (odds ratio [OR], 2.54; P = 1.20 × 10(-6)) and lymphocyte cytosolic protein-1 (LCP1) (OR, 3.29; P = 2.96 × 10(-6)). SNPs in two genes expressed in neurons were also associated with NAFLD: lipid phosphate phosphatase-related protein type 4 (LPPR4) (OR, 2.30; P = 4.82 × 10(-6)) and solute carrier family 38 member 8 (SLC38A8) (OR, 3.14; P = 1.86 × 10(-6) ). Hepatic GC mRNA was significantly reduced (by 83%) and LCP1 mRNA was increased (by 300%) in liver biopsy samples from patients with NAFLD compared to controls (P < 0.05). Mean serum levels of GC protein were significantly lower in patients with NAFLD than controls (250 ± 90 versus 298 ± 90, respectively; P = 0.004); GC protein levels decreased with increasing severity of hepatic steatosis (P < 0.01). CONCLUSION: The association between GC and LCP1 SNPs and NAFLD as well as altered biological expression implicate these genes in the pathogenesis of NAFLD.

Evaluation of prescription medication changes following sleeve gastrectomy surgery.

Objective: The increasing global prevalence of obesity, coupled with its association with chronic health conditions and rising healthcare costs, highlights the need for effective interventions; however, despite the availability of treatment options, the ongoing success of primary interventions in maintaining long-term weight loss remains limited. This study examined the prescription medication dispensing changes following sleeve gastrectomy in Australians aged 45 years and over. Methods: In a retrospective analysis of 847 bariatric surgery patients from the New South Wales 45 and Up Study, the assessment of medication patterns categorizing into three groups: gastrointestinal, metabolic, cardiorespiratory, musculoskeletal, and nervous systems was conducted. Each drug class was analyzed, focusing on patients with dispensing records within the 12 months before surgery. This study employed interrupted time-series analysis to compare pre- and post-surgery medication usage. Results: With a predominantly female population (76.9%) and an average age of 57.2 (standard deviation 5.71), there were statistically significant reductions in both unique medications (12.5% decrease, p = 0.004) and total medications dispensed (15.9% decrease, p = 0.003) from 12 months before surgery to 13-24 months after bariatric surgery. All medication categories, except opioids, showed reductions. Notably, the most significant reductions were observed in diabetes (38.6%), agents acting on the renin-angiotensin system (40.4%), lipid modifying agents (26.5%), anti-inflammatory products (46.3%), and obstructive airway diseases (53.3%) medications during this time frame. Conclusion: These findings suggest that sleeve gastrectomy provides an effective therapeutic intervention for patients with comorbidities requiring multiple medications, especially for obesity-related diseases such as diabetes, cardiovascular, respiratory and musculoskeletal disorders.

Evaluation of the Swedish adjustable gastric band VC (SAGB-VC) in an Australian population: early results.

BACKGROUND: The Swedish adjustable gastric band VC (SAGB-VC) has been in use in Australia since 2007. We evaluated its efficacy and safety. METHODS: We retrospectively analyzed the prospective clinical data of patients who received the implant between November 2007 and June 2009 at 3 Australian bariatric centres. RESULTS: In all, 1176 patients (mean age 45.9 [standard deviation (SD) 12.3] yr, mean body mass index 43.4 [SD 7.6]) received the SAGB-VC. At a mean follow-up of 11 (SD 3) months, weight reduced by a mean of 18.4 (SD 11.1) kg with an excess weight loss of 37.8% (SD 19.9%). Body mass index decreased (from mean 43.4 [SD 7.7] to mean 36.7 [SD 6.5], p < 0.001). Type 2 diabetes (T2DM) was reported in 167 patients and hypertension in 373. Improvement occurred in 73.5% of patients with T2DM and 31% with hypertension, with patient-reported reduction or cessation of medication. Metabolic syndrome indices improved during follow-up: high-density lipoprotein cholesterol (mean 1.3 [SD 0.3] v. mean 1.4 [SD 0.3] mmol/L, p < 0.001), triglycerides (mean 1.6 [SD 0.8] v. mean 1.3 [SD 0.7] mmol/L, p < 0.001), waist circumference (men 141 [SD 103] to 121 [SD 15] cm, women 117 [SD 14] to 105 [SD 14] cm, both p < 0.001), C-reactive protein (90.5 [SD 75.2] v. 53.3 [SD 61.9] nmol/L, p < 0.001). The complication rate was 4.2%. CONCLUSION: The SAGB-VC is safe and effective for treating obesity and its comorbidities. The results are reproducible in separate Australian centres and consistent with published literature.

Biomechanical stability of hernia-damaged abdominal walls.

Hernia occurs when the peritoneum and/or internal organs penetrate through a defect in the abdominal wall. Implanting mesh fabrics is a common way to reinforce the repair of hernia-damaged tissues, despite the risks of infection and failure associated with them. However, there is neither consensus on the optimum mesh placement within the abdominal muscles complex nor on the minimum size of hernia defect that requires surgical correction. Here we show that the optimum position of the mesh depends on the hernia location; placing the mesh on the transversus abdominis muscles reduces the equivalent stresses in the damaged zone and represents the optimum reinforcement solution for incisional hernia. However, retrorectus reinforcement of the linea alba is more effective than preperitoneal, anterectus, and onlay implantations in the case of paraumbilical hernia. Using the principles of fracture mechanics, we found that the critical size of a hernia damage zone becomes severe at 4.1 cm in the rectus abdominis and at larger sizes (5.2-8.2 cm) in other anterior abdominal muscles. Furthermore, we found that the hernia defect size must reach 7.8 mm in the rectus abdominis before it influences the failure stress. In other anterior abdominal muscles, hernia starts to influence the failure stress at sizes ranging from 1.5 to 3.4 mm. Our results provide objective criteria to decide when a hernia damage zone becomes severe and requires repair. They demonstrate where mesh should be implanted for a mechanically stable reinforcement, depending on the type of hernia. We anticipate our contribution to be a starting point for sophisticated models of damage and fracture biomechanics. For example, the apparent fracture toughness is an important physical property that should be determined for patients living with different obesity levels. Furthermore, relevant mechanical properties of abdominal muscles at various ages and health conditions would be significant to generate patient specific results.

The Australian Obesity Management Algorithm: A simple tool to guide the management of obesity in primary care.

Obesity is a complex and multifactorial chronic disease with genetic, environmental, physiological and behavioural determinants that requires long-term care. Obesity is associated with a broad range of complications including type 2 diabetes, cardiovascular disease, dyslipidaemia, metabolic associated fatty liver disease, reproductive hormonal abnormalities, sleep apnoea, depression, osteoarthritis and certain cancers. An algorithm has been developed (with PubMed and Medline searched for all relevant articles from 1 Jan 2000-1 Oct 2021) to (i) assist primary care physicians in treatment decisions for non-pregnant adults with obesity, and (ii) provide a practical clinical tool to guide the implementation of existing guidelines (summarised in Appendix 1) for the treatment of obesity in the Australian primary care setting. MAIN RECOMMENDATIONS AND CHANGES IN MANAGEMENT: Treatment pathways should be determined by a person's anthropometry (body mass index (BMI) and waist circumference (WC)) and the presence and severity of obesity-related complications. A target of 10-15% weight loss is recommended for people with BMI 30-40 kg/m2 or abdominal obesity (WC > 88 cm in females, WC > 102 cm in males) without complications. The treatment focus should be supervised lifestyle interventions that may include a reduced or low energy diet, very low energy diet (VLED) or pharmacotherapy. For people with BMI 30-40 kg/m2 or abdominal obesity and complications, or those with BMI > 40 kg/m2 a weight loss target of 10-15% body weight is recommended, and management should include intensive interventions such as VLED, pharmacotherapy or bariatric surgery, which may be required in combination. A weight loss target of > 15% is recommended for those with BMI > 40 kg/m2 and complications and they should be referred to specialist care. Their treatment should include a VLED with or without pharmacotherapy and bariatric surgery.

Ten Years of Change in Bariatric/Metabolic Surgery in the Asia-Pacific Region with COVID-19 Pandemic: IFSO-APC National Reports 2021.

BACKGROUND: On November 25, 2021, the IFSO-Asia-Pacific Chapter (IFSO-APC) Virtual Meeting 2021 was held online, and the representatives from the Asia-Pacific region presented 10 years of change in bariatric/metabolic surgery and the influence of COVID-19 in the special session of "IFSO-APC National Reports 2010-2020". We herein report the summarized data. METHODS: National bariatric/metabolic surgery data, which included the data of 2010 and 2020, were collected from the representatives using a questionnaire that consisted of 10 general questions. At the congress, the data were calculated and summarized. RESULTS: Thirteen of the 14 national societies responded to the survey. From 2010 to recent years, the populations of individuals with obesity (BMI ≥ 30 kg/m2) and individuals with diabetes both significantly increased. Eight countries and regions expanded the lower limit of criteria for bariatric surgery by 2-5 kg/m2 (BMI), and 5 countries newly established criteria for metabolic surgery in the last ten years. Sixty-nine percent of the countries currently run public health insurance systems, which doubled from 2010. The number of bariatric surgeons and institutions increased more than threefold from 2010. In 2010, 2019, and 2020, surgeons in IFSO-APC societies performed 18,280, 66,010, and 49,553 bariatric/metabolic surgeries, respectively. Due to the COVID pandemic, restriction policies significantly reduced access to surgery in South and Southeast Asian countries. The biggest changes included increased numbers of bariatric surgeons and institutions, operation numbers, public insurance coverage, raising awareness, and national registry systems. CONCLUSION: For the last 10 years, bariatric/metabolic surgery has rapidly grown in the Asia-Pacific region.

Minimally invasive retroperitoneal pancreatic necrosectomy.

INTRODUCTION: This article describes a case series outlining the experience and results of the retroperitoneal minimally invasive pancreatic necrosectomy (MIPN) procedure performed by, or done under the supervision of, a single surgeon. METHODS: All data of the patients who underwent MIPN from 2006 to 2008 were entered into a prospectively maintained, computerized database. RESULTS: A total of 93 MIPN procedures were performed on 32 patients. All patients had severe acute pancreatitis. The median number of MIPN procedures per patient was 3. Only 6 patients needed intensive care unit (ICU) admission after MIPN. There were 15 complications, which included bleeding requiring transfusion (n = 3), bowel fistulae (n = 7), thromboembolic events (n = 2) and acute myocardial infarction (n = 3). Four patients died after the procedure (13%); 1 died of ongoing multiorgan failure in spite of the MIPN. Four patients developed pancreatic pseudocysts within the follow-up period of 2 years. Three of these patients required intervention. CONCLUSION: This case series demonstrates that MIPN can be performed with acceptable morbidity and mortality and with good end results. The ICU dependency after the procedure is minimal. As seen in this series, multiple MIPNs may be needed to eradicate the necrosis satisfactorily. and IAP.

Video-Rated Performance Assessment of Simulated Laparoscopic Sleeve Gastrectomy: Validation of a Sleeve Gastrectomy Rating Scale.

PURPOSE: The global rise in obesity has been accompanied by widespread uptake of the procedure of laparoscopic sleeve gastrectomy. Despite this, the key components for performance assessment have not been standardized for this procedure. The aim of this study was to develop and demonstrate the validity of a Sleeve Objective Structured Assessment of Technical Skill (SOSATS) scale for learning the procedure of laparoscopic sleeve gastrectomy (LSG). MATERIALS AND METHODS: The SOSATS evaluation tool was based upon critical steps of the LSG procedure. Both the SOSATS and the Global Rating Scale (GRS) component of the Objective Structured Assessment of Technical Skill (OSATS) tools were utilized in a prospective single-blinded observational study design of 26 video recordings of surgeons performing sleeve gastrectomies using a novel simulation. The surgeons were allocated into "novice" or "experienced" groups dependent on case-volume criteria. Surgical performance was assessed using both the GRS and SOSATS scales by blinded assessors of the video recordings. RESULTS: Face and content validity were demonstrated for key components of the simulated model. An overall positive correlation was established inferring concurrent validity between the accepted OSATS Global Rating Scale against the SOSATS procedural scale. Construct validity was established for a number of areas of the SOSATS scale. CONCLUSION: The SOSATS scale is shown to exhibit construct and concurrent validity in the simulated setting for the procedure of sleeve gastrectomy. Utilizing this scale to review surgical performance is potentially feasible and reliable but would require further research prior to use in high-stakes assessment processes such as credentialing.

Development of an International Standardized Curriculum for Laparoscopic Sleeve Gastrectomy Teaching Utilizing Modified Delphi Methodology.

BACKGROUND: The performance of laparoscopic sleeve gastrectomy has increased markedly to become the single-most performed bariatric surgical procedure globally. To date, a means of standardized trainee teaching has not been developed. The aim of this study was to design a laparoscopic curriculum for trainees of bariatric surgery utilizing modified Delphi consensus methodology. METHODS: A panel of surgeons was assembled to devise an academic framework of technical, non-technical and cognitive skills utilized in the performance of laparoscopic sleeve gastrectomy. The panel invited 18 bariatric surgeons experienced in laparoscopic gastrectomy from 11 countries to rate the items for inclusion in the curriculum to a predefined level of agreement. RESULTS: A consensus of experts was achieved for 24 of the 30 proposed elements for inclusion within the first round of the curriculum Delphi panel. All components pertaining to anatomical knowledge, peri-operative considerations and non-technical items were accepted. A second round further examined six statements, of which three were accepted. Agreement of the panel was reached for 27 of the cognitive, technical and non-technical components after two rounds. Three statements found no consensus. CONCLUSIONS: Utilizing modified Delphi methodology, a curriculum outlining the most important components of teaching the procedure of laparoscopic sleeve gastrectomy, has been determined by a consensus of international experts in bariatric surgery. The curriculum is suggested as a standard in proficiency-based training of this procedure. It forms a generic template which facilitates individual jurisdictions to perform content validation, adapting the curriculum to local requirements in teaching the next generation of bariatric surgeons.

Do factors related to participation in physical activity change following restrictive bariatric surgery? A qualitative study.

AIMS: To explore participants' ability to participate in physical activity (PA), and barriers and facilitators to PA, at 12 months following restrictive bariatric surgery, and how these differed from participants' pre-surgery perceptions. Motivators for PA post-surgery were also explored. METHODS: Qualitative one-on-one in-depth interviews were conducted pre- and 12 months post-surgery. Data were analysed using inductive thematic analysis. RESULTS: Fourteen adults (12 females), with a mean (range) age of 41.4 years (25.0-56.0), body mass index (BMI) of 31.7kg/m2 (22.3-48.2), and excess weight loss of 66% (2-127) completed both interviews. Lack of participation in PA during the first 3-6 months post-surgery was a common theme. Although participants reported increased ability to participate in PA, attributing this to a reduction in obesity-related physical barriers to PA, many participants reported that some pre-surgery obesity-related barriers to PA remained at 12 months post-surgery. For most participants, pre-surgery non-obesity related barriers to PA also remained at 12 months post-surgery. Facilitators to PA were consistent pre- and post-surgery. Weight loss and improvement in physical appearance were the most common motivators for PA post-surgery. CONCLUSIONS: At 12 months following surgery, many participants reported residual obesity and non-obesity related barriers to PA. These barriers may explain the small, if any, pre- to post-surgery change in PA levels reported by earlier research. Facilitators to PA did not change and post-surgery motivators for PA were mostly esteem-related. These data are relevant to shape interventions aimed at optimising PA in this population.

Treatment Success: Investigating Clinically Significant Change in Quality of Life Following Bariatric Surgery.

BACKGROUND: One of the most important outcomes following bariatric surgery is an improvement in health-related quality of life (QOL). This study aimed to explore what degree of weight loss is required after bariatric surgery in order to achieve a clinically significant change in QOL from pre-surgery to 4 to 5 years after surgery. METHODS: Participants were assessed prior to having surgery (N = 280) and were invited to participate in a follow-up study 4 to 5 years after surgery. Sixty-seven of the original participants agreed to take part and completed a Web-based survey, which included the Impact of Weight on Quality of Life-Lite (IWQOL-Lite) questionnaire. Several analyses were conducted to examine the association between weight loss and clinically significant change in QOL. RESULTS: Mean age was 48.13 ± 10.37 years, 51 (76%) were female, 62 (92.5%) Caucasian, and mean baseline body mass index (BMI) was 41.11 ± 6.03 kg/m2. The mean percent of excess weight loss (EWL) was 46% (17% total weight loss), and 64% (n = 43) achieved a clinically significant change in QOL. The majority of those who lost ≥40% EWL had a clinically significant change in QOL, and their odds of achieving this change were 2.81 times higher than those that did not. CONCLUSIONS: Results indicated that an EWL of ≥40% may be sufficient for the majority of patients to achieve clinically significant change, but that ≥50% is a better predictor of clinically significant change.

Evaluation of Three-Dimensional Versus Conventional Laparoscopy for Kidney Transplant Procedures in a Human Cadaveric Model.

OBJECTIVES: There are increased reports that kidney transplant can be performed by laparoscopic surgery. The further development of this technique could revolutionize human kidney transplant surgery. However, laparoscopic kidney transplant demands a high level of skill for vascular anastomoses. The emerging technology of the three-dimensional, high-definition laparoscopic system may facilitate the application of this technique. Therefore, in this study, we evaluated this system in performing kidney transplant surgery versus the two-dimensional laparoscopic system. MATERIALS AND METHODS: Four fresh-frozen human cadavers were used in this study, with 2 for the 3-dimensional and 2 for the 2-dimensional system. Kidneys were retrieved by using the retroperitoneoscopic technique for living donor nephrectomy from the same cadaver. The kidney graft was transplanted at the right iliac fossa using a laparoscopic technique by extraperitoneal approach. The procedure was recorded, and the vessel anastomotic time was analyzed. RESULTS: Kidney transplant procedures were conducted successfully in the 3-dimensional, high-definition and the 2-dimensional groups. We recorded no significant differences in terms of vessel anastomotic time between the 2 groups. The total surgery time was shorter in the 3-dimensional, high-definition group than in the 2-dimensional group (P = .02). CONCLUSIONS: This pilot study reinforces that kidney transplant with either the 3-dimensional, high-definition or 2-dimensional laparoscopy is feasible in a human cadaveric model. The operation was the same as open kidney transplant, but the procedure was performed by a laparoscopic approach with a smaller incision.

Early trauma management skills in Australian general practitioners.

BACKGROUND: General practitioners (GPs) have a role in the early management of major trauma in rural Australia. The Early Management of Severe Trauma (EMST) course fulfils their educational needs by providing skills for the systematic management of the seriously injured patient. However, with any skill there is a natural loss over time. This study surveyed GPs who have completed the EMST course to determine their confidence in trauma management. METHODS: A two-page survey was mailed in December 2004 to all GPs who had completed an EMST course from 1989 to 2004 and were currently residing in Western Australia. The survey consisted of background questions, open-ended questions regarding the EMST course and skills confidence ratings using visual analogue scales. The final sample size was 223. RESULTS: Response rate was 55%. GPs were least confident in carrying out diagnostic peritoneal lavage and cricothyroidotomy. They were most confident inserting i.v. cannulas and managing fluid replacement. Their confidence in some of these skills were related to the frequency of managing trauma patients but not to the interval since completing the EMST course. GPs found the systematic approach to trauma management and practical/procedural skills as the most relevant components of EMST. They felt that EMST could be improved with more accessible refresher courses and more practical/procedural skills. CONCLUSION: Most of these GPs were involved in rural hospital work where they may be required to manage seriously injured patients. They require regular refresher courses to maintain their confidence levels in treating seriously injured patients.

Determining the Superior Technique for Living-donor Nephrectomy: the Laparoscopic Intraperitoneal Versus the Retroperitoneoscopic Approach.

OBJECTIVES: Laparoscopic living-donor nephrectomy is now widely used because of its many beneficial features. Currently, there are 2 major techniques: the laparoscopic intraperitoneal approach and the retroperitoneoscopic approach. There is no evidence to support one particular approach over another. Therefore, in this study, we conducted a systematic literature review with the aim of defining which technique is superior. MATERIALS AND METHODS: The Embase, PubMed, and Cochrane literature databases were searched for English language articles published between January 1994 and January 2013 using the terms "laparoscopic donor nephrectomy," "retroperitoneoscopic donor nephrectomy," and "live donor nephrectomy." A meta-analysis was undertaken, and I(2) statistical analyses were used to describe the percentage of variation across studies due to heterogeneity rather than chance. RESULTS: With the use of our selection criteria, 55 papers on the laparoscopic intraperitoneal approach and 6 papers on the retroperitoneoscopic approach were included in this study. We found significantly lower transfusion rate, fewer patients with delayed graft functions, less vessel injuries, and less conversion to open surgical procedure with the retroperitoneoscopic approach than with the laparoscopic intraperitoneal approach. CONCLUSIONS: From this review, a high degree of study heterogeneity was identified, suggesting an urgent need for consistency in reporting laparoscopic living-donor nephrectomy. Results of the meta-analyses may define a better technique for the future. The retroperitoneoscopic approach may be better than the laparoscopic intraperitoneal approach with fewer complications and fewer patients with delayed graft function. Further study of laparoscopic living-donor nephrectomy is recommended to define a standard and thus to minimize the surgical morbidities.

Comparison of safety between 1-stage and 2-stage surgery: from laparoscopic adjustable gastric banding to laparoscopic sleeve gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is becoming increasingly popular. With significant failure rates for laparoscopic adjustable gastric banding (LAGB), conversion to LSG is an attractive consideration for maintenance of target percentage excess weight loss (%EWL). Conversions can be successfully achieved in either 1-stage (OS) or 2-stage (TS) surgery. OBJECTIVES: We intend to examine safety between OS and TS surgery and determine features indicative for OS surgery. SETTING: Records were audited from the database of a private surgical practice located in Perth, Western Australia. METHODS: We analyzed 86 patients in a prospective observational study over a 3-year time frame (38 OS, 48 TS). The primary outcome was perioperative events, graded using the Clavien-Dindo classification system. Secondary outcomes included any preoperative, intraoperative, and postoperative events. RESULTS: Surgical complications were similar between OS and TS groups. Grades of complications were not significantly different. No difference was found in procedural normality between cohorts (P = .95). More adhesions were present in the TS group compared with the OS group after accounting for adjustments (P = .05). Patient demographic characteristics were not different between groups, with the exception of body mass index (BMI). There were no staple line leaks within the OS group; 2 leaks occurred in the TS group. CONCLUSION: OS surgery appears as safe as TS surgery provided surgeons carefully assess patient eligibility. We recommend the following features for ideal OS candidacy: no previous band complications, minimal peritoneal adhesions under laparoscopy, minimal co-morbidities, and a lower BMI at entry into conversion.

Evaluating trauma nursing education: An integrative literature review.

OBJECTIVE: A review of the current literature evaluating trauma nursing education. BACKGROUND: A variety of trauma nursing courses exist, to educate nurses working in trauma settings, and to maintain their continuing professional development. Despite an increase in the number of courses delivered, there appears to be a lack of evidence to demonstrate the effectiveness of trauma nursing education and in particular the justification for this resource allocation. DESIGN: Integrative literature review. DATA SOURCES: A search of international literature on trauma nursing education evaluation published in English from 1985 to 2015 was conducted through electronic databases CINAHL Plus, Google Scholar, PubMed, Austhealth, Science Citation Index Expanded (Web of Science), Sciverse Science Direct (Elsevier) & One file (Gale). Only peer reviewed journal articles identifying trauma course and trauma nursing course evaluation have been included in the selection criteria. REVIEW METHODS: An integrative review of both quantitative and qualitative literature guided by Whittemore and Knafl's theoretical framework using Bowling's and Pearson's validated appraisal checklists, has been conducted for three months. RESULTS: Only 17 studies met the inclusion criteria, including 14 on trauma course evaluation and 3 on trauma nursing course evaluation. Study findings are presented as two main themes: the historical evolution of trauma nursing education and evaluation of trauma nursing education outcomes. CONCLUSION: Trauma nursing remains in its infancy and education in this specialty is mainly led by continuing professional development courses. The shortage of evaluation studies on trauma nursing courses reflects the similar status in continuing professional development course evaluation. A trauma nursing course evaluation study will address the gap in this under researched area.