Robotic surgery costs: Revealing the real villains.

BACKGROUND: This study aimed to evaluate the main drivers of robot assisted radical prostatectomy (RARP) hospitalization costs, in addition to assess perioperative predictors that impact costs. METHODS: Overall, 474 RARP were analyzed between February 2018 and December 2019. The association between perioperative variables and total direct costs was analyzed by simple and multiple linear regression. DISCUSSION: The main drivers of RARP hospitalization costs were robotic surgical supplies. Costs increased with American Society of Anesthesiologists score 3, a one-hour increase in OR time, increased utilization of polymeric clip packs and longer length of hospital stay. There was a 11.5% reduction in costs with the use of four robotic instruments instead of five. CONCLUSION: Costs of hospitalization were mainly influenced by the OR time, use of surgical supplies and length of hospital stay. Reducing the number of robotic instruments used in RARP represented the potentially modifiable factor with the greatest impact on cost reduction.

Correction to: Diagnosis of Cutaneous Melanoma: the Gap between the Knowledge of General Practitioners and Dermatologists in a Brazilian Population.

The original version of this article unfortunately contained a mistake. The name of "Carolina Ledsham" is now corrected in the author group of this article.

Diagnosis of Cutaneous Melanoma: the Gap Between the Knowledge of General Practitioners and Dermatologists in a Brazilian Population.

The early diagnosis of cutaneous melanoma provides less aggressive treatment reducing mortality. General practitioners are responsible for cancer diagnoses in the Brazilian Public Health System and therefore play a crucial role in the prevention and early detection of melanoma. To assess the melanoma knowledge of a primary healthcare physician, the general practitioner, compared to a dermatologist. General practitioners and dermatologists answered a questionnaire about melanoma and the management of suspected cases. The results of both groups were compared. The sample consisted of 80 specialists and 160 general practitioners. When asked about the "ABCDE" rule, 96.2% of the dermatologists knew about it, compared to 34.4% of the general practitioners. The percentage of dermatologists who examined the whole skin of the patient at high risk for melanoma was 90% vs. 24.5% amongst general practitioners. The most cited reasons for the absence of the examination of patients at risk for melanoma were lack of time at the consultations (17.6% specialists, 66.1% generalists) and an excessive number of patients (17.6% specialists, 61.5% generalists). General practitioner has less knowledge about melanoma compared to the dermatologists and presents deficient behaviors about patients at risk or who have suspicious lesions, indicating the need for training and continuing education.

Jejunostomy or nasojejunal tube after esophagectomy: a review of the literature.

Patients undergoing esophagectomy for cancer are a difficult to treat group of patients. At diagnosis they will present some degree of malnutrition in up to 80% and the causes are from multifactorial origin: the inability of food ingestion, advanced age, taste disturbances, and morbidity related to neoadjuvant treatment. In order to restaure the nutritional status, enteral nutritional support is preferable to parenteral support because of the risks of septic complications associated with venous catheters. During the postoperative period, the oral route is often inaccessible in these patients due to swallowing disorders and eventually mechanical ventilation, and if possible, often it does not provide sufficient caloric amounts for postoperative energy balance. For these reasons, it is usually recommended additional nutritional support. There are few studies in the literature that specifically address which is the most adequate route for enteral nutrition in patients undergoing esophagectomy. Nasojejunal catheters present a higher incidence of local complications, such as displacement and occlusion, whereas jejunostomy is more associated with reinterventions for the treatment of complications secondary to extravasation. Although there is weak evidence in the literature and a lack of randomized, prospective and multicenter studies evaluating the best enteral nutrition route in the postoperative period of esophagectomy, the use of the nasoenteric catheter seems to be adequate due to its simplicity of positioning and low rates of severe complications. In this paper a review is performed of the evidence about this subject.

Randomized clinical trial: nasoenteric tube or jejunostomy as a route for nutrition after major upper gastrointestinal operations.

BACKGROUND: Curative treatment of upper gastrointestinal tract neoplasms is complex and associated with high morbidity and mortality. In general, the patients are already malnourished, and early postoperative enteral nutrition is recommended. However, there is no consensus concerning the best enteral access route in these cases. METHODS: A prospective randomized trial was performed from 2008 to 2012 with 59 patients who underwent esophagectomy, total gastrectomy, or pancreaticoduodenectomy. In all, 4 patients declined to participate, and 13 did not meet the inclusion criteria and were excluded. Of the 42 included patients, 21 had nasoenteric tubes, and 21 had a jejunostomy. RESULTS: The two groups were similar in demographic and clinical aspects. The nasoenteric (NE) and jejunostomy groups underwent early enteral therapy in 71 and 62 % of cases (p > 0.05), respectively. The median length of enteral therapy use was less in the NE group (5.0 vs. 8.5 days), but the difference was not statistically significant. The NE group required introduction of parenteral therapy more frequently than the jejunostomy group (p < 0.05). Complications related to the enteral route occurred in 38.0 and 28.5 % of patients (p > 0.05) in the NE and jejunostomy groups, respectively. In the NE group, there were four losses and four tube obstructions. In the jejunostomy group, there were two losses, four obstructions, and two cases of leakage around the tube. In the latter group, patients who underwent therapy for a longer time had tubal complications (p < 0.05) and longer intensive care unit and hospital stays (p < 0.05). CONCLUSION: The two enteral routes were associated with the same number of complications. However, the presence of a jejunostomy allowed enteral therapy for longer periods, especially in patients with complications, thus avoiding the need for parenteral nutrition.