Career goals of surgeons in Switzerland.

PURPOSE: Recent studies from the United States and Germany have shown a general decline in the number of surgical residents, as trainees increasingly prioritize a positive work-life balance. The current study sought to evaluate the career goals of surgeons in Switzerland. METHODS: Members of the Swiss College of Surgeons, being surgical consultant or attending regardless of specialty, were surveyed online as to their purported career goals, future employment ideals, aspired leadership positions, and managerial training. RESULTS: A total of 269 questionnaires were analysed. Most participants (93%) were board- certified and 30% of participants were female. With regard to desired specialty, 50% of participants intended to pursue a career in visceral surgery followed by general surgery, traumatology, hand and plastic surgery, vascular surgery and thoracic surgery. Regardless of specialty, 53% of respondents strived for the position of senior physician, while 28% indicated a desire to become chief physician. In terms of work environment, most participants preferred to seek employment at a cantonal hospital, followed by a rural hospital, a university hospital, private practice or a non-clinical setting. About half of respondents favoured the option of part time employment of 80% or less and about a quartile intended to retire before 62 years of age. CONCLUSION: The current study found that surgeons in Switzerland remain highly motivated to pursue leadership positions in their respective fields. Going forward, the challenge will lie in reconciling the needs of the respective departments with the personal ambition, career opportunities, and desired work-life balance of young trainees.

Evidence mapping on how to perform an optimal surgical repair of large hiatal hernias.

BACKGROUND: Symptomatic and large hiatal hernia (HH) is a common disorder requiring surgical management. However, there is a lack of systematic, evidence-based recommendations summarizing recent reviews on surgical treatment of symptomatic HH. Therefore, this systematic review aimed to create evidence mapping on the key technical issues of HH repair based on the highest available evidence. METHODS: A systematic review identified studies on eight key issues of large symptomatic HH repair. The literature was screened for the highest level of evidence (LE from level 1 to 5) according to the Oxford Center for evidence-based medicine's scale. For each topic, only studies of the highest available level of evidence were considered. RESULTS: Out of the 28.783 studies matching the keyword algorithm, 47 were considered. The following recommendations could be deduced: minimally invasive surgery is the recommended approach (LE 1a); a complete hernia sac dissection should be considered (LE 3b); extensive division of short gastric vessels cannot be recommended; however, limited dissection of the most upper vessels may be helpful for a floppy fundoplication (LE 1a); vagus nerve should be preserved (LE 3b); a dorso-ventral cruroplasty is recommended (LE 1b); routine fundoplication should be considered to prevent postoperative gastroesophageal reflux (LE 2b); posterior partial fundoplication should be favored over other forms of fundoplication (LE 1a); mesh augmentation is indicated in large HH with paraesophageal involvement (LE 1a). CONCLUSION: The current evidence mapping is a reasonable instrument based on the best evidence available to guide surgeons in determining optimal symptomatic and large HH repair.

Transition from a circular to a linear stapling protocol in laparoscopic Roux-en-Y gastric bypass surgery and its impact on quality of life: a 5-year outcome study.

PURPOSE: Surgical technique in bariatric surgery has been refined over the past decades. This study analysed the effect of changing the stapling protocol on the quality of life (QoL) at a midterm follow-up. METHODS: The retrospective cohort study included patients undergoing Roux-en-Y gastric bypass between June 2012 and March 2016. Patients were stratified into the circular stapling protocol (CSP, n = 117) or the linear stapling protocol (LSP, n = 118). QoL was quantified by the Moorehead score at 12, 24 and 60 months. Multivariate testing was used to identify confounders. RESULTS: The age was 42.8 ± 11.5 years and the body mass index (BMI) was 43.8 ± 6.2 kg/m2, with no baseline intergroup differences. Overall baseline Moorehead score was 0.42 ± 1.1 and improved in both groups after 12 months (1.97 ± 0.74, p < 0.001), 24 months (1.86 ± 0.79, p < 0.001) and 60 months (1.71 ± 0.9, p < 0.001). LSP was associated with improved Moorehead score after 60 months (odds ratio [OR] 1.251, 95% confidence interval [CI] 1.06-1.48, p = 0.010). Overall, a drop of mean BMI occurred and this effect lasted throughout the observation period (- 12.48 kg/m2, p < 0.001). More profound BMI reduction was further positively associated with Moorehead scores after 24 and after 60 months (OR 0.97, p = 0.028; OR 0.96, p = 0.007). Complications, rehospitalisations and reoperations were more frequent in the CSP group (50% vs 23.7%, p < 0.001; 39.7% vs 22.9%, p = 0.009; 37.1% vs 18.6%, p = 0.003). CONCLUSION: The CSP and LSP achieve a long-lasting increase in QoL, although the LSP is associated with fewer complications, persistent weight loss and improved Moorehead score. Therefore, the LSP might be considered the favourable protocol in Roux-en-Y gastric bypass.

Hand-assisted living-donor nephrectomy: a retrospective comparison of two techniques.

BACKGROUND: Living-donor nephrectomy (LDN) is challenging, as surgery is performed on healthy individuals. Minimally invasive techniques for LDN have become standard in most centers. Nevertheless, numerous techniques have been described with no consensus on which is the superior approach. Both hand-assisted retroperitoneoscopic (HARS) and hand-assisted laparoscopic (HALS) LDNs are performed at Zurich University Hospital. The aim of this study was to compare these two surgical techniques in terms of donor outcome and graft function. METHOD: Retrospective single-center analysis of 60 consecutive LDNs (HARS n = 30; HALS n = 30) from June 2010 to May 2012, including a one-year follow-up of the recipients. RESULTS: There was no mortality in either group and little difference in the overall complication rates. Median warm ischemia time (WIT) was significantly shorter in the HARS group. The use of laxatives and the incidence of postoperative vomiting were significantly greater in the HALS group. There was no difference between right- and left-sided nephrectomies in terms of donor outcome and graft function. CONCLUSIONS: Both techniques appear safe for both donors and donated organs. The HARS technique is associated with a shorter WIT and a reduced incidence of postoperative paralytic ileus. Therefore, we consider HARS LDN a valuable alternative to HALS LDN.

Planned secondary wound closure at the circular stapler insertion site after laparoscopic gastric bypass reduces postoperative morbidity, costs, and hospital stay.

PURPOSE: The aims of the present study were to assess whether planned secondary wound closure at the insertion site of the circular stapler reduces wound infection rate and postoperative morbidity after laparoscopic Roux-en-Y gastric bypass (RYGB) and to identify independent predictive factors increasing the risk for wound infections after RYGB. METHODS: This paper is a retrospective single-center analysis of a prospectively collected database of 1400 patients undergoing RYGB surgery in circular technique between June 2000 and June 2016. Planned secondary wound closure at the circular stapler introduction site was performed at postoperative day 3 in 291 (20.8%) consecutive patients and compared to a historical control of 1109 (79.2%) consecutive patients with primary wound closure. Independent predictive factors for wound infection were assessed by multivariable analysis. RESULTS: Secondary wound closure significantly decreased wound infection rate from 9.3% (103/1109) to 1% (3/291) (p < 0.001) leading to a shorter hospital stay (mean 9 (SD8) vs. 7 days (SD2), p < 0.001), lower costs (p = 0.039), and reduced postoperative morbidity (mean 90-day Comprehensive Complication Index (CCI) 7.4 (SD14.0) vs. 5.1 (SD11.1) p = 0.008) when compared to primary wound closure. Primary wound closure, dyslipidemia, and preoperative gastritis were independent predictive risk factors for developing wound infections both in the univariate (p < 0.001; p = 0.048; p = 0.003) and multivariable analysis (p < 0.001; p = 0.040; p = 0.012). Further, on multivariable analysis, the female gender was a predictive factor (p = 0.034) for wound infection development. CONCLUSIONS: Secondary wound closure at the circular stapler introduction site in laparoscopic RYGB significantly reduces the overall wound infection rate as well as postoperative morbidity, costs, and hospital stay when compared to primary wound closure.

Perforated Peptic Ulcer Repair: Factors Predicting Conversion in Laparoscopy and Postoperative Septic Complications.

OBJECTIVE: The surgical treatment for perforated peptic ulcers can be safely performed laparoscopically. The aim of the study was to define simple predictive factors for conversion and septic complications. METHODS: This retrospective case-control study analyzed patients treated with either laparoscopic surgery or laparotomy for perforated peptic ulcers. RESULTS: A total of 71 patients were analyzed. Laparoscopically operated patients had a shorter hospital stay (13.7 vs. 15.1 days). In an intention-to-treat analysis, patients with conversion to open surgery (analyzed as subgroup from laparoscopic approach group) showed no prolonged hospital stay (15.3 days) compared to patients with a primary open approach. Complication and mortality rates were not different between the groups. The statistical analysis identified four intraoperative risk factors for conversion: Mannheim peritonitis index (MPI) > 21 (p = 0.02), generalized peritonitis (p = 0.04), adhesions, and perforations located in a region other than the duodenal anterior wall. We found seven predictive factors for septic complications: age >70 (p = 0.02), cardiopulmonary disease (p = 0.04), ASA > 3 (p = 0.002), CRP > 100 (p = 0.005), duration of symptoms >24 h (p = 0.02), MPI > 21(p = 0.008), and generalized peritonitis (p = 0.02). CONCLUSION: Our data suggest that a primary laparoscopic approach has no disadvantages. Factors necessitating conversions emerged during the procedure inhibiting a preoperative selection. Factors suggesting imminent septic complications can be assessed preoperatively. An assessment of the proposed parameters may help optimize the management of possible septic complications.

How to cope with insufficient pneumoperitoneum and exposure when performing laparoscopic gastric bypass surgery.

OBJECTIVE: Despite following international guidelines and conducting routine preoperative dietary counseling, every bariatric surgeon will encounter technical challenges in laparoscopic gastric bypass surgery. We present a series of patients in whom the bariatric procedure was stopped after encountering insufficient exposure during diagnostic laparoscopy. These patients were sent back for dietary counseling and underwent surgery after conservative weight loss. The data from this two-step procedure are analyzed and discussed. METHODS: This concept was applied and studied in 14 patients from a series of 620 bariatric procedures. Patients who underwent a primary laparoscopic gastric bypass (n = 593) were used as references. RESULTS: The patients in the study group were significantly heavier than those in the reference group (165 vs. 127 kg, p < 0.001), with 79 % having a BMI >50 kg/m(2). The patients lost a median of 11 kg after 2 months of conservative treatment, and the mean BMI decreased from 55.7 to 52.6 kg/m(2). All the patients in the study group underwent laparoscopic surgery for the second procedure with no need for conversion. The complication rate was not elevated in the study group. Overall hospital costs were higher for the study group compared with those for the primary laparoscopic bypass group (27,136 vs. 19,601 USD, p = 0.034). CONCLUSION: The primary laparoscopic procedure can be stopped in patients with insufficient exposure instead of having them undergo conversion to open surgery. These patients may undergo successful laparoscopic procedures after conservative weight loss with no increased risk and with all of the possible benefits of a laparoscopic approach. As a result of this study, we have established a fixed, preoperative lower limit of 10 % excess weight reduction before accepting superobese patients (BMI >50 kg/m(2)) for surgery at our hospital.

Anesthetic management of patients undergoing bariatric surgery: two year experience in a single institution in Switzerland.

BACKGROUND: In the field of anesthesia for bariatric surgery, a wide variety of recommendations exist, but a general consensus on the perioperative management of such patients is missing. We outline the perioperative experiences that we gained in the first two years after introducing a bariatric program. METHODS: The perioperative approach was established together with all relevant disciplines. Pertinent topics for the anesthesiologists were; successful airway management, indications for more invasive monitoring, and the planning of the postoperative period and deposition. This retrospective analysis was approved by the local ethics committee. Data are mean [SD]. RESULTS: 182 bariatric surgical procedures were performed (147 gastric bypass procedures (GBP; 146 (99.3%) performed laparascopically). GBP patients were 43 [10] years old, 78% female, BMI 45 [7] kg/m(2), 73% ASA physical status of 2. 42 patients (28.6%) presented with obstructive sleep apnea syndrome. 117 GBP (79.6%) patients were intubated conventionally by direct laryngoscopy (one converted to fiber-optic intubation, one aspiration of gastric contents). 32 patients (21.8%) required an arterial line, 10 patients (6.8%) a central venous line. Induction lasted 25 [16] min, the procedure itself 138 [42] min. No blood products were required. Two patients (1.4%) presented with hypothermia (<35 °C) at the end of their case. The emergence period lasted 17 [9] min. Postoperatively, 32 patients (21.8%) were transferred to the ICU (one ventilated). The other patients spent 4.1 [0.7] h in the post anesthesia care unit. 15 patients (10.2%) required take backs for surgical revision (two laparotomies). CONCLUSIONS: The physiology and anatomy of bariatric patients demand a tailored approach from both the anesthesiologist and the perioperative team. The interaction of a multi-disciplinary team is key to achieving good outcomes and a low rate of complications. TRIAL REGISTRATION: DRKS00005437 (date of registration 16(th) December 2013).

Effect of artificial or autologous coverage of the pancreatic remnant or anastomosis on postoperative pancreatic fistulas after partial pancreatectomy: meta-analysis of randomized clinical trials.

BACKGROUND: Postoperative pancreatic fistulas remain a driver of major complications after partial pancreatectomy. It is unclear whether coverage of the anastomosis or pancreatic remnant can reduce the incidence of postoperative pancreatic fistulas. The aim of this study was to evaluate the effect of autologous or artificial coverage of the pancreatic remnant or anastomosis on outcomes after partial pancreatectomy. METHODS: A systematic literature search was performed using MEDLINE and the Cochrane Central Register of Controlled Trials (CENTRAL) up to March 2024. All RCTs analysing a coverage method in patients undergoing partial pancreatoduodenectomy or distal pancreatectomy were included. The primary outcome was postoperative pancreatic fistula development. Subgroup analyses for pancreatoduodenectomy or distal pancreatectomy and artificial or autologous coverage were conducted. RESULTS: A total of 18 RCTs with 2326 patients were included. In the overall analysis, coverage decreased the incidence of postoperative pancreatic fistulas by 29% (OR 0.71, 95% c.i. 0.54 to 0.93, P < 0.01). This decrease was also seen in the 12 RCTs covering the remnant after distal pancreatectomy (OR 0.69, 95% c.i. 0.51 to 0.94, P < 0.02) and the 4 RCTs applying autologous coverage after pancreatoduodenectomy and distal pancreatectomy (OR 0.53, 95% c.i. 0.29 to 0.96, P < 0.04). Other subgroup analyses (artificial coverage or pancreatoduodenectomy) showed no statistically significant differences. The secondary endpoints of mortality, reoperations, and re-interventions were each affected positively by the use of coverage techniques. The certainty of evidence was very low to moderate. CONCLUSION: The implementation of coverage, whether artificial or autologous, is beneficial after partial pancreatectomy, especially in patients undergoing distal pancreatectomy with autologous coverage.

Schistosomiasis (Schistosoma mansoni)-a rare cause of complex liver cysts.

In this paper, we describe the case of a 40-year-old patient with an expanding and symptomatic complex liver cyst. Despite comprehensive diagnostics, including labs, imaging and biopsy, a clear etiology could not be determined. As a result, a partial liver resection was performed. The histopathological examination revealed evidence of schistosomas. We postulate that the displacement of the portal fields created a pseudocyst and that the resultant ischemia was the root cause of the patient's discomfort. Postoperatively, the patient received an antihelmintic therapy with praziquantel with which she was able to fully recover.

Bariatric metabolic surgery eliminates body mass index as a risk factor for unemployment.

BACKGROUND: The effects of bariatric metabolic surgery (BMS) on health and comorbidities are well-known. Socioeconomic factors have been increasingly in focus in recent investigations. OBJECTIVE: The aim of this study was to analyze the effects of BMS on predictive variables for unemployment. SETTING: This study as performed in one reference center for BMS. Patients were treated between 2011 and 2017. METHODS: The study design was a retrospective cohort study. Inclusion criteria were Roux-en-Y gastric bypass surgery, follow-up of 60 months, and complete data on employment rate. Exclusion criteria were secondary BMS, secondary referral, loss of follow-up, or patients aged 60 years and above. Patients were stratified as employed independent of part-time work and as unemployed if the patient had no current employment at the time of the visit. Follow-up visits were performed after 6, 12, 24, 48, and 60 months. RESULTS: This study included 623 patients; prior to BMS, 239 (38.36%) patients were employed and 384 (61.64%) unemployed. Risk factors for baseline unemployment included increased body mass index (BMI) (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.01 to 1.05; P = .010) and increased American Society of Anesthesiology (ASA) score (OR, 3.55; 95% CI, 2.56 to 4.90; P < .001). Unemployment rate dropped to 32.4% after 24 months (P < .001) and increased to 62.8% after 60 months. The BMI continuously decreased. Following BMS, the unemployment rate was no longer associated with BMI (24 months: OR, 0.97; 95% CI, 0.95 to 1.01; P = .220; 60 months: 1.04; 95% CI, 0.97 to 1.11; P = .269). The initial ASA status remained associated with unemployment (OR, 2.20; 95% CI, 1.60 to 3.01; P < .001). CONCLUSION: BMI showed some association with the unemployment rate prior to BMI. The unemployment rate significantly decreased 24 months after BMS but increased to baseline values after 60 months. Following BMS, BMI was no longer associated with unemployment.

Multiple endocrine neoplasia type 4: a new member of the MEN family.

Objective: Multiple endocrine neoplasia type 4 (MEN4) is caused by a CDKN1B germline mutation first described in 2006. Its estimated prevalence is less than one per million. The aim of this study was to define the disease characteristics. Methods: A systematic review was performed according to the PRISMA 2020 criteria. A literature search from January 2006 to August 2022 was done using MEDLINE® and Web of ScienceTM. Results: Forty-eight symptomatic patients fulfilled the pre-defined eligibility criteria. Twenty-eight different CDKN1B variants, mostly missense (21/48, 44%) and frameshift mutations (17/48, 35%), were reported. The majority of patients were women (36/48, 75%). Men became symptomatic at a median age of 32.5 years (range 10-68, mean 33.7 ± 23), whereas the same event was recorded for women at a median age of 49.5 years (range 5-76, mean 44.8 ± 19.9) (P = 0.25). The most frequently affected endocrine organ was the parathyroid gland (36/48, 75%; uniglandular disease 31/36, 86%), followed by the pituitary gland (21/48, 44%; hormone-secreting 16/21, 76%), the endocrine pancreas (7/48, 15%), and the thyroid gland (4/48, 8%). Tumors of the adrenal glands and thymus were found in three and two patients, respectively. The presenting first endocrine pathology concerned the parathyroid (27/48, 56%) and the pituitary gland (11/48, 23%). There were one (27/48, 56%), two (13/48, 27%), three (3/48, 6%), or four (5/48, 10%) syn- or metachronously affected endocrine organs in a single patient, respectively. Conclusion: MEN4 is an extremely rare disease, which most frequently affects women around 50 years of age. Primary hyperparathyroidism as a uniglandular disease is the leading pathology.

Minimally invasive versus open pancreatic surgery: meta-analysis of randomized clinical trials.

BACKGROUND: Widespread implementation of the minimally invasive technique in pancreatic surgery has proven to be challenging. The aim of this study was to compare the perioperative outcomes of minimally invasive (laparoscopic and robotic) pancreatic surgery with open pancreatic surgery using data obtained from RCTs. METHODS: A literature search was done using Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Web of Science; all available RCTs comparing minimally invasive pancreatic surgery and open pancreatic surgery in adults requiring elective distal pancreatectomy or partial pancreatoduodenectomy were included. Outcomes were mortality rate, general and pancreatic surgery specific morbidity rate, and length of hospital stay. RESULTS: Six RCTs with 984 patients were included; 99.0 per cent (486) of minimally invasive procedures were performed laparoscopically and 1.0 per cent (five) robotically. In minimally invasive pancreatic surgery, length of hospital stay (-1.3 days, -2 to -0.5, P = 0.001) and intraoperative blood loss (-137 ml, -182 to -92, P < 0.001) were reduced. In the subgroup analysis, reduction in length of hospital stay was only present for minimally invasive distal pancreatectomy (-2 days, -2.3 to -1.7, P < 0.001). A minimally invasive approach showed reductions in surgical site infections (OR 0.4, 0.1 to 0.96, P = 0.040) and intraoperative blood loss (-131 ml, -173 to -89, P < 0.001) with a 75 min longer duration of surgery (42 to 108 min, P < 0.001) only in partial pancreatoduodenectomy. No significant differences were found with regards to mortality rate and postoperative complications. CONCLUSION: This meta-analysis presents level 1 evidence of reduced length of hospital stay and intraoperative blood loss in minimally invasive pancreatic surgery compared with open pancreatic surgery. Morbidity rate and mortality rate were comparable, but longer duration of surgery in minimally invasive partial pancreatoduodenectomy hints that this technique in partial pancreatoduodenectomy is technically more challenging than in distal pancreatectomy.

Prospective randomized controlled trial of simulator-based versus traditional in-surgery laparoscopic camera navigation training.

BACKGROUND: Surgical residents often use a laparoscopic camera in minimally invasive surgery for the first time in the operating room (OR) with no previous education or experience. Computer-based simulator training is increasingly used in residency programs. However, no randomized controlled study has compared the effect of simulator-based versus the traditional OR-based training of camera navigation skills. METHODS: This prospective randomized controlled study included 24 pregraduation medical students without any experience in camera navigation or simulators. After a baseline camera navigation test in the OR, participants were randomized to six structured simulator-based training sessions in the skills lab (SL group) or to the traditional training in the OR navigating the camera during six laparoscopic interventions (OR group). After training, the camera test was repeated. Videos of all tests (including of 14 experts) were rated by five blinded, independent experts according to a structured protocol. RESULTS: The groups were well randomized and comparable. Both training groups significantly improved their camera navigational skills in regard to time to completion of the camera test (SL P = 0.049; OR P = 0.02) and correct organ visualization (P = 0.04; P = 0.03). Horizon alignment improved without reaching statistical significance (P = 0.20; P = 0.09). Although both groups spent an equal amount of actual time on camera navigation training (217 vs. 272 min, P = 0.20), the SL group spent significantly less overall time in the skill lab than the OR group spent in the operating room (302 vs. 1002 min, P < 0.01). CONCLUSION: This is the first prospective randomized controlled study indicating that simulator-based training of camera navigation can be transferred to the OR using the traditional hands-on training as controls. In addition, simulator camera navigation training for laparoscopic surgery is as effective but more time efficient than traditional teaching.

An ileo-colic intussusception reaching down to the descending colon - A case report.

INTRODUCTION AND IMPORTANCE: Intussusception in healthy adults is rare and often associated with oncologic diseases. This case report presents a case of an ileo-colic intussusception reaching down to the descending colon in a healthy adult that required ileo-colic resection. CASE PRESENTATION: We present a case of a 78-year-old male patient with acute onset unspecific abdominal pain. The medical history was unremarkable. Preoperative radiologic assessments showed an invagination of the small intestine into the colon without any signs of polyps or tumours. An emergency laparotomy with resection of the affected intestine was performed. The pathologist described a 49 cm length of intussuscepted colon and an additional 7 cm intussusception of the terminal ileum. A circular area with multiple polyps extending over 8 cm in the colon could be identified. The microscopic findings showed a low-grade dysplasia within this area. Following surgery, the patient was discharged to rehabilitation after a ten-day hospitalization. CLINICAL DISCUSSION: Intussusception in adults is rare and the clinical presentation includes unspecific symptoms making the diagnosis challenging. In 90% of the cases, a pathologic lesion is found (two-thirds are neoplasms). An intussusception involving the colon should be treated surgically without prior reduction due to the high incidence of a neoplasm and the risk for perforation and tumour dissemination. CONCLUSION: In the literature, neoplastic disease represents the major cause for intussusception in adults. This report presents a rare case of an ileo-colic intussusception reaching down to the descending colon treated successfully with a subtotal colectomy.

Improved Clinical and Financial Outcomes in Proximal Gastric Bypass Surgery Following the Transition from a Conventional Circular Stapling to an Augmented Linear Stapling Protocol.

Bariatric techniques for bypass surgery evolve constantly. Switching from one well-established protocol to another in a running surgical teaching program is challenging. We analyzed clinical and financial outcomes at a single bariatric center transitioning from circular to an augmented linear bypass protocol. MATERIALS AND METHODS: Between 2011 and 2018, 454 patients were included in this retrospective study. The circular bypass protocol (CIRC; n = 177) was used between 2011 and 2012. Between 2013 and 2015 the transition occurred. Thereafter, the augmented linear protocol (aLIN; n = 277) was primarily utilized. RESULTS: Overall, the mean preoperative BMI dropped from 42.2 to 29.6 kg/m2 after 5 years with no difference between groups. Operation times were significantly shorter in the aLIN vs. CIRC group at 108 (± 32) vs. 120 (± 34) min (P < 0.001), respectively. The reoperation rate was significantly higher in the CIRC vs. aLIN group at n = 65 (36%) vs. n = 35 (13%; P < 0.001), respectively. Specifically, revision due to internal hernia occurred much more frequently in the CIRC-group, n = 36 (20%) vs. n = 12 (4%; P < 0.001). Moreover, reoperation rates for gastrojejunostomy leakage and endoscopic dilatations for anastomotic stenosis were higher in the CIRC vs. aLIN group (P < 0.001). Adjusted overall mean cost per case was lower in aLIN-patients at 15,403 (± 7848) vs. CIRC-patients at 18,525 (± 7850) Swiss francs (P < 0.001). Overall profit was 2555 ± 4768 vs. 1455 ± 5638 Swiss francs in the aLIN vs. CIRC-group, respectively (P = 0.026). CONCLUSION: This study shows improved clinical and financial outcomes after a gradual transition from a circular stapling protocol to an augmented linear stapling protocol in proximal gastric bypass surgery.

The implementation of physicians assistant in a surgical ward improves continuity in daily clinical work and increases comprehensibility of nurses and physicians.

INTRODUCTION: Physician Assistant (PA) have been deployed to increase the capacity of a team, supporting continuity and medical cover. The goal of this study was to assess the implementation of PAs on continuity of surgical rounds, on the collaboration of nurses and physicians and on support of administrative work. METHODS: This cross-sectional survey was performed on nurses and physicians who work full-time at a surgical ward in a Swiss reference center. PAs were introduced in our institution in 2019. Participants answered a self-developed questionnaire 6 and 12 months after the implementation of PAs. Administrative work, teamwork, improvement of workflow, and training of physicians has been assessed. Participants answered questions on a 5-point Likert scale and were stratified according to profession (nurse, physician). RESULTS: Participants (n = 53) reported a positive effect on the regular conduct of rounds (2.9, SD 1.1 points after 6 weeks and 3.5, SD 1.1 points after 12 weeks, p = 0.05). A significant improvement of nurse-doctor collaboration has been reported (3.6, SD 1.0 and 4.2, SD 0.8, p = 0.05). Nurses (n = 28, 52.8%) reported the that PAs are integrated in the physicians team rather than the nurses team (4.0, SD 0.0 points and 4.4, SD 0.7 points, p = 0.266) and a significant beneficial effect on the surgical clinic (3.7, SD 1.0 points and 4.4, SD 0.8 points, p = 0.043). Improved overall management of surgical cases was reported by the physicians (n = 25, 47.2%) (4.8, SD 0.4 and 4.3, SD 0.6, p = 0.046). CONCLUSION: The implementation of PA has improved the collaboration of physicians and nurses substantially. Continuity of rounds has improved and the administrative workload for residents decreased substantially. Overall, the implementation of PA was reported to be beneficial for the surgical clinic.

The impact of complications on costs of major surgical procedures: a cost analysis of 1200 patients.

OBJECTIVE: To assess the impact of postoperative complications on full in-hospital costs per case. BACKGROUND: Rising expenses for complex medical procedures combined with constrained resources represent a major challenge. The severity of postoperative complications reflects surgical outcomes. The magnitude of the cost created by negative outcomes is unclear. PATIENTS AND METHODS: Morbidity of 1200 consecutive patients undergoing major surgery from 2005 to 2008 in a tertiary, high-volume center was assessed by a validated, complication score system. Full in-hospital costs were collected for each patient. Statistical analysis was performed using a multivariate linear regression model adjusted for potential confounders. RESULTS: This study population included 393 complex liver/bile duct surgeries, 110 major pancreas operations, 389 colon resections, and 308 Roux-en-Y gastric bypasses. The overall 30-day mortality rate was 1.8%, whereas morbidity was 53.8%. Patients with an uneventful course had mean costs per case of US$ 27,946 (SD US$ 15,106). Costs increased dramatically with the severity of postoperative complications and reached the mean costs of US$ 159,345 (SD US$ 151,191) for grade IV complications. This increase in costs, up to 5 times the cost of a similar operation without complications, was observed for all types of investigated procedures, although the magnitude of the increase varied, with the highest costs in patients undergoing pancreas surgery. CONCLUSION: This study demonstrates the dramatic impact of postoperative complications on full in-hospital costs per case and that complications are the strongest indicator of costs. Furthermore, the study highlights a relevant savings capacity for major surgical procedures, and supports all efforts to lower negative events in the postoperative course.

Treatment of ureteral complications after kidney transplantation with native ureteropyelostomy reduces the risk of pyelonephritis.

Urological complications contribute to morbidity and graft loss after kidney transplantation. Aim of this study was to assess the role of revisional surgery on patient outcome. From 1997 to 2007, 887 patients underwent kidney transplantation in our institution. Clinical data of patients with urological complications were analyzed. Ureteral complications were observed in 50 of 887 (5.6%) recipients, including ureteral necrosis (0.9%), stenosis (3.6%) and ureteral reflux with recurrent graft pyelonephritis (1.1%). Thirty-five patients underwent native ureteropyelostomy, and 14 patients had redo-ureterocystostomy. All patients treated for recurrent graft pyelonephritis had no further episodes. Overall, the rate of ureteral stenosis was significantly higher after secondary surgery, compared to the primary anastomosis (10% vs. 3.6%, p = 0.039). A significantly lower incidence of graft pyelonephritis was observed in patients after native ureteropyelostomy compared to patients treated with redo-ureterocystostomy (p = 0.019). In conclusion, reflux and recurrent graft pyelonephritis can be treated effectively by secondary surgery. The use of native ureteropyelostomy may offer protection from graft pyelonephritis after secondary surgery.