RESUMO
INTRODUCTION: There is a paucity of literature comparing safety outcomes between formal fundoplication and gastric fixation procedures for hiatal hernia repairs, especially in the emergency setting. The objective of this study was to evaluate 30-day clinical outcomes between fundoplication and gastric fixation performed in emergency hiatal hernia repairs. METHODS: A retrospective cohort study using the National Surgery Quality Improvement Program (NSQIP) database from 2011 to 2021 was conducted. The study population was determined using ICD9/10 codes describing diaphragmatic hernia without obstruction or gangrene, with obstruction, and with gangrene. Elective cases were excluded. CPT codes were used to group fundoplication procedures and gastric fixation procedures. The primary outcome was the 30-day complication rate. Secondary outcomes included 30-day readmission, reoperation and mortality rates. A multivariable logistic regression analysis was used to adjust for clinically relevant confounding variables. RESULTS: A total of 971 and 346 were in the fundoplication and gastric fixation groups, respectively. Fundoplication was associated with a significantly lower (p < 0.05) 30-day complication, reoperation and mortality rates. There was no statistically significant difference with respect to readmission. After adjustment, fundoplication was significantly associated with a decrease in odds of 30-day complications (OR 0.53, p < 0.001 95% CI 0.40-0.71) and mortality (OR 0.55, p = 0.033 95% CI 0.32-0.95). However, there was no significant difference with respect to 30-day readmission (OR 0.86, p = 0.449 95% CI 0.59-1.27) and reoperation (OR 0.66, p = 0.063 95% CI 0.42-1.02). CONCLUSION: Patients with hiatal hernias that underwent emergent repair with fundoplication had a significantly lower 30-day complication and mortality rates compared to those who underwent gastric fixation procedures. Fundoplication is a safe and feasible approach to manage hiatal hernias in the emergency setting for select patients.
RESUMO
BACKGROUND: Associations between procedure volumes and outcomes can inform minimum volume standards and the regionalization of health services. Robot-assisted surgery continues to expand globally; however, data are limited regarding which hospitals should be using the technology. STUDY DESIGN: Using administrative health data for all residents of Ontario, Canada, this retrospective cohort study included adult patients who underwent a robot-assisted radical prostatectomy (RARP), total robotic hysterectomy (TRH), robot-assisted partial nephrectomy (RAPN), or robotic portal lobectomy using 4 arms (RPL-4) between January 2010 and September 2021. Associations between yearly hospital volumes and 90-day major complications were evaluated using multivariable logistic regression models adjusted for patient characteristics and clustering at the level of the hospital. RESULTS: A total of 10,879 patients were included, with 7567, 1776, 724, and 812 undergoing a RARP, TRH, RAPN, and RPL-4, respectively. Yearly hospital volume was not associated with 90-day complications for any procedure. Doubling of yearly volume was associated with a 17-min decrease in operative time for RARP (95% confidence interval [CI] - 23 to - 10), 8-min decrease for RAPN (95% CI - 14 to - 2), 24-min decrease for RPL-4 (95% CI - 29 to - 19), and no significant change for TRH (- 7 min; 95% CI - 17 to 3). CONCLUSION: The risk of 90-day major complications does not appear to be higher in low volume hospitals; however, they may not be as efficient with operating room utilization. Careful case selection may have contributed to the lack of an observed association between volumes and complications.
Assuntos
Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos , Nefrectomia , Complicações Pós-Operatórias , Prostatectomia , Procedimentos Cirúrgicos Robóticos , Humanos , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Masculino , Feminino , Estudos Retrospectivos , Pessoa de Meia-Idade , Ontário , Prostatectomia/métodos , Nefrectomia/métodos , Idoso , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Duração da Cirurgia , Histerectomia/métodos , Histerectomia/estatística & dados numéricos , AdultoRESUMO
BACKGROUND: Digital surgery is a new paradigm within the surgical innovation space that is rapidly advancing and encompasses multiple areas. METHODS: This white paper from the SAGES Digital Surgery Working Group outlines the scope of digital surgery, defines key terms, and analyzes the challenges and opportunities surrounding this disruptive technology. RESULTS: In its simplest form, digital surgery inserts a computer interface between surgeon and patient. We divide the digital surgery space into the following elements: advanced visualization, enhanced instrumentation, data capture, data analytics with artificial intelligence/machine learning, connectivity via telepresence, and robotic surgical platforms. We will define each area, describe specific terminology, review current advances as well as discuss limitations and opportunities for future growth. CONCLUSION: Digital Surgery will continue to evolve and has great potential to bring value to all levels of the healthcare system. The surgical community has an essential role in understanding, developing, and guiding this emerging field.
Assuntos
Procedimentos Cirúrgicos Robóticos , Cirurgiões , Humanos , Inteligência Artificial , Aprendizado de Máquina , PrevisõesRESUMO
BACKGROUND: Robot-assisted surgery has been rapidly adopted. It is important to define the learning curve to inform credentialling requirements, training programs, identify fast and slow learners, and protect patients. This study aimed to characterize the hospital learning curve for common robot-assisted procedures. STUDY DESIGN: This cohort study, using administrative health data for Ontario, Canada, included adult patients who underwent a robot-assisted radical prostatectomy (RARP), total robotic hysterectomy (TRH), robot-assisted partial nephrectomy (RAPN), or robotic portal lobectomy using four arms (RPL-4) between 2010 and 2021. The association between cumulative hospital volume of a robot-assisted procedure and major complications was evaluated using multivariable logistic models adjusted for patient characteristics and clustering at the hospital level. RESULTS: A total of 6814 patients were included, with 5230, 543, 465, and 576 patients in the RARP, TRH, RAPN, and RPL-4 cohorts, respectively. There was no association between cumulative hospital volume and major complications. Visual inspection of learning curves demonstrated a transient worsening of outcomes followed by subsequent improvements with experience. Operative time decreased for all procedures with increasing volume and reached plateaus after approximately 300 RARPs, 75 TRHs, and 150 RPL-4s. The odds of a prolonged length of stay decreased with increasing volume for patients undergoing a RARP (OR 0.87; 95% CI 0.82-0.92) or RPL-4 (OR 0.77; 95% CI 0.68-0.87). CONCLUSION: Hospitals may adopt robot-assisted surgery without significantly increasing the risk of major complications for patients early in the learning curve and with an expectation of increasing efficiency.
Assuntos
Procedimentos Cirúrgicos Robóticos , Masculino , Adulto , Feminino , Humanos , Procedimentos Cirúrgicos Robóticos/métodos , Estudos de Coortes , Curva de Aprendizado , Prostatectomia/efeitos adversos , Hospitais , Ontário , Resultado do TratamentoRESUMO
BACKGROUND: Benign biliary strictures can have a significant negative impact on patient quality of life. There are several modalities which can be utilized with the goal of stricture resolution. These techniques include balloon dilatation, placement of multiple plastic stents and more recently, the use of metal stents. The aim of this study was to evaluate the local success of self-expanding metal stents in successfully resolving benign biliary strictures. METHODS: This was a single institution, retrospective case series. Patients included in our study were patients who underwent endoscopic retrograde cholangiopancreatography with placement of self expanding metal stents for benign biliary strictures at our institution between 2016-2022. Patients were excluded for the following: malignant stricture, and inability to successfully place metal stent. Data was evaluated using two-sided t-test with 95% confidence interval. RESULTS: A total of 31 patients underwent placement of 43 self-expanding metal stents and met inclusion criteria. Mean age of patients was 59 ± 10 years, and were largely male (74.2% vs. 25.8%). Most strictures were anastomotic stricture post liver transplant (87.1%), while the remainder were secondary to chronic pancreatitis (12.9%). Complications of stent placement included cholangitis (18.6%), pancreatitis (2.3%), stent migration (20.9%), and inability to retrieve stent (4.7%). There was successful stricture resolution in 73.5% of patients with anastomotic stricture and 33.3% of patients with stricture secondary to pancreatitis. Resolution was more likely if stent duration was > / = 180 days (73.3% vs. 44.4%, p < 0.05). There was no demonstrated added benefit when stent duration was > / = 365 days (75% vs. 60.9%, p = 0.64). CONCLUSIONS: This study demonstrates that self expanding metal stents are a safe and effective treatment for benign biliary strictures, with outcomes comparable to plastic stents with fewer interventions. This study indicates that the optimal duration to allow for stricture resolution is 180-365 days.
Assuntos
Colestase , Pancreatite Crônica , Humanos , Masculino , Pessoa de Meia-Idade , Idoso , Constrição Patológica/etiologia , Constrição Patológica/terapia , Estudos Retrospectivos , Qualidade de Vida , Colestase/etiologia , Colestase/cirurgia , Stents/efeitos adversos , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Resultado do Tratamento , Pancreatite Crônica/complicações , MetaisRESUMO
BACKGROUND: Owing to important differences in surgical technique, laparoscopic right colectomy with intracorporeal (ICA) compared to extracorporeal (ECA) anastomotic technique may result in improved patient outcomes. We aimed to compare both techniques according to incisional hernias and other pertinent perioperative characteristics, post-operative complications, and oncologic quality markers. METHODS: All adult patients undergoing laparoscopic right colectomies between 2015 and 2020 at a single institution were included. ICA and ECA techniques were compared based on selected outcomes using univariable and multivariable statistical analyses, as appropriate. Subgroup analyses were restricted to patients with neoplastic indications for surgery and non-urgent operations. RESULTS: A total of 517 patients met inclusion criteria, of which 139 (26.9%) underwent ICA and 378 (73.1%) underwent ECA. ICA and ECA patients had similar baseline characteristics. At two years of follow-up, a lower proportion of ICA patients developed a hernia at the extraction incision (1.5% vs. 7.1%, p = 0.02) and ICA was associated with an 80% reduction in extraction incision hernias (aHR 0.20, p = 0.03). These results were stable through subgroup and sensitivity analyses. Median operative time was longer in the ICA group (186 min vs. 135 min, p < 0.001), but the gap in operative time narrowed during the study period. Median length of stay was one calendar day shorter in the ICA group (3 days vs. 4 days, p = 0.007) and ICA was associated with a 13% decrease in the length of stay (aRR 0.87, p = 0.02). The incidence of superficial wound infections, anastomotic leaks and re-interventions was lower in ICA patients, but this difference was not statistically significant. 90-day unscheduled visits, readmissions, and mortalities were similar across both groups, as were oncologic outcomes. CONCLUSION: Laparoscopic right colectomies with intracorporeal anastomoses are associated with a reduction in incisional hernias and shorter hospital lengths of stay without compromising on patient safety or oncologic principles.
Assuntos
Neoplasias do Colo , Hérnia Incisional , Complicações Pós-Operatórias , Adulto , Humanos , Anastomose Cirúrgica/métodos , Colectomia/métodos , Neoplasias do Colo/cirurgia , Hérnia Incisional/etiologia , Hérnia Incisional/prevenção & controle , Hérnia Incisional/cirurgia , Laparoscopia/métodos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
INTRODUCTION: Robotic surgery has integrated into the healthcare system despite limited evidence demonstrating its clinical benefit. Our objectives were (i) to describe secular trends and (ii) patient- and system-level determinants of the receipt of robotic as compared to open or laparoscopic surgery. METHODS: This population-based retrospective cohort study included adult patients who, between 2009 and 2018 in Ontario, Canada, underwent one of four commonly performed robotic procedures: radical prostatectomy, total hysterectomy, thoracic lobectomy, partial nephrectomy. Patients were categorized based on the surgical approach as robotic, open, or laparoscopic for each procedure. Multivariable regression models were used to estimate the temporal trend in robotic surgery use and associations of patient and system characteristics with the surgical approach. RESULTS: The cohort included 24,741 radical prostatectomy, 75,473 total hysterectomy, 18,252 thoracic lobectomy, and 4608 partial nephrectomy patients, of which 6.21% were robotic. After adjusting for patient and system characteristics, the rate of robotic surgery increased by 24% annually (RR 1.24, 95%CI 1.13-1.35): 13% (RR 1.13, 95%CI 1.11-1.16) for robotic radical prostatectomy, 9% (RR 1.09, 95%CI 1.05-1.13) for robotic total hysterectomy, 26% (RR 1.26, 95%CI 1.06-1.50) for thoracic lobectomy and 26% (RR 1.26, 95%CI 1.13-1.40) for partial nephrectomy. Lower comorbidity burden, earlier disease stage (among cancer cases), and early career surgeons with high case volume at a teaching hospital were consistently associated with the receipt of robotic surgery. CONCLUSION: The use of robotic surgery has increased. The study of the real-world clinical outcomes and associated costs is needed before further expanding use among additional providers and hospitals.
Assuntos
Laparoscopia , Procedimentos Cirúrgicos Robóticos , Robótica , Masculino , Adulto , Feminino , Humanos , Procedimentos Cirúrgicos Robóticos/métodos , Estudos Retrospectivos , Laparoscopia/métodos , Hospitais de Ensino , OntárioRESUMO
BACKGROUND: Surgical video recording provides the opportunity to acquire intraoperative data that can subsequently be used for a variety of quality improvement, research, and educational applications. Various recording devices are available for standard operating room camera systems. Some allow for collateral data acquisition including activities of the OR staff, kinematic measurements (motion of surgical instruments), and recording of the endoscopic video streams. Additional analysis through computer vision (CV), which allows software to understand and perform predictive tasks on images, can allow for automatic phase segmentation, instrument tracking, and derivative performance-geared metrics. With this survey, we summarize available surgical video acquisition technologies and associated performance analysis platforms. METHODS: In an effort promoted by the SAGES Artificial Intelligence Task Force, we surveyed the available video recording technology companies. Of thirteen companies approached, nine were interviewed, each over an hour-long video conference. A standard set of 17 questions was administered. Questions spanned from data acquisition capacity, quality, and synchronization of video with other data, availability of analytic tools, privacy, and access. RESULTS: Most platforms (89%) store video in full-HD (1080p) resolution at a frame rate of 30 fps. Most (67%) of available platforms store data in a Cloud-based databank as opposed to institutional hard drives. CV powered analysis is featured in some platforms: phase segmentation in 44% platforms, out of body blurring or tool tracking in 33%, and suture time in 11%. Kinematic data are provided by 22% and perfusion imaging in one device. CONCLUSION: Video acquisition platforms on the market allow for in depth performance analysis through manual and automated review. Most of these devices will be integrated in upcoming robotic surgical platforms. Platform analytic supplementation, including CV, may allow for more refined performance analysis to surgeons and trainees. Most current AI features are related to phase segmentation, instrument tracking, and video blurring.
Assuntos
Inteligência Artificial , Procedimentos Cirúrgicos Robóticos , Humanos , Endoscopia , Software , Privacidade , Gravação em VídeoRESUMO
BACKGROUND: Robotic surgery was integrated into some healthcare systems despite there being few well designed, real-world studies on safety or benefit. This study compared the safety of robotic with laparoscopic, thoracoscopic, and open approaches in common robotic procedures. METHODS: This was a population-based, retrospective study of all adults who underwent prostatectomy, hysterectomy, pulmonary lobectomy, or partial nephrectomy in Ontario, Canada, between 2008 and 2018. The primary outcome was 90-day total adverse events using propensity score overlap weights, and secondary outcomes were minor or major morbidity/adverse events. RESULTS: Data on 24 741 prostatectomy, 75 473 hysterectomy, 18 252 pulmonary lobectomy, and 6608 partial nephrectomy operations were included. Relative risks for total adverse events in robotic compared with open surgery were 0.80 (95 per cent c.i. 0.74 to 0.87) for radical prostatectomy, 0.44 (0.37 to 0.52) for hysterectomy, 0.53 (0.44 to 0.65) for pulmonary lobectomy, and 0.72 (0.54 to 0.97) for partial nephrectomy. Relative risks for total adverse events in robotic surgery compared with a laparoscopic/thoracoscopic approach were 0.94 (0.77 to 1.15), 1.00 (0.82 to 1.23), 1.01 (0.84 to 1.21), and 1.23 (0.82 to 1.84) respectively. CONCLUSION: The robotic approach is associated with fewer adverse events than an open approach but similar to a laparoscopic/thoracoscopic approach. The benefit of the robotic approach is related to the minimally-invasive approach rather than the platform itself.
Assuntos
Laparoscopia , Procedimentos Cirúrgicos Robóticos , Adulto , Feminino , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Masculino , Nefrectomia/efeitos adversos , Nefrectomia/métodos , Ontário , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversosRESUMO
INTRODUCTION: Repeat abdominal surgery in the bariatric surgery patient population may be challenging for non-bariatric-accredited institutions. The impact of regionalized bariatric care on clinical outcomes for bariatric surgery patients requiring repeat abdominal surgery is currently unknown. This study aims to investigate the association between bariatric center designation and clinical outcomes following hepatobiliary, hernia, and upper and lower gastrointestinal operations among patients with prior bariatric surgery. METHODS: This is a cohort study of a large sample of Ontario residents who underwent primary bariatric surgery between 2010 and 2017. A comprehensive list of eligible abdominal operations was captured using administrative data. The primary outcome was 30-d complications. Secondary outcomes included 30-d mortality, readmission, and length of stay. RESULTS: Among the 3301 study patients, 1305 (40%) received their first abdominal reoperation following bariatric surgery at a designated bariatric center. Nonbariatric center designation was not associated with significantly higher rates of 30-d complications (5.73% versus 5.72%), mortality (0.80% versus 0.77%), readmissions (1.11% versus 1.85%), or median postoperative length of stay (4 versus 4 d). After grouping the category of reoperations, upper gastrointestinal (odds ratio [OR] 0.66, confidence interval [CI] 0.39-1.11) and abdominal wall hernia surgery (OR 0.52, CI 0.27-0.99) showed a lower adjusted OR for complications among bariatric centers. CONCLUSIONS: Our study demonstrates that after adjustment for case-mix and patient characteristics, bariatric surgery patients undergoing repeat abdominal surgery at nonbariatric centers is not associated with higher proportion of complications or mortality. Complex hernia surgery may be considered the most appropriate for referral.
Assuntos
Cirurgia Bariátrica , Obesidade Mórbida , Humanos , Obesidade Mórbida/cirurgia , Obesidade Mórbida/complicações , Estudos de Coortes , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Cirurgia Bariátrica/efeitos adversos , Hérnia/complicações , Estudos RetrospectivosRESUMO
BACKGROUND: Indocyanine green, near infrared, fluorescence angiography (ICG-FA) is increasingly adopted in colorectal surgery for intraoperative tissue perfusion assessment to reduce anastomotic leakage rates. However, the economic impact of this intervention has not been investigated. This study is a cost analysis of the routine use of ICG-FA in colorectal surgery from the hospital payer perspective. METHODS: A decision analysis model was developed for colorectal resections considering two scenarios: resection without using ICG-FA and resection with intraoperative ICG-FA for anastomotic perfusion assessment. Incorporated into the model were the costs of ICG agent, fluorescence angiography equipment, surgery, anastomotic leak, and the leak rates with and without ICG-FA. All input data were derived from recent publications. RESULTS: The routine use of ICG-FA for colorectal anastomosis is cost saving when cost analysis is performed using the following base case assumptions: 8.6% leak rate without ICG-FA, odds ratio of 0.46 for reduction of leakage with ICG-FA (4.8% leak rate relative to 8.6% base case), cost of ICG-FA of $250, and incremental cost of leak, not requiring reoperation, of $9,934.50. In one-way sensitivity analyses, routine use of ICG-FA was cost saving if the cost of an anastomotic leak is more than $5616.29, the cost of ICG-FA is less than $634.44, the leak rate (without ICG-FA) is higher than 4.9%, or the odds ratio for reduction of leak with ICG-FA is less than 0.69. There is a per-case saving of $192.22 with the use of ICG-FA. CONCLUSION: Using the best available evidence and most conservative base case values, routine use of ICG-FA in colorectal surgery was found to be cost saving. Since the evidence suggests there is a reduction in leak rate, the routine use of ICG-FA is a dominating strategy. However, the overall quality of evidence is low and there is a clear need for prospective, randomized controlled trials.
Assuntos
Neoplasias Colorretais , Cirurgia Colorretal , Humanos , Fístula Anastomótica/etiologia , Fístula Anastomótica/prevenção & controle , Verde de Indocianina , Angiofluoresceinografia , Estudos Prospectivos , Anastomose Cirúrgica/efeitos adversos , Neoplasias Colorretais/cirurgia , Custos e Análise de CustoRESUMO
BACKGROUND: Colonoscopy is a technically challenging procedure. The colonoscope is prone to forming loops in the colon, which can lead patient discomfort and even perforation. We hypothesized that expert endoscopists use techniques to avoid loop formation, identify and straighten loops earlier, and thus exert less force. METHODS: Using a commercially available physical colon simulator model (Kyoto Kagaku), electromagnetic tracking markers (NDI Medical) were placed along the mobile segments of the colon (sigmoid, transverse) to measure the degree of displacement of the colon as the scope was advanced to the cecum. The colon model was set for each participant to simulate a redundant alpha loop in the sigmoid colon. Gastroenterology and surgical trainees and attendings were assessed. Demographic data were collected for each participant. RESULTS: Seventy-five participants were enrolled in the study. There were 17 (22.7%) attending physicians, and 58 (77.3%) trainees. Attending physicians advanced the scope to the cecum faster. The mean time required for procedure completion was 360.5 s compared to 178.4 s for the trainee and attending groups respectively (mean difference: 182.1 s, 95% CI: 93.0, 269.7; p = 0.0002). Attending physicians exerted significantly lower mean colonic displacement than trainees. The mean colonic displacement was 79.8 mm for the trainee group and 57.9 mm for the attending group (mean difference: 21.9 mm, 95% CI: 2.6, 41.2; p = 0.04). Those who used torque steering caused lower maximum colonic displacement than those who used knob steering. CONCLUSION: Attending physicians advance the scope during colonoscopy in a manner that results in significantly less colonic displacement than resident trainees. Although prior studies have shown a difference in force application between endoscopists and inexperienced students, ours is the first to differentiate across varying degrees of endoscopic skill. Future studies will define metrics for incorporation into endoscopic training curricula, focusing on techniques that encourage safety and comfort for patients.
Assuntos
Competência Clínica , Colonoscópios , Colo , Colonoscopia/métodos , Endoscopia Gastrointestinal , HumanosRESUMO
Background: Laparoscopic intracorporeal continuous suturing is being employed in a growing number of minimally invasive procedures. However, there is a lack of adequate bench models for gaining proficiency in this complex task. The purpose of this study was to assess a novel simulation model for running suture. Methods: Participants were grouped as novice (LSN) or expert (LSE) at laparoscopic suturing based on prior experience and training level. A novel low-cost bench model was developed to simulate laparoscopic intracorporeal continuous closure of a defect. The primary outcome measured was time taken to complete the task. Videos were scored by independent raters for Global Operative Assessment of Laparoscopic Skills (GOALS). Results: Sixteen subjects (7 LSE and 9 LSN) participated in this study. LSE completed the task significantly faster than LSN (430 ± 107 vs 637 ± 164 seconds, P ≤ .05). LSN scored higher on accuracy penalties than LSE (Median 30 vs 0, P ≤ .05). Mean GOALS score was significantly different between the 2 groups (LSE 20.64 ± 2.64 vs LSN 14.28 ± 1.94, P < .001) with good inter-rater reliability (ICC ≥ .823). An aggregate score using the formula: Performance Score = 1200-time(sec)-(accuracy penalties x 10) was significantly different between groups with a mean score of 741 ± 141 for LSE vs 285 ± 167 for LSN (P < .001). Conclusion A novel bench model for laparoscopic continuous suturing was able to significantly discriminate between laparoscopic experts and novices. This low-cost model may be useful for both training and assessment of laparoscopic continuous suturing proficiency.
Assuntos
Laparoscopia , Treinamento por Simulação , Humanos , Técnicas de Sutura/educação , Competência Clínica , Reprodutibilidade dos Testes , Projetos Piloto , Laparoscopia/métodos , Suturas , Treinamento por Simulação/métodosRESUMO
OBJECTIVE: The aim of this work is to formulate recommendations based on global expert consensus to guide the surgical community on the safe resumption of surgical and endoscopic activities. BACKGROUND: The COVID-19 pandemic has caused marked disruptions in the delivery of surgical care worldwide. A thoughtful, structured approach to resuming surgical services is necessary as the impact of COVID-19 becomes better controlled. The Coronavirus Global Surgical Collaborative sought to formulate, through rigorous scientific methodology, consensus-based recommendations in collaboration with a multidisciplinary group of international experts and policymakers. METHODS: Recommendations were developed following a Delphi process. Domain topics were formulated and subsequently subdivided into questions pertinent to different aspects of surgical care in the COVID-19 crisis. Forty-four experts from 15 countries across 4 continents drafted statements based on the specific questions. Anonymous Delphi voting on the statements was performed in 2 rounds, as well as in a telepresence meeting. RESULTS: One hundred statements were formulated across 10 domains. The statements addressed terminology, impact on procedural services, patient/staff safety, managing a backlog of surgeries, methods to restart and sustain surgical services, education, and research. Eighty-three of the statements were approved during the first round of Delphi voting, and 11 during the second round. A final telepresence meeting and discussion yielded acceptance of 5 other statements. CONCLUSIONS: The Delphi process resulted in 99 recommendations. These consensus statements provide expert guidance, based on scientific methodology, for the safe resumption of surgical activities during the COVID-19 pandemic.
Assuntos
COVID-19/prevenção & controle , Procedimentos Cirúrgicos Eletivos , Endoscopia , Controle de Infecções/organização & administração , COVID-19/epidemiologia , COVID-19/transmissão , Consenso , Técnica Delphi , Humanos , Internacionalidade , Colaboração Intersetorial , TriagemRESUMO
BACKGROUND: Same-day surgery is an increasingly utilized and cost-effective strategy to manage common surgical conditions. However, many institutions limit ambulatory surgical services to only healthy individuals. There is also a paucity of data on the safety of same-day discharge among high-risk patients. This study aims to determine whether same-day discharge is associated with higher major morbidity and readmission rates compared with overnight stay in high-risk general surgery patients. METHODS: This is a retrospective cohort using the data from the National Surgical Quality Improvement Program from 2005 to 2017. Patients with an American Society of Anesthesiologists class ≥3 undergoing general surgical procedures amenable to same-day discharge were identified. Primary and secondary outcomes were major morbidity and readmission at 30 d. A multivariable logistic regression model using mixed effects was used to adjust for the effect of same-day discharge. RESULTS: Of 191,050 cases, 137,175 patients (72%) were discharged on the same day. At 30 d, major morbidity was 1.0%, readmission 2.2%, and mortality <0.1%. Adjusted odds ratio of same-day discharge was 0.59 (95% confidence interval 0.54-0.64; P < 0.001) for major morbidity and 0.75 (95% confidence interval 0.71-0.80; P < 0.001) for readmission. Significant risk factors for morbidity and readmission included nonindependent functional status, ascites, renal failure, and disseminated cancer. CONCLUSIONS: Major morbidity and readmission rates are low among this large sample of high-risk general surgery patients undergoing common ambulatory procedures. Same-day discharge was not associated with increased adverse events and could be considered in most high-risk patients after uncomplicated surgery.
Assuntos
Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Tempo de Internação/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Ambulatórios/estatística & dados numéricos , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Estudos Retrospectivos , Medição de Risco/estatística & dados numéricos , Fatores de Risco , Fatores de Tempo , Adulto JovemRESUMO
BACKGROUND: Bariatric surgery in older patients is safe and effective. Current guidelines do not endorse age limits for surgery; however, older patients may encounter difficulties with access given perceived risks. This study compares the adjusted probability of failing to receive bariatric surgery between older (≥ 60 years) and younger (< 60 years) patients referred to a publicly funded program. STUDY DESIGN: This is a retrospective cohort study of adult patients referred to a bariatric surgery program in Ontario from 2010-2016. Ontario health administrative databases and the Ontario Bariatric Registry were used for the analysis. The primary outcome was receipt of bariatric surgery within 3 years of referral. A multivariable logistic regression analysis was performed to determine the adjusted effect of older age (≥ 60 years) on the probability of not receiving surgery. Sensitivity analysis was performed using only healthy patients. RESULTS: Among 19,510 patients referred to the program, 1,795 patients (9.2%) were ≥ 60 years old, of which 60% received bariatric surgery within 3 years compared to 90% in younger patients. The odds older patients do not receive surgery after adjustment were significantly higher compared to younger patients (OR 1.69 [1.52-1.88], P < .001). This effect persists even among a subgroup of older patients with a Charlson Comorbidity Index = 0 (OR 1.78 [1.56-2.04], P < .001). CONCLUSIONS: Age alone, rather than comorbidities had a more significant effect on the access to bariatric surgery in older patients. Given the demonstrated benefits of bariatric surgery in older populations, ensuring equity in access to bariatric surgery should be encouraged. Future research is required to explore the underlying reasons why older patients who could benefit from bariatric surgery may not have the opportunity.
Assuntos
Cirurgia Bariátrica , Obesidade Mórbida , Adulto , Idoso , Comorbidade , Humanos , Pessoa de Meia-Idade , Obesidade Mórbida/epidemiologia , Encaminhamento e Consulta , Estudos RetrospectivosRESUMO
Preoperative malnutrition in patients with colorectal cancer is associated with several postoperative consequences and poorer prognosis. Currently, there is a lack of a universal screening tool to assess nutritional status, and intervention to treat preoperative malnutrition is often neglected. This review summarizes and compares preoperative screening and interventional tools to help providers optimize malnourished patients with colorectal cancer for surgery. We found that nutritional screenings, such as the Subjectibe Global Assessment, Patient-Generated Subjective Global Assessment, Prognostic Nutritional Index, Nutrition Risk Index, Malnutrition Universal Screening Tool, Nutrition Risk Screening 2002, Nutrition Risk Score, serum albumin, and prealbumin, have all effectively predicted postoperative outcome. Physicians should consider which of these tools best fits their needs based on the their mode of assessment, efficiency, and specified parameters. Additionally, preoperative nutritional support, such as trimodal prehabilitation, modified peripheral parenteral nutrition, and N-3 fatty acid and arginine supplementation, which have also benefited patients postoperatively, ought to be implemented appropriately according to their ease of execution. Given the high prevalence of preoperative malnutrition in patients undergoing surgery for colorectal cancer, it is essential that health care providers assess and treat this malnutrition to reduce postoperative complications and length of hospital stay, and to improve prognosis to augment a patient's quality of care.La malnutrition préopératoire chez les patients atteints d'un cancer colorectal est associée à plusieurs complications postopératoires et à un pronostic plus sombre. Il n'existe actuellement aucun outil universel d'évaluation du statut nutritionnel, et les mesures visant à corriger la malnutrition préopératoire font souvent défaut. La présente revue résume et compare les outils de dépistage et d'intervention préopératoires pour aider les professionnels à améliorer l'état des patients dénutris qui doivent subir une chirurgie pour le cancer colorectal. Nous avons constaté que le dépistage nutritionnel à l'aide de questionnaires tels que l'Évaluation globale subjective, l'Index nutritionnel pronostique, l'Outil universel de dépistage de la malnutrition, NRS 2002 (Nutrition Risk Screening 2002), l'évaluation du risque nutritionnel, et le dosage de l'albumine et de la préalbumine sériques, a permis de prédire avec justesse l'issue de la chirurgie. Les médecins devraient vérifier lequel de ces outils est le mieux adapté à leurs besoins selon leur modalité d'évaluation, leur efficience et autres paramètres spécifiques. Également, un soutien nutritionnel préopératoire, comme la préadaptation trimodale, la nutrition parentérale périphérique modifiée et les suppléments d'acides gras N-3 et d'arginine, qui ont aussi donné des résultats postopératoires favorables, devrait être appliqué selon sa facilité d'administration. Étant donné la forte prévalence de la malnutrition préopératoire chez les patients soumis à une chirurgie pour cancer colorectal, les professionnels de la santé se doivent d'évaluer et de corriger la malnutrition afin de prévenir les complications postopératoires, d'abréger la durée du séjour hospitalier, et d'améliorer ainsi le pronostic et la qualité des soins.
Assuntos
Neoplasias Colorretais/cirurgia , Desnutrição , Avaliação Nutricional , Cuidados Pré-Operatórios , Humanos , Hipoalbuminemia/sangue , Estado Nutricional , Período Pré-Operatório , Albumina Sérica/metabolismo , Resultado do TratamentoRESUMO
BACKGROUND: Few studies have investigated the potential impact of robotic assistance on cognitive ergonomics during advanced minimally invasive surgery. The purpose of this study was to assess the impact of robotic assistance on mental workload and downstream cognitive performance in surgical trainees. METHODS: Robot-naïve trainees from general surgery, urology and gynaecology, stratified by specialty and level of training, were randomised to either laparoscopic surgery (LS) or robotic-assisted laparoscopic surgery (RALS) and performed a time-limited, complex laparoscopic suturing task after watching a 5-min instructional video. The RALS group received an additional 5-min orientation to the robotic console. Subjective mental workload was measured using NASA Task Load Index. Concentration and executive cognitive function were assessed using Psychomotor Vigilance Task (PVT) and Wisconsin Card Sorting Test (WCST), respectively. A p value of 0.05 was considered significant. RESULTS: Sixteen senior residents (SR; ≥ PGY3) and 14 junior residents (JR; PGY1-2) completed the study. There was no difference in mental workload between LS and RALS. Within JR there was no difference in task completion time comparing LS versus RALS; however, LS was associated with impaired concentration post-task versus pre-task (PVT reaction time 306 versus 324 ms, p = 0.03), which was not observed for RALS. In contrast, amongst SR, RALS took significantly longer than LS (10.3 vs. 14.5 min, p = 0.02) and was associated with significantly worse performance on WCST (p < 0.01). CONCLUSIONS: Robotic assistance, in this setting, did not provide a technical performance advantage nor impact subjective mental workload with novice users regardless of level of surgery training. We observed a protective effect on cognitive performance offered by RALS to junior trainees with limited LS experience, yet a detrimental effect on senior trainees with greater LS ability and inadequate pre-study robotic training, suggesting that robotic consoles may be mentally taxing for robotic novices and consideration should be given to formal console training prior to initial clinical exposure.
Assuntos
Laparoscopia/psicologia , Procedimentos Cirúrgicos Robóticos/psicologia , Cirurgiões/psicologia , Desempenho Profissional , Carga de Trabalho/psicologia , Competência Clínica , Cognição , Ergonomia , Feminino , Humanos , Laparoscopia/educação , Masculino , Procedimentos Cirúrgicos Robóticos/educação , Cirurgiões/educaçãoRESUMO
BACKGROUND: Both laparoscopy and endoscopy are image-based procedures, which are less intuitive than traditional open surgery and require extensive training to reach adequate proficiency. Currently, there is lack of understanding as to how the skills in one image-based procedure translate to another, such as endoscopy to laparoscopy and vice versa. The aim of our study was to explore the relationship between endoscopic and laparoscopic skills using a Fundamentals of Laparoscopic Surgery (FLS) trainer, a traditional virtual reality endoscopic trainer and a "desk-top" endoscopic physical simulator. METHODS: Senior surgical residents from across Canada participating in an advanced laparoscopic foregut training course were enrolled in the study. Participants were assessed performing the FLS laparoscopic suturing task, the Endobubble 2 task (Simbionix, GI Mentor), and a forward viewing peg transfer on the novel Basics in Endoscopic Skills Training Box (BEST Box). RESULTS: There was significant correlation between the participant's skill in simulated laparoscopic suturing and simulated endoscopic skill using the BEST box (Pearson coefficient (r) was 0.551 (p = 0.033) and the coefficient of determination (r2) was 0.304). There was a trend towards correlation between laparoscopic suturing time and Endobubble 2 score, but this did not reach statistical significance (r = 0.458, p = 0.086; r2 = 0.210). CONCLUSIONS: Performance in the two physical simulators, laparoscopic suturing and simulated flexible endoscopy using the BEST box, showed a correlation. This study adds to the growing body of evidence that laparoscopic and endoscopic skills are complementary and has the potential to impact simulation training involving both skill sets.
Assuntos
Simulação por Computador/normas , Endoscopia/métodos , Laparoscopia/métodos , Treinamento por Simulação/métodos , Feminino , Humanos , MasculinoRESUMO
Summary: The World Health Organization declared a pandemic when coronavirus disease 2019 (COVID-19) started to sweep the globe. Growing concerns for the safety of health care workers was raised when up to 80% of people with COVID-19 showed mild or no symptoms at all. Some surgical procedures will be inevitable during the pandemic, and proper safety measures must be in place to avoid transmission risks. Surgical smoke is a common by-product from the use of energy devices in the operating room. The effects of surgical smoke have been studied for more than 40 years, and potential health hazards have been reported. Chemicals, carcinogens and biologically active materials, such as bacteria and viruses, have been isolated in surgical smoke. To ensure the safety of operating room personnel, we must consider whether there is any concern of viral transmission from the inhalation of surgical smoke.