High-resolution standardization reduces delay due to workflow disruptions in laparoscopic cholecystectomy.

BACKGROUND: Optimal resource utilization in high-cost environments like operating theatres is fundamental in today's cost constrained health care systems. Interruptions of the surgical workflow, i.e. microcomplications (MC), lead to prolonged procedure times and higher costs and can be indicative of surgical mistakes. Reducing MC can improve operating room efficiency and prevent intraoperative complications. We, therefore, aimed to evaluate the impact of a high-resolution standardized laparoscopic cholecystectomy protocol (HRSL) on operative time and intraoperative interruptions in a teaching hospital. METHODS: HRSL consisted of a detailed stepwise protocol for the procedure, supported by a teaching video, both to be reviewed as mandatory preparation by each team member before surgery. Audio-video records of laparoscopic cholecystectomies were reviewed regarding type, frequency and duration of MC before and after implementation of HRSL. RESULTS: Thirty-nine (20 control and 19 HRSL) audio-video records of laparoscopic cholecystectomies with a total duration of 51.36 h (28.92 pre 22.44 post) were reviewed. The majority of operations (86%) were performed by teams who had completed less than 10 procedures together previously. Communication-related interruptions and instrument changes accounted for the majority of MC. Median frequency and duration of MC were 95 events/h and 15.6 min/h, respectively, of surgery pre-intervention. With HRSL this was reduced to 76 events/h and 10.6 min/h of operating. In multivariable analysis, HRSL was an independent predictor for shorter delay and lower frequency of MC [percentage decrease 27% (95% CI 18-35%), resp. 30% (95% CI 19-40%)]. Procedure-related risk factors for the longer delay due to MC in multivariable analysis were less experience of the surgeon and intraoperative adhesiolysis. CONCLUSIONS: HRSL is effective in reducing delays due to MC in a teaching institution with limited team experience. These findings should be tested in larger potentially cluster-randomized controlled trials. The trial has been registered with clinicaltrials.gov: NCT03329859.

Detailed assessment of microvasculature markers in non-small cell lung cancer reveals potentially clinically relevant characteristics.

Tumor angiogenesis is important for the progression of cancer and is orchestrated by various factors associated with tumor vessels, tumor cells, and stromal cells. Angiogenic signaling in non-small cell lung cancer (NSCLC) needs to be further clarified, especially regarding existing and upcoming therapeutic approaches. Expression of CD34, CD105, Mel-CAM, VE-cadherin, D2-40, VEGF, VEGFR1, and VEGFR2 was assessed immunohistochemically on a cohort of 371 well documented, surgically resected NSCLC using a standardized tissue microarray platform. Extensive clinical data and a postoperative follow-up period of up to 18 years allowed us to assess clinicopathological correlations in detail. Microvasculature in NSCLC was significantly denser at the tumor periphery as compared to the tumor center. Squamous cell carcinomas (SCC) were associated with a notably lower microvessel density (MVD) than adenocarcinomas (ACA). CD105 was present at significantly higher levels on stromal cells of ACA as compared to SCC. Expression of VE-cadherin by tumor cells (6% of cases, mainly ACA) as well as decreased MVD in the tumor centers was independently associated with poor prognosis in the entire cohort. Low MVD in SCC might be related to lower efficacy of and fatal bleeding during therapy with bevacizumab. In other NSCLC entities for which treatment with VEGF inhibitors is studied in clinical trials, the predictive value of MVD for therapy response merits to be prospectively examined. Our data suggest that patients with ACA may be candidates for therapies targeting CD105. VE-cadherin is another promising target for therapy, but its expression also provides independent prognostic information.