Quality of Life and Timing of Stoma Closure in Patients With Rectal Cancer Undergoing Low Anterior Resection With Diverting Stoma: A Multicenter Longitudinal Observational Study.

BACKGROUND: After low anterior resection for rectal cancer, creation of a diverting stoma is recommended. Data on the impact of a diverting stoma on quality of life are conflicting. Optimal timing of stoma closure in the setting of adjuvant chemotherapy is unclear. OBJECTIVE: The purpose of this study was to investigate the impact of a diverting stoma on quality of life in patients undergoing rectal cancer resection before and after stoma closure. Furthermore, the study was conducted to look at the timing of stoma reversal and the potential influence of factors such as adjuvant chemotherapy. DESIGN: This was a longitudinal, observational, multicenter study. SETTINGS: The study was conducted at 17 German colorectal centers. PATIENTS: Patients with rectal cancer who planned for elective curative surgery with creation of temporary diverting stoma were included. MAIN OUTCOME MEASURES: This longitudinal observational study assessed quality of life at 3 occasions using European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core Questionnaire/Colorectal Cancer Module before cancer resection, before stoma closure, and 6 months after stoma closure. Furthermore, the timing of stoma closure and continence were evaluated. RESULTS: A total of 120 patients (64% men; mean age, 63.2 ± 11.5 years) were analyzed. Longitudinal global quality of life was not influenced by the presence of a stoma. Several functional and GI symptom scales were markedly impaired after stoma creation. Physical, role functioning, and sexual interest recovered after stoma closure. Social functioning stayed impaired (p < 0.0001). Median time to stoma closure was 5 months (range, 17 days to 18 months). A total of 3.4% of patients had very early stoma closure (within 30 days). Adjuvant chemotherapy delayed stoma closure (median, 5.6 vs 3.4 months without chemotherapy; p = 0.0001). LIMITATIONS: The study was limited by its missing quality-of-life data for sexual function. CONCLUSIONS: The presence of a stoma had a negative impact on social functioning and GI symptoms. However, this had no clinically relevant influence on global quality of life. Time to stoma closure was nearly doubled when patients underwent adjuvant chemotherapy.

Clinical relevance of morphologic MRI criteria for the assessment of lymph nodes in patients with rectal cancer.

AIM: The aim of this study is the evaluation of lymph node staging by magnetic resonance imaging (MRI) within clinical routine in patients with rectal cancer. METHOD: Routine MRI reports (3 T) of 65 consecutive patients with rectal cancer were retrospectively categorized in lymph node tumor positive or negative (mriN+; mriN0) and compared to the final histopathological results (pN+; pN0). Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy were calculated. The original MRI readings were then reanalyzed in order to identify the longest short-axis lymph node diameter for each patient. A receiver operating characteristic (ROC) curve was used to calculate a possible cutoff value for the short-axis lymph node diameter. RESULTS: Overall sensitivity was 94 %, specificity 13 %, NPV 86 %, PPV 28 %, and accuracy 34 %. The best accuracy could be calculated for a short-diameter cutoff of ≤5 mm (83 %); pN+ and pN0 groups were then significantly different (p < 0.0001). CONCLUSION: In clinical routine, lymph node assessment in patients with rectal cancer through MRI tends to overstage malignant lymphadenopathy. A ≤5-mm cutoff value for the short-axis lymph node diameter of benign nodes is able to improve the accuracy and has potential to lower the risk of overstaging.

Effects of a clinical pathway of pulmonary lobectomy and bilobectomy on quality and cost of care.

PURPOSE: This study evaluates medical and economic effects of a clinical pathway (CP) for open lobectomy and bilobectomy with respect to process quality, outcome quality, and hospital cost. METHODS: We compared 38 consecutive patients who underwent open lobectomy or bilobectomy between April 2007 and June 2008 and were treated with a CP (CP group) with 43 consecutive patients treated without CP between 2005 and 2007 (pre-pathway group). Indicators for process quality were duration of catheter placement, pain intensity, respiratory exercising, and mobilization. Outcome quality was measured through morbidity, mortality, re-operations, and re-admissions. Cost of hospital stay was calculated using an imputed daily rate. RESULTS: Central venous catheters were used in 90% of patients in the CP group (pre-pathway group 40%; p < 0.0001). Epidural catheters were placed in 84% of patients in the CP group (pre-pathway group 56%; p = 0.01). Variation in duration of catheter placement was reduced in the CP group. The reduction of hospital stay was 3 days (-19%, p = 0.003). Perioperative outcome quality remained unchanged. There was a significant cost reduction of 1,614 euros per stay after CP introduction (-19%; p = 0.003). CONCLUSIONS: After CP implementation for open lobectomy the quality and standardization of care improved. Although length of hospital stay was significantly reduced, there was no significant increase of re-admissions or morbidity. Patients benefited from a shortened hospital stay while the hospital achieved cost reduction. This early analysis shows that the implementation of CP for open lobectomy has positive effects in terms of quality and cost of care.

Effects of a clinical pathway for video-assisted thoracoscopic surgery (VATS) on quality and cost of care.

PURPOSE: The purpose of this study was to evaluate effects of a clinical pathway (CP) for video-assisted thoracoscopic surgery (VATS) on process quality, outcome quality, and hospital costs. MATERIALS AND METHODS: We implemented a CP for VATS and compared 34 patients treated with CP to 77 patients treated without CP. Indicators for process quality were duration of catheter placement, pain intensity, respiratory exercising, and mobilization. Outcome quality was measured through morbidity, mortality, reoperations, and readmissions. Cost of hospital stay was calculated using an imputed daily rate. RESULTS: Foley catheters were removed significantly earlier after CP implementation. All patients on CP were mobilized and received pulmonary exercising on the operation day. Pain levels were low after CP implementation. Median hospital stay significantly reduced by 5 days. Perioperative outcome quality remained unchanged. Costs significantly diminished by 1,510 Euro per stay. CONCLUSIONS: CP implementation had positive effects on process quality. Specifically, catheter management was improved and a good pain control achieved. Patients benefited from shortened stay and were treated at lower cost. A clear effect on outcome quality was not found. CPs are a promising tool for quality improvement and cost containment in thoracic surgery.

Clinical Pathways in surgery: should we introduce them into clinical routine? A review article.

BACKGROUND AND AIMS: In modern health care systems, care providers face ever new challenges with regard to quality and cost of care, as well as to satisfaction and training of staff. Due to the intensiveness of the subject, these challenges are particularly pronounced in surgery. Clinical Pathways, i.e. detailed care plans defining the desired measures to be performed for each treatment period, are thought to be a tool to improve care in surgery with regard to these issues. METHODS: We performed a literature review to identify studies reporting effects of the implementation of Clinical Pathways into clinical care for the most common surgical interventions. We subdivided findings into Clinical Pathways' effects on economic aspects, quality of care, treatment transparency, staff satisfaction and staff training. RESULTS: Our search identified 30 studies. Twenty four studies were trials with a before-after design. Four trials had only an intervention group, one trial was a non-randomised controlled trial and one was a randomised controlled trial. Study sizes ranged from six to 1,200 patients. The mean number of patients was 119 in the treatment group and 120 in the comparison group (where existent). Clinical Pathway implementation in surgery has manifold advantages. They improve objective and subjective quality of care, decrease hospitals' costs, increase staff satisfaction and are valuable tools for training. Their effect seems to be most pronounced for high-volume or particularly complex treatments. CONCLUSION: There is substantial evidence that Clinical Pathways lead to various improvements in clinical care in surgery. Their widespread use should therefore be encouraged. However, more research encompassing all facets of Clinical Pathway usage and implying sound methods is strongly required.

Evaluation of MR-angiography for pre-operative assessment of living kidney donors.

INTRODUCTION: Pre-operative magnetic resonance tomography (MR) and MR-angiography (MRA) have rendered favorable results for the assessment of renal anatomy preceding living-related kidney transplantation. However, limited value of MRA in the detection of accessory renal vasculature is reported. METHODS: We compared the results of pre-operative contrast-medium-enhanced MRA of the last 30 consecutively performed nephrectomies in living kidney donors with the intraoperative findings of vascular, parenchymal, and ureteral anatomy. RESULTS: Pre-operative MRA diagnosed a solitary renal artery in 24 cases (80%) and a normal venous, ureteral and parenchymal anatomy in all cases. Intraoperatively, the surgeon confirmed the normal pre-operative MRA findings of ureter and parenchyma. Yet, in 6 out of 30 patients (20%) vascular architecture differed from the pre-operative imaging: four of them, who had a radiologically regular anatomy, were found to have accessory vessels upon surgical preparation. In the fifth patient, MRA revealed an accessory lower polar artery, which was confirmed during surgery. An undiagnosed third arterial vessel, located behind the renal vein, led to an aortic bleeding. In the sixth case, the adrenal gland artery was misinterpreted as an accessory superior polar artery of the kidney in MRA. Additionally, a radiologically undetected inferior polar artery was dissected during nephrectomy and led to partial hypoperfusion of the graft. Subsequent retrospective reevaluation of the MRA by experienced radiologists was unable to identify the intraoperative anatomical discrepancies. Hence, sensitivity of MRA was 60% (6 out of 10 cases) for accessory renal vessel detection and 80% (24 out of 30 cases) for overall sensitivity in determining renal vessel number. DISCUSSION: MRA is a reliable method for the non-invasive investigation of living kidney donors and provides valuable information required by the surgeon. But, as the technique misses small diameter vessels, it cannot be recommended as sole diagnostic tool in unclear cases.

Fishing line suture: cost-saving alternative for atraumatic intracutaneous skin closure--randomized clinical trial in Rwanda.

Experience with the use of nylon fishing line for surgical sutures has been reported from several African countries. A recent publication suggested that fishing line and an injection needle may provide an atraumatic suture that is especially suitable for intracutaneous skin closures. This article provides further empirical support for such alternative technology. We describe a randomized, blinded clinical trial conducted in Butare (Rwanda) with 220 cutaneous wounds closed by intracutaneous sutures, with either the homemade suture or a commercial nylon thread (Ethilon). We compared the clinical outcomes as well as the costs of those two materials. There are no significant differences between the two sutures in terms of clinical findings or in the reported ease of use by the surgeons. The cost of a homemade atraumatic suture is US $0.07, which is less than one-thirtieth the cost of the commercial thread. The advantage of the commercial thread is the assurance of quality. We consider whether this quality assurance justifies the large price difference, and if the homemade suture should be recommended to surgeons in countries where the costs of surgical material often remain an obstacle for life-saving operations.