Surgical management and pathological assessment of pancreatoduodenectomy with venous resection: an international survey among surgeons and pathologists.

BACKGROUND: The aim of this survey was to gain insights in the current surgical management and pathological assessment of pancreatoduodenectomy with portal-superior mesenteric vein resection (VR). METHODS: A systematic literature search was performed to identify international expert surgeons (N = 150) and pathologists (N = 40) who published relevant studies between 2009 and 2019. These experts and Dutch surgeons (N = 17) and pathologists (N = 20) were approached to complete an online survey. RESULTS: Overall, 76 (46%) surgeons and 37 (62%) pathologists completed the survey. Most surgeons (71%) estimated that preoperative imaging corresponded correctly with intraoperative findings of venous involvement in 50-75% of patients. An increased complication risk following VR was expected by 55% of surgeons, mainly after Type 4 (segmental resection-venous conduit anastomosis). Most surgeons (61%) preferred Type 3 (segmental resection-primary anastomosis). Most surgeons (75%) always perform the VR themselves. Standard postoperative imaging for patency control was performed by 54% of surgeons and 39% adjusted thromboprophylaxis following VR. Most pathologists (76%) always assessed tumor infiltration in the resected vein and only 54% of pathologists always assess the resection margins of the vein itself. Variation in assessment of tumor infiltration depth was observed. CONCLUSION: This international survey showed variation in the surgical management and pathological assessment of pancreatoduodenectomy with venous involvement. This highlights the lack of evidence and emphasizes the need for research on imaging modalities to improve patient selection for VR, surgical techniques, postoperative management and standardization of the pathological assessment.

Cost-effectiveness of the prevention of adhesions and adhesive small bowel obstruction after colorectal surgery with adhesion barriers: a modelling study.

Background: Adhesion barriers have proven to reduce adhesion-related complications in colorectal surgery. However, barriers are seldom applied. The aim of this study was to determine the cost-effectiveness of adhesion barriers in colorectal surgery. Methods: A decision-tree model was developed to compare cost-effectiveness of no adhesion barrier with the use of an adhesion barrier in open and laparoscopic surgery. Outcomes were incidence of clinical consequences of adhesions, direct healthcare costs, and incremental cost-effectiveness ratio per adhesion prevented. Deterministic and probabilistic sensitivity analyses were performed. Results: Adhesion barriers reduce adhesion incidence and incidence of adhesive small bowel obstruction in open and laparoscopic surgery. Adhesion barriers in open surgery reduce costs compared to no adhesion barrier ($4376 versus $4482). Using an adhesion barrier in laparoscopic procedures increases costs by $162 ($4482 versus $4320). The ICER in the laparoscopic cohort was $123. Probabilistic sensitivity analysis showed 66% and 41% probabilities of an adhesion barrier reducing costs for open and laparoscopic colorectal surgery, respectively. Conclusion: The use of adhesion barriers in open colorectal surgery is cost-effective in preventing adhesion-related problems. In laparoscopic colorectal surgery, an adhesion barrier is effective at low costs.

The Value of Decision Analytical Modeling in Surgical Research: An Example of Laparoscopic Versus Open Distal Pancreatectomy.

OBJECTIVE: To illustrate how decision modeling may identify relevant uncertainty and can preclude or identify areas of future research in surgery. SUMMARY BACKGROUND DATA: To optimize use of research resources, a tool is needed that assists in identifying relevant uncertainties and the added value of reducing these uncertainties. METHODS: The clinical pathway for laparoscopic distal pancreatectomy (LDP) versus open (ODP) for nonmalignant lesions was modeled in a decision tree. Cost-effectiveness based on complications, hospital stay, costs, quality of life, and survival was analyzed. The effect of existing uncertainty on the cost-effectiveness was addressed, as well as the expected value of eliminating uncertainties. RESULTS: Based on 29 nonrandomized studies (3.701 patients) the model shows that LDP is more cost-effective compared with ODP. Scenarios in which LDP does not outperform ODP for cost-effectiveness seem unrealistic, e.g., a 30-day mortality rate of 1.79 times higher after LDP as compared with ODP, conversion in 62.2%, surgically repair of incisional hernias in 21% after LDP, or an average 2.3 days longer hospital stay after LDP than after ODP. Taking all uncertainty into account, LDP remained more cost-effective. Minimizing these uncertainties did not change the outcome. CONCLUSIONS: The results show how decision analytical modeling can help to identify relevant uncertainty and guide decisions for future research in surgery. Based on the current available evidence, a randomized clinical trial on complications, hospital stay, costs, quality of life, and survival is highly unlikely to change the conclusion that LDP is more cost-effective than ODP.

Quality of life, functional status and adhesiolysis during elective abdominal surgery.

BACKGROUND: Adhesiolysis during abdominal surgery can cause iatrogenic organ injury, increased operative time and a more complicated convalescence. We assessed the impact of adhesiolysis and adhesiolysis-related complications on quality of life and functional status following elective abdominal surgery. METHODS: Prospective cohort study, comparing patients requiring and not requiring adhesiolysis during an elective laparotomy or laparoscopy using the SF-36 and DASI questionnaire scores. RESULTS: 518 patients were included. Pre- and postoperative quality of life did not significantly differ between both groups. Patients with adhesiolysis had a significantly lower pre- and postoperative functional status (p < 0.01). Higher age, concomitant pulmonary disease, postoperative complications, readmissions and chronic abdominal pain 6 months after surgery were all associated with a significant and independent decline in quality of life and functional status six months after surgery. CONCLUSION: Adhesiolysis in itself does not affect functional status and quality of life six months after surgery. Postoperative complications, readmissions and chronic abdominal pain are associated with a lower health status.

In-hospital costs of an admission for adhesive small bowel obstruction.

BACKGROUND: Previous research on the costs of treatment for ASBO is outdated and often based on reimbursements, rather than true healthcare provider costs of the admission and related interventions. An accurate estimate of the true costs of treatment is necessary to understand the healthcare burden and to model cost-efficacy of adhesion strategies. The aim of this study was to provide an accurate cost estimate of the in-hospital costs for treatment of adhesive small bowel obstruction (ASBO) using micro-costing methods. METHODS: Consecutive patients admitted for ASBO to the Radboud University Medical Center from November 2013 to November 2015 were included. An episode of ASBO was defined as an admission for SBO with operative confirmation of adhesions or after radiological exclusion of other causes for SBO. For the purpose of generalization we used the costs of medication and interventions as provided by the Dutch Healthcare Authority and only if these were not available local hospital costs. We evaluated costs separately for operative and non-operative treatment for ASBO. RESULTS: During the study period 39 admissions for ASBO were eligible for analysis. An operative treatment was required in 19 patients (48.7 %). Mean hospital stay for ASBO with operative treatment was 16.0 ± 11 days versus 4.0 ± 2.0 days for non-operative treatment (P = 0.003). A total of 12 patients developed complications, 2 in the non-operative group (10 %) and 10 in the operative group (52.6 %; P = 0.004). Overall costs for an admission for ASBO with operative treatment were €16 305 (SD €2 513), and for non-operative treatment € 2 277 (SD € 265) (p = <0.001). The highest expenditure with operative treatment for ASBO was made for ward stay (mean €7 856, SD €6 882), OR time (mean €2 6845, SD €1 434), ICU stay (mean €2 183, SD €4 305) and (parenteral) feeding costs (mean €1797, SD €2070). A table with correction coefficient to correct for differences in price levels for goods and services between different countries has been added. CONCLUSION: The in-hospital costs of an admission for ASBO are higher than previously thought. These costs can be used to guide hospital reimbursement policy and for the development of a cost-effective model for the use of adhesion barriers.

Impact of Adhesiolysis on Outcome of Colorectal Surgery.

BACKGROUND/AIMS: Adhesiolysis is a frequent part of colorectal surgery, potentially impeding the operation and causing inadvertent bowel injury. Such difficulties might compromise convalescence and oncological quality of resection. The aim of this prospective cohort study was to assess the impact of adhesiolysis on clinical outcomes and histopathological results in colorectal surgery. METHODS: Colorectal procedures were selected from a prospective cohort study of adhesiolysis-related problems. We compared the incidence of bowel injury, morbidity, costs, and the histopathology between patients undergoing elective colorectal surgery with or without adhesiolysis. RESULTS: Two hundred and forty nine colorectal surgeries were analysed. Adhesiolysis was required in 59.0%. The mean adhesiolysis time was 28 min. In the adhesiolysis group, enterotomies occurred in 6.1% and seromuscular injuries in 27.2% compared to 0 and 6.9% respectively in the non-adhesiolysis group (p = 0.012 and p < 0.001). In patients requiring adhesiolysis, 29.9% had major surgery-related complications (MSRC) compared to 15.7% without adhesiolysis (p = 0.007). There were no statistically significant differences regarding inpatient costs and resection margin or number of harvested lymph nodes. CONCLUSIONS: Adhesiolysis during colorectal surgery is related to an increased incidence of iatrogenic bowel injuries and MSRC. Despite the technical challenges associated with adhesiolysis, good histopathological results were obtained in oncological resections.

[Transanal single-port surgery for local excision of rectal tumours]. / Flexibele toegangspoort voor excisie rectumtumoren.

Transanal endoscopic microsurgery (TEM) is the technique of choice for rectum-preserving treatment of rectal tumours. However, the instruments are relatively expensive and TEM is a highly-complex technique. From 2010 a few case reports describing a new technique for local excision of rectal tumours using a single-access laparoscopic port have appeared. These single-access ports are flexible multichannel ports for transumbilical laparoscopic surgery. Even though not developed for transanal use these ports are ideal because of their shape and the material they are made from. Transanal surgery using a single-access port is a relatively simple procedure and does not require any investment in new instruments. This new technique will enable more surgeons to carry out transanal endoscopic surgery.