Assessment of quality-of-care indicators for colorectal cancer surgery at a single centre in a developing country.

BACKGROUND: The implementation of quality-of-care indicators aiming to improve colorectal cancer (CRC) outcomes has been previously described by Cancer Care Ontario. The aim of this study was to assess the quality-of-care indicators in CRC at a referral centre in a developing country and to determine whether improvement occurred over time. METHODS: We performed a retrospective study of our prospectively collected database of patients after CRC surgery from 2001 to 2016. We excluded patients who underwent local transanal excision, pelvic exenteration or palliative procedures. We evaluated trends over time using the Cochran-Armitage test for trend. RESULTS: A total of 343 patients underwent surgical resection of CRC over the study period. There was improvement of the following indicators over time: the proportion of patients detected by screening (p = 0.03), the proportion of patients with preoperative liver imaging (p = 0.001), the proportion of patients with stage II or III rectal cancer who received neoadjuvant chemotherapy (p = 0.03), the proportion of patients with pathology reports that indicated the number of lymph nodes examined and the number of positive nodes (p = 0.001), and the proportion of patients with pathology reports describing the details on margin status (p = 0.001). CONCLUSION: This study showed the feasibility of applying the Cancer Care Ontario indicators for evaluating outcomes in CRC treatment at a single centre in a developing country. Although there was an improvement of some of the quality-of-care indicators over time, policies and interventions must be implemented to improve the fulfillment of all indicators.

CONTEXTE: Action Cancer Ontario a déjà décrit l'application d'indicateurs de la qualité des soins dans le but d'améliorer l'issue du cancer colorectal (CCR). Le but de cette étude était d'évaluer les indicateurs de la qualité de soins pour le CCR dans un centre de référence d'un pays en voie de développement et de déterminer si des améliorations ont pu être observées avec le temps. MÉTHODES: Nous avons procédé à une étude rétrospective de notre base de données recueillies prospectivement auprès de patients ayant subi une chirurgie pour CCR entre 2001 et 2016. Nous avons exclu les patients qui ont subi une exérèse transanale locale, une exentération pelvienne ou des traitements palliatifs. Nous avons évalué les tendances au fil du temps à l'aide du test Cochran­Armitage pour dégager les tendances. RÉSULTATS: En tout, 343 patients ont subi une résection chirurgicale de CCR au cours de la période de l'étude. On a noté une amélioration des indicateurs suivants au fil du temps : proportion de patients ayant subi un dépistage (p = 0,03), proportion de patients ayant subi des épreuves d'imagerie hépatique préopératoires (p = 0,001), proportion de patients atteints d'un cancer rectal de stade II ou III ayant reçu une chimiothérapie néoadjuvante (p = 0,03), proportion de patients dont les rapports d'anatomopathologie indiquaient le nombre de ganglions lymphatiques examinés et le nombre de ganglions positifs (p = 0,001) et proportion de patients dont les rapports d'anatomopathologie décrivaient le statut des marges (p = 0,001). CONCLUSION: Cette étude a démontré l'applicabilité des indicateurs d'Action Cancer Ontario pour évaluer les résultats du traitement pour CCR dans un seul centre d'un pays en voie de développement. Même si certains des indicateurs de la qualité des soins se sont améliorés au fil du temps, il faut appliquer des politiques et des interventions pour améliorer tous les indicateurs.

Safety assessment of the use of ultrasonic energy in the proximity of the recurrent laryngeal nerve in a porcine model.

BACKGROUND: Advanced bipolar and ultrasonic energy have demonstrated reduction of operating time and blood loss in thyroidectomy. However, these devices generate heat and thermal dispersion that may damage adjacent structures such as the recurrent laryngeal nerve (RLN). This study was designed to evaluate the safety profile of the Harmonic Focus+® (HF+) device through the evaluation of thermal injury to the RLN using different algorithms of distance and time with state of the art technology. METHODS: 25 Vietnamese pigs underwent activation of HF+ in the proximity of their RLN. They were divided into 4 groups according to activation distance (3 mm, 2 mm, 1 mm and on the RLN). Time of activation, time between tones of the ultrasonic generator, changes in the electromyographic signal using continuous nerve neuromonitoring, vocal fold mobility assessed by direct laryngoscopy and histological thermal damaged were evaluated. RESULTS: None of the pigs had loss of signal in the electromyography during the procedure; only one pig had isolated transient decrease in amplitude and one increase in latency. One pig had transient vocal fold paresis in the group with activation on the nerve. Evaluation of the nerves by histology and immunohistochemistry did not show significant changes attributed to thermal injury. CONCLUSIONS: The use of ultrasonic energy close to the RLN is safe, provided that activation time does not exceed the necessary time to safely transect the tissue.

Assessment of two different diagnostic guidelines criteria (National Cholesterol Education Adult Treatment Panel III [ATP III] and International Diabetes Federation [IDF]) for the evaluation of metabolic syndrome remission in a longitudinal cohort of patients undergoing Roux-en-Y gastric bypass.

BACKGROUND: Bariatric surgery has proven to provide durable weight loss and control of comorbid conditions, including the metabolic syndrome (MS). Existing definitions of MS have caused substantial confusion regarding their concordance for identifying the same individuals. The aim of this study was to assess the value of 2 different diagnostic guidelines criteria (National Cholesterol Education Adult Treatment Panel III [ATP III] and International Diabetes Federation [IDF]) for the evaluation of remission of MS after Roux-en-Y gastric bypass (RYGB). PATIENTS AND METHODS: A cohort of 381 patients who underwent a primary RYGB, satisfied the criteria for MS, and had at least o1 postoperative visit were selected. Weight loss and MS remission were analyzed 6 and 12 months after surgery by ATP III and IDF criteria. RESULTS: Before surgery, 381 (48.9%) and 354 (45.4%) patients fulfilled the criteria for MS according to the ATP III and IDF, respectively. According to the ATP III definition, remission of MS after bariatric surgery occurred in 209 of 239 (87.4%) and 98/102 (96.1%) patients at 6 and 12 months, respectively. According to the IDF definition, this occurred in 180 of 232 (77.6%) and 54 of 64 (84.4%) at the same time periods. On the basis of different percentage of excess body weight loss cut-off values, the area under the curve in receiver operating characteristic analysis at 12 months was slightly better for ATP III (0.77) than IDF criteria (0.68) for remission of MS. CONCLUSIONS: With the use of the IDF definition, the remission rate of MS was 10% more rigorous than with use of the ATP-III criteria. This feature is attributable to a greater discrimination of patients with high blood pressure, glycemia, and dyslipidemia. The IDF criteria seem more accurate to evaluate MS remission.

Evaluation of spirometric testing as a routine preoperative assessment in patients undergoing bariatric surgery.

BACKGROUND: The value of spirometry as a routine preoperative test for bariatric surgery is debatable. The aim of this study was to assess the relationship between spirometry results and the frequency of postoperative pulmonary complications in 602 obese patients. METHODS: Clinical files of patients undergoing bariatric surgery between 2004 and 2013 were reviewed. Demography, risk factors, respiratory symptoms, and spirometry results (forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), FEV1/FVC) were recorded, and their relationship with postoperative pulmonary complications was evaluated. RESULTS: There were 256 males and 346 females with a mean age of 40.2 ± 11.6 years and a mean BMI of 42.1 ± 6.4 kg/m2. History of smoking was found in 408 patients (68 %). Preoperative respiratory symptoms were present in 328 (54.5 %). Most frequent symptoms were snoring (288), dyspnea (119), bronchospasm [6], and chronic productive cough [6]. In 153 patients, history of respiratory disease was documented. The obstructive sleep apnea syndrome (OSAS) was present in 124, 20 requiring continuous positive airway pressure (CPAP). Asthma was present in 27 and chronic obstructive pulmonary disease (COPD) in 2. Variables associated to a higher risk of pulmonary complications were OSAS (OR 2.3), an abnormal spirometry (OR 2.6), male gender (OR 1.9), and preoperative respiratory symptoms (OR 1.9). Using multivariate logistic regression, an abnormal spirometry was a significant predictor of postoperative pulmonary complications in patients with respiratory symptoms and/or OSAS. However, it lost prognostic significance when both conditions were subtracted. CONCLUSIONS: In obese patients undergoing bariatric surgery, abnormal preoperative spirometry predicts postoperative respiratory complications only in patients with OSAS.