Esophageal Doppler monitoring during colorectal resection offers cost-effective improvement of hemodynamic control.

OBJECTIVES: Hemodynamic control can improve the outcome of surgery. Esophageal Doppler monitoring measures blood flow by ultrasound waves. This work investigates the cost-effectiveness of this procedure during colorectal resection. METHODS: Meta-analyses of randomized controlled trials of esophageal Doppler monitoring used in colorectal resection were conducted to help determine its cost-effectiveness. An analytical decision model was used to compare the cost-effectiveness of strategies involving conventional clinical assessment with or without the measurement of central venous pressure, with or without esophageal Doppler monitoring. Avoided mortality and avoided major complications were used as measures of clinical effectiveness. RESULTS: In the meta-analyses comparing conventional clinical assessment plus central venous pressure monitoring with or without esophageal Doppler monitoring, statistically significant differences in total and major complications favoring the use of Doppler were found. No differences were seen in mortality. The use of esophageal Doppler monitoring was associated with lower costs, mainly due to fewer complications, shorter hospital stays and shorter surgery times. CONCLUSIONS: Although the information regarding the clinical effectiveness of esophageal Doppler monitoring in colorectal resection is limited, strategies including this form of blood flow monitoring may be cost-effective. Further comparisons of Doppler monitoring against other hemodynamic monitoring systems should be undertaken.

Enhanced recovery in colorectal surgery: a multicentre study.

BACKGROUND: Major colorectal surgery usually requires a hospital stay of more than 12 days. Inadequate pain management, intestinal dysfunction and immobilisation are the main factors associated with delay in recovery. The present work assesses the short and medium term results achieved by an enhanced recovery program based on previously published protocols. METHODS: This prospective study, performed at 12 Spanish hospitals in 2008 and 2009, involved 300 patients. All patients underwent elective colorectal resection for cancer following an enhanced recovery program. The main elements of this program were: preoperative advice, no colon preparation, provision of carbohydrate-rich drinks one day prior and on the morning of surgery, goal directed fluid administration, body temperature control during surgery, avoiding drainages and nasogastric tubes, early mobilisation, and the taking of oral fluids in the early postoperative period. Perioperative morbidity and mortality data were collected and the length of hospital stay and protocol compliance recorded. RESULTS: The median age of the patients was 68 years. Fifty-two % of the patients were women. The distribution of patients by ASA class was: I 10%, II 50% and III 40%. Sixty-four % of interventions were laparoscopic; 15% required conversion to laparotomy. The majority of patients underwent sigmoidectomy or right hemicolectomy. The overall compliance to protocol was approximately 65%, but varied widely in its different components. The median length of postoperative hospital stay was 6 days. Some 3% of patients were readmitted to hospital after discharge; some 7% required repeat surgery during their initial hospitalisation or after readmission. The most common complications were surgical (24%), followed by septic (11%) or other medical complications (10%). Three patients (1%) died during follow-up. Some 31% of patients suffered symptoms that delayed their discharge, the most common being vomiting or nausea (12%), dyspnoea (7%) and fever (5%). CONCLUSION: The following of this enhanced recovery program posed no risk to patients in terms of morbidity, mortality and shortened the length of their hospital stay. Overall compliance to protocol was 65%. The following of this program was of benefit to patients and reduces costs by shortening the length of hospital stay. The implantation of such programmes is therefore highly recommended.

Efficacy of the Da Vinci surgical system in abdominal surgery compared with that of laparoscopy: a systematic review and meta-analysis.

AIM: The main aim of this review was to compare the safety and efficacy of the Da Vinci Surgical System (DVSS) and conventional laparoscopic surgery (CLS) in different types of abdominal intervention. SUMMARY OF BACKGROUND DATA: DVSS is an emerging laparoscopic technology. The surgeon directs the robotic arms of the system through a console by means of hand controls and pedals, making use of a stereoscopic viewing system. DVSS is currently being used in general, urological, gynecologic, and cardiothoracic surgery. METHODS: This systematic review analyses the best scientific evidence available regarding the safety and efficacy of DVSS in abdominal surgery. The results found were subjected to meta-analysis whenever possible. RESULTS: Thirty-one studies, 6 of them randomized control trials, involving 2166 patients that compared DVSS and CLS were examined. The procedures undertaken were fundoplication (9 studies, one also examining cholecystectomy), Heller myotomy (3 studies), gastric bypass (4), gastrectomy (2), bariatric surgery (1), cholecystectomy (4), splenectomy (1), colorectal resection (7), and rectopexy (1). DVSS was found to be associated with fewer Heller myotomy-related perforations, a more rapid intestinal recovery time after gastrectomy-and therefore a shorter hospital stay, a shorter hospital stay following cholecystectomy (although the duration of surgery was longer), longer colorectal resection surgery times, and a larger number of conversions to open surgery during gastric bypass. CONCLUSIONS: The publications reviewed revealed DVSS to offer certain advantages with respect to Heller myotomy, gastrectomy, and cholecystectomy. However, these results should be interpreted with caution until randomized clinical trials are performed and, with respect to oncologic indications, studies include variables such as survival.

Validity of newly developed appropriateness criteria for cataract surgery.

OBJECTIVE: The introduction of phacoemulsification in the early 1990s significantly changed the treatment of cataract. It is possible that appropriateness criteria for cataract extraction developed before the widespread adoption of phacoemulsification no longer is as accurate or valid as possible. The objective of this study was to validate newly developed explicit appropriateness criteria. DESIGN: Prospective, observational cohort study. PARTICIPANTS: Consecutive patients with a diagnosis of cataract who were on waiting lists to undergo cataract extraction by phacoemulsification were recruited. METHODS: Newly developed explicit appropriateness criteria for cataract extraction, following Research and Development methodology, were applied in this study conducted in 17 public teaching hospitals. Data necessary to classify the appropriateness of the intervention, including demographic and clinical data and that related to the surgery and complications, were recorded by previously trained ophthalmologists in all centers before the intervention and at the 6-week visit afterward. MAIN OUTCOME MEASURES: Subjects completed 2 questionnaires that measure health-related quality of life--the Short Form 36 and the Visual Function Index 14 (VF-14)--before the procedure and 3 months afterward. Also, visual acuity was recorded by ophthalmologists previous to the intervention and at 6 weeks after. RESULTS: Five thousand two hundred fifty-seven cases were included in the study. At 3 months after cataract extraction, 4335 (82.5%) patients had responded to the questionnaires. Patients whose procedures were classified as necessary or appropriate by the new appropriateness criteria had greater improvements in visual acuity and VF-14 scores than those undergoing procedures classified as inappropriate. These differences seemed to be clinically relevant by measures such as the minimal clinically important difference and minimal detectable change. Complications rates were similar among all appropriateness categories, except for complications occurring in the peri-intervention period. CONCLUSIONS: These results suggest a direct relationship between the newly developed explicit appropriateness criteria for cataract extraction and outcomes, as measured by clinical evaluation and health-related quality-of-life instruments. The results support the use of these criteria for clinical evaluation or the development of clinical guidelines.

Interhospital variation in appropriateness of cataract surgery.

OBJECTIVE: The aim of this study was to analyse the inter-hospital variation in the appropriateness of cataract phacoemulsification in Spain. METHODS: This observational, multicentre, prospective study involved patients aged 18-90 years. Each phacoemulsification intervention was classified as 'necessary', 'appropriate', 'uncertain' or 'inappropriate' according to explicit appropriateness criteria previously established using the RAND/UCLA methodology. A descriptive statistical analysis was performed, followed by univariate and multivariate logistic regression analysis, in order to examine the differences between hospitals. RESULTS: In total, 5063 patients from 15 hospitals were enrolled. The percentage of patients in each hospital who inappropriately underwent phacoemulsification varied from 1.2% to 24.0% (P < 0.0001). The most common inappropriate scenario was that of patients with a simple, unilateral cataract with no limitation of their visual function, with a pre-surgery visual acuity of ≥ 0.5 in both eyes, and for whom surgical correction would involve low technical complexity. CONCLUSIONS: The variation in appropriateness of phacoemulsification cannot be attributed solely to the clinical differences between the hospitals' patients. There is room for improvement in the appropriate indication of phacoemulsification. Measures based on the dissemination of appropriateness criteria might improve quality of care.

Economic assessment of cardiac resynchronization therapy.

INTRODUCTION AND OBJECTIVES: Cardiac resynchronization devices have been shown to be effective in treating heart failure. They reduce overall mortality, heart failure mortality and hospitalizations due to heart failure. The aim of this study was to compare the cost-effectiveness of cardiac resynchronization therapy (CRT) with that of optimal drug therapy (ODT) by carrying out an economic assessment in the Spanish healthcare setting. METHODS: An existing model was adapted for use in the Spanish healthcare setting. The effectiveness of cardiac resynchronization therapy was determined from published systematic reviews. The costs of the various interventions were determined using a range of Spanish data sources. The model adopted the perspective of the public health system and the time horizon considered was the remainder of the patient's life. The outcome variables were life-years gained and quality-adjusted life-years (QALYs) gained. RESULTS: Overall, ODT, CRT and CRT with a defibrillator resulted in gains of 2.11, 2.8 and 3.19 QALYs, respectively, at a cost of €11,722, €31,629 and €52,592, respectively. Consequently, each QALY gained with CRT relative to ODT involved the consumption of €28,612 of additional resources. Similarly, the use of CRT with a defibrillator cost an additional €53,547 per QALY relative to CRT without a defibrillator. CONCLUSIONS: The use of CRT without a defibrillator could be a cost-effective alternative to ODT for treating heart failure in a carefully selected group of patients. The study results were sensitive to uncertainties in many of the variables used in the model.

Laparoscopic hysterectomy in the treatment of endometrial cancer: a systematic review.

We sought to compare the safety and efficacy of laparoscopic hysterectomy and bilateral salpingo-oophorectomy with or without lymphadenectomy and open surgery in women with endometrial cancer. A systematic review of the literature was undertaken. Bibliographic searches of the Health Technology Assessment, National Health Service Economic Evaluation, DARE, Cochrane Database of Systematic Reviews, MEDLINE, Embase, Pascal Biomed, and Cinahl databases were made. This study sought to include systematic reviews, health technology assessment reports, and randomized clinical trials comparing laparoscopic surgery (LS) with open surgery for the treatment of endometrial cancer. The quality of the included studies was assessed using a clinical trial checklist. The clinical studies finally included were 4 randomized clinical trials. The short-term results described show that LS offers advantages with respect to postoperative recovery, including reduced bleeding, a need for fewer days of intravenous fluid therapy, and a reduced need for pain killers. In addition, intraoperative and postoperative complications were fewer among those who underwent LS in all the studies consulted. The mean hospital stay of those who underwent LS was 3 to 4 days shorter, and they returned to normal activity sooner. The number of lymph glands resected was the same with both techniques. The LS was associated with a better quality of life after surgery. With respect to long-term results, no significant differences were found in relation to overall, disease-free or cause-specific survival, according to 1 study. The short-term results of LS are equivalent or better than those achieved with open surgery, whereas the long-term results obtained by both seems equivalent but more studies are needed assessing this outcome.