Original Article: The impacts of DRG payment system on financial balance of multiple trauma: Experiences of three trauma centers in Taiwan.

INTRODUCTION: There are concerns regarding the adequacy of applying the diagnosis-related groups (DRG) payment system for multiple traumas (i.e., major diagnostic category 24, MDC-24) patients in Taiwan. Therefore, this study used a multi-center dataset to assess the influence of the DRG payment system on the cost and outcome of multiple trauma care. MATERIALS AND METHODS: We collected data of all multiple trauma patients from the Trauma Registry of three hospitals from 2014 - 2017. Next, we selected patients who met the criteria of MDC-24 and calculated the corresponding DRG payment. Subsequently, we combined the clinical care information with health insurance information to analyze the problems of applying the DRG payment system to multiple trauma care. RESULTS: Overall, of 465 cases, 367 met the criteria of MDC-24, and the mean injury severity score (ISS) was high (average 20.1). The total deficit of the polytrauma DRG cases amounted to 131,445 USD, and the average deficit in each case was 397 USD. In the multivariable analysis, higher revised trauma score and specific lower abbreviated Injury Scale (AIS) scores in certain body regions resulted in profits, while increased length of stay in intensive care units, longer operative time, and higher AIS score in the thorax were significantly correlated with deficits in medical costs. CONCLUSION: Our study revealed that the current DRG payment system results in financial losses for hospitals. Further, the payment grouping of MDC-24 should consider adding more disease severity factors to reduce the financial constraints faced by trauma centers.

The preventability of trauma-related death: A two-year cohort study in a trauma center in middle Taiwan.

INTRODUCTION: The preventable death rate (PDR) is an important parameter in the quality assurance of traumatic care. Medical errors or untimely management may occur during stressful trauma care, resulting in preventable deaths. We aimed to develop an applicable PDR model in a trauma center in middle Taiwan. MATERIALS AND METHODS: We identified adult trauma-related deaths which occurred from January 1, 2018 to December 31, 2019 at our hospital. Patients with a trauma and injury severity score (TRISS) <75% or ≥75% but with a chance of preventability, as determined by a trauma surgeon, were discussed by a panel comprising an emergency physician and surgeons specializing in different fields of medicine. Deaths were subsequently classified as definitely preventable (DP), potentially preventable (PP), or non-preventable (NP). Causes of DP or PP deaths were categorized as delayed diagnosis, delayed treatment, technical error, or inadequate infection prevention/control. The relationship between the time and cause of preventable deaths was also analyzed. RESULTS: This study included 127 trauma-related deaths, of which 39 were discussed by the panel. Eight patients (6.3%) were categorized as DP, eight (6.3%) as PP, and 111 (87.4%) as NP. Among patients with preventable deaths, inadequate infection prevention/control, delayed treatment, delayed diagnosis, and technical error were identified in six (37.5%), five (31.2%), three (18.8%), and two (12.5%) patients, respectively. Four patients in the inadequate infection prevention/control group (4/6, 66.7%) died of aspiration pneumonia during the recovery phase. CONCLUSION: A PDR evaluation model was developed and revealed that postoperative care is as important as a timely diagnosis and treatment to avoid preventable deaths following trauma.

Initial management of esophageal anastomotic strictures after transhiatal esophagectomy for esophageal cancer with dilations up to 18-20 mm.

INTRODUCTION: Esophageal anastomotic stricture is a well-known complication after transhiatal esophagectomy (THE), but there is limited data regarding the initial management and subsequent outcomes after stricture dilation. There is concern that dilating to larger diameters upon the initial encounter, specifically with high-grade strictures, will lead to increased risk for complications. We therefore reviewed one surgeon's experience with esophageal dilations after THE and provided data and treatment recommendations based upon these findings. METHODS: A retrospective review of patients who underwent esophageal dilations ≥ 18 mm up to 20 mm after THE between 2006 and 2019 at our institution was performed. Patient demographics were n = 97, age = 70, 81 males. RESULTS: For all cases, the mean location, length, diameter of the stricture, and number of days from surgery and initial dilation were 20 cm, 1.9 cm, 6.7 mm, and 106 days, respectively. Most dilations (79%) occurred within 2 weeks to 3 months from surgery. 29.9% were dilated up to 18 mm, 10.3% were dilated up to 19 mm, and 59.8% were dilated up to 20 mm upon initial dilation. Even 1-mm-diameter lesions could be safely dilated upon 18-20 mm. In this study group there were no complications after endoscopic dilation that required hospitalization or further surgical or endoscopic interventions. CONCLUSION: These results suggest that early aggressive endoscopic management of esophageal anastomotic strictures after THE can be safely performed.

Is robotic hepatectomy cost-effective? In view of patient-reported outcomes.

BACKGROUND: Robotic hepatectomy has been accepted as an alternative for patients needing surgery. However, few reports addressed the patient-reported outcomes and long-term quality of life (QoL) of patients having undergone robotic liver surgery. METHODS: This study presented the QoL and cost-effectiveness associated with robotic and open hepatectomy by performing a comparative survey using two standardized questionnaires (Short Form-36 and Gastrointestinal Quality of Life Index). RESULTS: One hundred patients completed the study. The robotic group tended to experienced longer operation time but shorter length of hospital stay compared to open group. Moreover, the robotic group had faster return to daily activities, less need of patient-controlled anesthesia, and less wound-related complaints in long-term follow-up. The robotic group incurred higher peri-operative expenses; however, the cost of inpatient care was lower. CONCLUSIONS: Our study suggested that robotic hepatectomy provided good post-operative QoL and recovery of daily activity. However, efforts for lowering the financial burden of medical care by reducing the cost of robotic surgery is necessary for further application.

Robotic-assisted right posterior segmentectomies for liver lesions: single-center experience of an evolutional method in left semi-lateral position.

Despite the popularity of minimally invasive surgery (MIS) for hepatectomy, limitations in the approach of the right posterior section of the liver remain. Although skills and approach techniques have been developed for hepatectomy of lesions in the posterior segments of the liver, most are performed laparoscopically and are limited to few experienced hands using rigid laparoscopic instruments. In this study, we tried a different approach area via the aid of a flexible robotic system. Since 2012, we have successfully completed more than 200 robotic hepatectomy procedures in our institution. Two different patient settings have been applied for right posterior segment lesions, including supine position as general setting in early cases and left semi-lateral decubitus setting in our later cases. The demographic data and perioperative outcomes between the two groups were analyzed in regard to different positioning. A total of 25 patients with right posterior segment lesions underwent robotic-assisted resection, 13 were placed in supine position and 12 in left semi-lateral position. The left semi-lateral group had significantly shorter operation time (306.0 versus 416.8 min, p = 0.023), less blood loss (203.9 versus 1092.3 mL, p = 0.030), and lower transfusion rates (0 versus 46.2%, p = 0.015). We described an evolutionary technique for robotic right posterior segmentectomies with the patient placed in left semi-lateral position. This method can be applied for most patients easily and is demonstrated as a safe and feasible approach in selected patients owing to its ability to overcome the difficulty of MIS hepatectomy for right posterior lesions.

[Mineral composition analysis and hemostatic effect of limonitum with different mineral genesis].

Models were established in mice with warfarin sodium method, and their bleeding time and hemostasis time were measured by tail cutting method and slide method respectively. Rats were administered for 15 consecutive days to measure their recalcification time, plasma viscosity, platelet adhesion rate, platelet aggregation rate and other blood indexes. As compared with the blank group, the bleeding time was prolonged in model groupn(P<0.05). As compared with the model group, the results showed that the positive vitamin K, the leaching type water decoction and the sediment type decoction could significantly shorten the bleeding time (P<0.01); positive vitamin K significantly (P<0.01) shortened clotting time, and the leaching type water decoction, the sediment type water decoction and the sediment type powder could also shorten the clotting time (P<0.05). As compared with blank group, low dose, medium dose of leaching type water decoction, medium dose of powder, high dose of sediment type decoction and low dose of drug residues could reduce plasma viscosity (P<0.05), and high dose of leaching powder and low dose of water decoction could significantly reduce (P<0.01) plasma viscosity. As compared with blank group, Limonitum leaching type decoction high dose group could significantly reduce the platelet adhesion rate (P<0.05), while sediment type water decoction could significantly increase the platelet adhesion rate (P<0.05); the high dose of leaching type water decoction, high dose of drug residues, low dose of leaching type powder and low dose of drug residues could decrease the platelet aggregation rate (P<0.05), while high dose of leaching type water decoction and high dose of the powder could increase the platelet aggregation rate (P<0.05). Analysis of mineral compositions was conducted by polarized light microscopy and X-ray diffraction (XRD). The results of the both methods showed that Limonitum mineral compositions contained goethite, quartz, and kaolinite, and sedimentary type also contained illite and albite. Sediment type of Limonitum showed better hemostatic effect, which may be related to the high content of goethite and illite.

Robotic Versus Open Hepatectomy for Hepatocellular Carcinoma: A Matched Comparison.

BACKGROUND: Robotic hepatectomy has been suggested to be a safe and effective approach for liver disease; however, studies comparing robotic hepatectomy with the conventional open approach regarding oncologic outcomes for hepatocellular carcinoma (HCC) are limited. Accordingly, we performed a matched comparison of surgical and oncological outcomes between robotic and open hepatectomy. METHODS: Between January 2012 and October 2015, a total of 183 patients underwent robotic hepatectomy and 275 patients underwent open hepatectomy by the same surgical team in our center. Eighty-one newly diagnosed HCC cases in each group were compared under propensity score matching (PSM) in a 1:1 ratio. RESULTS: With robotic hepatectomy, the conversion rate was 1.6 % and the complication rate was 4.4 %. On PSM, the groups had a comparable percentage of major liver resections (41.9 vs. 39.5 %) and liver cirrhosis (45.7 vs. 46.9 %). Compared with the open group, the robotic group required longer operation times (343 vs. 220 min), shorter hospital stays (7.5 vs. 10.1 days), and lower dosages of postoperative patient-controlled analgesia (350 vs. 554 ng/kg). The 3-year disease-free survival of the robotic group was comparable with that of the open group (72.2 % vs. 58.0 %; p = 0.062), as was the 3-year overall survival (92.6 vs. 93.7 %; p = 0.431). CONCLUSIONS: This is the first oncological study comparing robotic liver resection for HCC with open resection. Robotic hepatectomy can be applied for challenging major resections in patients with cirrhotic liver disease with less postoperative pain and shorter hospital stays without compromising oncological outcomes.

Robotic liver donor right hepatectomy: A pure, minimally invasive approach.

Right hepatectomy for a living liver donor via a pure minimally invasive approach is a challenging procedure and only a few cases have been reported. Between May 2013 and August 2015, 13 patients underwent robotic living donor right hepatectomy in our institute, and 54 patients received open surgery. In this series, no conversion was conducted for robotic donor right hepatectomy. The 2 groups shared similar blood loss (169 versus 146 mL), complication rates (7.7% versus 9.3%), and recovery of donor liver function (peak alanine aminotransferase, 269 versus 252 IU/mL). The robotic group needed longer operation time (596 versus 383 minutes) but less postoperative patient-controlled analgesia (0.58 versus 0.84 ng/kg) and a shorter period before returning to work/school (52.9 versus 100.0 days) and sex (100.0 versus 156.0 days). For recipient outcomes regarding the donor procedure, the robotic group shared similar experiences in early allograft dysfunction, complications, and 1-year recipient liver function with the open group. With respect to documented benefits of minimally invasive left-sided liver donor procedure, the development of right donor hepatectomy is slow. In conclusion, with substantial improvements in patient recovery after the minimally invasive approach, the robotic platform would be a big step toward completing pure minimally invasive liver donor surgery. Liver Transplantation 22 1509-1518 2016 AASLD.

Endoscopy training in Canadian general surgery residency programs.

Currently, general surgeons provide about 50% of endoscopy services across Canada and an even greater proportion outside large urban centres. It is essential that endoscopy remain a core component of general surgery practice and a core competency of general surgery residency training. The Canadian Association of General Surgeons Residents Committee supports the position that quality endoscopy training for all Canadian general surgery residents is in the best interest of the Canadian public. However, the means by which quality endoscopy training is achieved has not been defined at a national level. Endoscopy training in Canadian general surgery residency programs requires standardization across the country and improved measurement to ensure that competency and basic credentialing requirements are met.

Outcomes following endovascular or open repair for ruptured abdominal aortic aneurysm in a Chinese population.

To determine whether emergent endovascular repair (eEVAR) can be an alternative for anatomically suitable ruptured abdominal aortic aneurysms (RAAA) in a Chinese population compared to open aneurysm repair (OAR), 36 patients with RAAA undergoing either OAR or eEVAR in National Taiwan University Hospital from 2005 to 2012 were analyzed retrospectively. Thirty-five (97.2 %) patients were treated. Among them, 20 (57.1 %) were treated by OAR and 15 (42.9 %) by eEVAR. The overall 30-day survival rate was 77.1 %. There was no significant difference in 30-day mortality rate (OAR 15.0 % vs. eEVAR 33.3 %, p = 0.201) and midterm mortality rate (OAR 20.0 % vs. eEVAR 46.7 %, p = 0.093) between these two groups. On univariate analysis, free peritoneal rupture (p < 0.001), pre-operative shock (p = 0.001) and female gender (p = 0.016) are related to a higher 30-day mortality rate, while free peritoneal rupture (p = 0.012) and pre-operative shock (p = 0.030) are associated with a higher midterm mortality rate in both repair techniques. On multivariate analysis, free peritoneal rupture was associated with higher 30-day (OR 26.0, 95 % CI 2.2-295.6, p = 0.009) and midterm (OR 13.1, 95 % CI 1.2-37.6, p = 0.032) mortality rates. In patients with RAAA, there is no significant difference in 30-day mortality and midterm mortality between eEVAR and OAR groups in our study. eEVAR could be an alternative therapy for anatomically suitable RAAA in a Chinese population.

[Project to improve the free flap survival rate in oral cancer microreconstruction free flap surgery].

BACKGROUND&PROBLEMS: Free-flap thrombosis risk factors affect the success of microreconstruction surgery that involves the use of a free flap. The free flap survival rate in our unit was 92.65%. Relevant risk factors identified included: (1) poor nursing assessment cognizance and low accuracy rates; (2) lack of standardized of postoperative monitoring protocols; (3) lack of assessment tools; (4) inadequate inter-team communication; and (5) lack of a free flap care monitoring audit. PURPOSE: The purpose of this project was to improve the free flap survival rate from 92.65% to at least 97%. RESOLUTIONS: The authors: (1) held relevant educational training programs; (2) evaluated nurse skills in clinical settings; (3) established a standardized nursing monitoring protocol; (4) provided sufficient assessment equipment; (5) improved inter-team communication mechanisms; and (6) formulated a monitoring audit protocol. RESULTS: The free flap survival rate rose from 92.65% to 100%, with no failed flaps during the assessment period December 2011 to May 2012. CONCLUSIONS: The resolutions proposed by this project may significantly improve the free flap survival rate.

Role of progesterone in TLR4-MyD88-dependent signaling pathway in pre-eclampsia.

The role of progesterone in the Toll-like receptor 4 (TLR4)-MyD88-dependent signaling pathway in pre-eclampsia was studied. Peripheral blood mononuclear cells (PBMCs) from pre-eclampsia (PE) patients were subjected to primary culture, and stimulated with different concentrations of progesterone (0, 10(-8), 10(-6), and 10(-4) mol/L). The mRNA expression of TLR4, MyD88 and nuclear factor-kappaB (NF-κB) was detected by using real-time PCR. The Ikappa-B protein expression was detected by using Western blotting. The expression of tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) in the supernatant was determined by using ELISA. With the concentrations of progesterone increasing, the mRNA expression levels of TLR4, MyD88 and NF-κB in 2(-ΔΔCT) value were significantly decreased, and the IkappaB protein expression levels were significantly increased. The TNF-α and IL-6 expression showed a downward trend when the progesterone concentration increased, and there were significant differences among all of the groups (P<0.05). It was suggested that progesterone can inhibit the TLR4-MyD88-dependent signaling pathway in PE significantly and benefit for the pregnancy.

Analysis of the risk factors of untransplantable recurrence after primary curative resection for patients with hepatocellular carcinoma.

PURPOSE: To determine the prognostic factors that predict recurrence of hepatocellular carcinoma (HCC) exceeding the University of California at San Francisco (UCSF) criteria after primary resection. METHODS: HCC patients who underwent curative liver resections between 2001 and 2007 and who were within the UCSF criteria (n = 716) were examined. Independent prognostic factors were examined by the Cox proportional hazard model. RESULTS: A total of 285 patients (39.8 %) developed recurrences. Of the patients who developed recurrences, 180 had HCC still within the UCSF criteria (63.2 %), and 105 developed HCC beyond this criteria (36.8 %). Among the population with primary transplantable HCC, patients with larger primary tumor sizes, serum α-fetoprotein (AFP) levels over 400 ng/mL, satellite nodules, vascular invasion, or undifferentiated HCC had a risk of untransplantable recurrence, as shown by univariate analysis. In multivariate analysis, undifferentiated HCC and vascular invasion were identified as the significant predictors with adjusted hazard ratios of 9.25 [95 % confidence interval (CI) 2.13-40.21] and 2.19 (95 % CI 1.34-3.58), respectively. When only preoperative factors were considered in multivariate analysis, primary tumor size and serum AFP levels over 400 ng/mL were identified as significant predictors with adjusted hazard ratios of 1.24 (95 % CI 1.07-1.45) and 1.72 (95 % CI 1.05-2.82), respectively. CONCLUSIONS: For primary HCC patients within the UCSF criteria, larger tumor sizes and AFP levels over 400 ng/mL were associated with postresection recurrence of HCC exceeding the UCSF criteria. Because these are clearly markers for aggressive tumor biology, whether early primary transplant will alter the aggressive tumor behaviors warrant further investigation.

MR imaging of human pancreatic cancer xenograft labeled with superparamagnetic iron oxide in nude mice.

The aim of this work was to investigate the MRI findings on tumor xenografts induced in nude mice by the inoculation of human pancreatic cancer cells labeled with superparamagnetic iron oxide (SPIO), and to monitor the kinetics of SPIO distribution in tumor xenografts. The labeled cancer cells were subcutaneously inoculated into 11 nude mice to induce tumor xenograft. The unlabeled cancer cells served as a control inoculated into nine nude mice. MR imaging was performed with a 1.5 T MR scanner for the tumor xenograft at the first, second and third week after the inoculation. We found that the tumor xenograft was induced in 100% nude mice on MR imaging for both groups in the first week after the inoculation. In the SPIO group, the tumors showed homogeneous hypointensity on T1 - and T2 -weighted and FIESTA images 1 week after inoculation. Two and 3 weeks after inoculation, the center of the tumors was still hypointense on all the above sequences. The tumor periphery was isointense on T1 -weighted, and hyperintense on T2 -weighted and FIESTA images. The tumors in control group were homogeneously hypointense or isointense on T1 -weighted, and hyperintense on T2 -weighted and FIESTA images in the first, second and third week after the inoculation. The size and signal-to-noise ratio of the tumor center in the SPIO group had decreased subsequent to the inoculation in all T1 - and T2 -weighted images and FIESTA. Our results showed the human pancreatic cancer cells labeled with SPIO can induce tumor xenograft in nude mice and MRI can monitor the kinetics of SPIO distribution in tumor xenografts.

Magnetic resonance imaging for pancreatic ductal adenocarcinomas induced by N-nitrosobis (2-oxopropyl) amine in Syrian golden hamsters.

OBJECTIVES: This study aimed to study magnetic resonance imaging (MRI) findings of pancreatic ductal adenocarcinomas (PDAs) induced by N-nitrosobis (2-oxopropyl) amine (BOP) in Syrian hamsters. METHODS: A total of 101 female hamsters, 8 weeks old, were randomized into 3 groups. They were randomized into a BOP-treated group (n = 80; with weekly subcutaneous injections of BOP [10 mg/kg body weight] for 7 consecutive weeks), a saline-treated group (n = 16), and an untreated group (n = 5). Hamsters underwent abdominal MRI on 1.5-T MR scanners with a dedicated animal radiofrequency coil. Findings of the tumor from the MRI were compared those from histology. RESULTS: Pancreata in the saline-treated and in the untreated groups were normal. In the BOP-treated group, there were 23 and 31 BOP-induced PDAs on macroscopy and microscopy, respectively. Of the PDAs detected on macroscopy, 65.2% were depicted on MRI. As early as 13 and 19 weeks after the first injection of BOP, PDAs in hamsters were found on histology and MRI, respectively. Moreover, the tumor volume on MRI was correlated with the tumor weights excised (r = 0.96, P = 0.000, n = 15). CONCLUSIONS: N-nitrosobis (2-oxopropyl) amine successfully induced PDAs in hamsters. Magnetic resonance imaging has the ability to detect healthy pancreas and PDAs in hamsters and has the potential to monitor the development of PDAs.

[Effects of epidural ropivacaine labor analgesia on duration of labor and mode of delivery].

OBJECTIVE: To study the effects of ropivacaine on the duration of labor and mode of delivery in the primigravidas using patient-controlled epidural analgesia (PCEA). METHODS: Retrospective analysis was performed. The 190 healthy, full-term, and single-fetus parturient primigravidas who received PCEA with 0.1% ropivacaine + fentanyl (1 microg/ml) were in the epidural analgesia group. Another 222 primigravidas who did not receive PCEA were in the control group. The duration of labor and modes of delivery, and the neonatal Apgar scores in both two groups were recorded and evaluated. RESULTS: Those in the epidural analgesia group experienced a significantly longer first stage [(426 +/- 161) minutes], longer second stage [(54 +/- 27) minutes] and longer full duration of delivery [(489 +/- 166) minutes] than those in the control one [(409 +/- 170) minutes, (364 +/- 167) minutes and (37 +/- 22) minutes]. The rate of using pitocin in the epidural analgesia group (30.2%) was significantly higher than that in the control group (4.1%). The cesarean section rate in epidural analgesia group (20.0%) was lower than that in the control one (28.4%); while the rate of instrumental delivery in the epidural analgesia group (20.0%) was significantly higher than that in the control one (6.3%). In summary, there were significant differences between two groups in the duration of labor, the rate of using pitocin, the rate of instrumental delivery and the rate of cesarean section. But there were no differences found for those newborn who had Apgar scores less than 7 at the point of both one and five minutes (7.9% and 4.5%, 2.6% and 0.5% respectively). CONCLUSION: Epidural ropivacaine labor analgesia lengthens the duration of labor and increases the rate of instrumental delivery, but it has no significant negative effects on the neonates.