Surgical quality indicators in low-resource settings: A new evidence-based tool.

BACKGROUND: Worldwide efforts to improve access to surgical care must be accompanied by improvements in the quality of surgical care; however, these efforts are contingent on the ability to measure quality. This report describes a novel, evidence-based tool to measure quality of surgical care in low-resource settings. METHODS: We defined a widely applicable, multidimensional conceptual framework for quality. The suitability of currently available quality metrics to low-resource settings was evaluated. Then we developed new indicators with sufficient supportive evidence to complete the framework. The complete set of metrics was condensed into four collection sources and tools. RESULTS: The following 15 final evidence-based indicators were defined: (1) Safe structure: morbidity and mortality conference; (2) safe process: use of the safe surgery checklist; (3) (4) safe outcomes: perioperative mortality rate and proportion of cases with complications graded >2 on the Clavien-Dindo scale; (5) effective structure: provider density; (6) effective process: procedure rate; (7) effective outcome: rate of caesarean sections; (8) patient-centered process: use of informed consent; (9) patient-centered outcome: patient hospital satisfaction questionnaire; (10) timely structure: travel time to hospital; (11) timely process: time from emergency department presentation to non-elective abdominal surgery; (12) timely outcome: patient follow-up plan; (13) efficient process: daily operating room usage; (14) equitable outcome: comparative income of patients compared with population; and (15) proportion of patients facing catastrophic expenditure because of surgical care. CONCLUSION: This tool provides an evidence-based conceptual tool to assess the quality of surgical care in diverse low-resource settings.

A peripheral blood biomarker estimates probability of survival: the neutrophil-lymphocyte ratio in noncancer patients.

AIM: Inflammatory biomarkers are associated with aging and disease-specific outcomes. We propose neutrophil-lymphocyte ratio (NLR) informs survival in a noncancer-bearing population. PATIENTS & METHODS: Retrospective cohort study of patients with a noncancer diagnosis. Calculation of NLR, ascertainment of age, gender, race, cardiovascular disease and diabetes status, and association with survival was determined. RESULTS: Elevated NLR was associated with worse overall survival, independent of age, gender and comorbid status. Overall survival was significantly worse for patients with high versus low NLR. CONCLUSION: Elevated NLR is associated with worse overall survival in noncancer patients. It remains unclear whether NLR reflects an acute inflammatory state, depressed host immune competence or both. NLR may simply be another predictor of survival, or potentially a modifiable risk factor.

Outcomes of the Memorial Sloan Kettering Cancer Center International General Surgical Oncology Fellowship.

BACKGROUND: Training of foreign medical graduates in surgical oncology is an undervalued intervention for improving global cancer care. The aim of this work was to describe the design and results of a clinical training program for international surgeons from a single comprehensive cancer center. STUDY DESIGN: Of 39 international fellows trained during 20 years, 34 were surveyed about education, research, and current context of surgical practice. A citation and H-index calculation (ie h number of publications that each has at least h citations) was performed to assess scientific productivity of each graduated fellow. RESULTS: Twenty-one of 39 (54%) fellows came from countries in which English is not the primary language. Europe was the continent with the most graduates (17 of 39 [43%]), and only 5 of 39 (13%) were from Latin America. Three of 39 (8%) were women. Thirty-one of 39 graduated fellows (80%) returned to their countries of origin. The survey response rate was 73% (25 of 34). Seventeen of twenty-five (68%) work in an academic setting and 13 (52%) reported surgical oncology as their main clinical practice. Total number of citations and H-index are homogeneous among the different regions from which the fellows originated, with a median of 165 citations and median H-index of 5. CONCLUSIONS: The International General Surgical Oncology Fellowship has successfully trained foreign surgeons for academic practice in surgical oncology. Most of the graduates have returned to their country of origin and contributed to education and research there.

Popliteal lymph node dissection for metastases of cutaneous malignant melanoma.

Popliteal lymph node dissection is performed when grossly metastatic nodal disease is encountered in the popliteal fossa or after microscopic metastasis is found in interval sentinel nodes during clinical staging of cutaneous malignant melanoma. Initially, an S-shaped incision is made to gain access to the popliteal fossa. A careful en bloc removal of fat tissue and lymph nodes is made to preserve and avoid the injury of peroneal and tibial nerves as well as popliteal vessels, following the previous recommendations. This rare surgical procedure was successfully employed in a patient with cutaneous malignant melanoma and nodal metastases at the popliteal fossa. The technique described by Karakousis was reproduced in a step-by-step fashion to allow anatomical identification of the neurovascular structures and radical resection with no post-operative morbidity and prompt recovery. Popliteal lymph node dissection is a rarely performed operative procedure. Following a lymphoscintigraphic examination of the popliteal nodal station, surgeons can be asked to explore the popliteal fossa. Detailed familiarity of the operative procedure is necessary, however, to avoid complications.

Mid-humeral sentinel lymph node dissection in patients with primary cutaneous malignant melanoma.

In rare cases, lymphatic drainage from the malignant melanomas in the upper extremity may follow an unpredictable pattern (outside the axillary nodes), and these aberrant sentinel nodes may represent the only site of regional lymph node metastases. The precise anatomical landmarks and technical aspects of surgical exploration of these aberrant sentinel lymph nodes are rarely described in the literature, including aberrant sentinel mid-humeral lymph nodes. This report describes a step-by-step dissection of the mid-humeral sentinel lymph nodes in two patients with a primary malignant melanoma in the upper extremity, identified by lymphatic mapping. Recognition of precise regional anatomy and following a special surgical technique makes the procedure safe and successful, thus avoiding local complications and allowing a prompt recovery.