Assessing the environmental impact of an anastomotic leak care pathway.

Background: The healthcare sector faces increasing pressure to improve environmental sustainability whilst continuing to meet the needs of patients. One strategy is to lower the avoidable demand on healthcare services, by reducing the number of surgical complications, such as anastomotic leak (AL). The aim of this study was to assess the environmental impact associated with the care pathway of AL. Methods: An environmental impact assessment was performed according to the Sustainable Healthcare Coalition (SHC) guidelines. A care pathway, describing the typical steps involved in the diagnosis and treatment of AL was developed. Activity and emission data for each stage of the care pathway were used to calculate the climate, water and waste impact of the treatment of AL patients. Results: The environmental impact assessment shows that AL is associated with an average climate, water and waste impact per patient of 1303 kg CO2-eq, 1803 m3 of water and 123 kg waste, respectively. Grade C leaks are associated with the greatest environmental impact, contributing to 89.3 %, 79.4 % and 97.9 % of each impact, respectively. A breakdown of the environmental impact of each activity shows that stoma home management is the largest contributor to the total climate (46.6 %) and waste (47.3 %) impact of AL patients, whilst in-patient hospital stay contributes greatest to the total water impact (46.7 %). Conclusions: The treatment of AL is associated with a substantial environmental impact. This study is, to our knowledge, the first to assess the environmental impact associated with the treatment of AL.

Cost-effectiveness of bariatric and metabolic surgery, and implications of COVID-19 in the United Kingdom.

BACKGROUND: People living with obesity have been among those most disproportionately impacted by the COVID-19 pandemic, highlighting the urgent need for increased provision of bariatric and metabolic surgery (BMS). OBJECTIVES: To evaluate the possible clinical and economic benefits of BMS compared with nonsurgical treatment options in the UK, considering the broader impact that COVID-19 has on people living with obesity. SETTING: Single-payer healthcare system (National Health Service, England). METHODS: A Markov model compared lifetime costs and outcomes of BMS and conventional treatment among patients with body mass index (BMI) ≥ 40 kg/m2, BMI ≥ 35 kg/m2 with obesity-related co-morbidities (Group A), or BMI ≥ 35 kg/m2 with type 2 diabetes (T2D; Group B). Inputs were sourced from clinical audit data and literature sources; direct and indirect costs were considered. Model outputs included costs and quality-adjusted life years (QALYs). Scenario analyses whereby patients experienced COVID-19 infection, BMS was delayed by five years, and BMS patients underwent endoscopy were conducted. RESULTS: In both groups, BMS was dominant versus conventional treatment, at a willingness-to-pay threshold of £25,000/QALY. When COVID-19 infections were considered, BMS remained dominant and, across 1000 patients, prevented 117 deaths, 124 hospitalizations, and 161 intensive care unit admissions in Group A, and 64 deaths, 65 hospitalizations, and 90 intensive care unit admissions in Group B. Delaying BMS by 5 years resulted in higher costs and lower QALYs in both groups compared with not delaying treatment. CONCLUSION: Increased provision of BMS would be expected to reduce COVID-19-related morbidity and mortality, as well as obesity-related co-morbidities, ultimately reducing the clinical and economic burden of obesity.

Teaching non-technical skills: the patient centered approach.

The surgical setting is a highly complex environment where, in ideal conditions, everything should be under control to ensure a positive outcome. However, the existing complexity opens the possibility for multiple failures along the process and many of those failures are related to what is call the non-technical skills of the members of the team. We cannot eradicate human error, but we can try to avoid future mistakes in our daily practice introducing the awareness for providing a high-quality care in which patient safety is crucial. This paper presents an easy approach to concepts and teaching possibilities of those non-technical skills.

Effectiveness, cost-effectiveness and safety of gabapentin versus placebo as an adjunct to multimodal pain regimens in surgical patients: protocol of a placebo controlled randomised controlled trial with blinding (GAP study).

INTRODUCTION: Gabapentin is an antiepileptic drug currently licensed to treat epilepsy and neuropathic pain but has been used off-label to treat acute postoperative pain. The GAP study will compare the effectiveness, cost-effectiveness and safety of gabapentin as an adjunct to standard multimodal analgesia versus placebo for the management of pain after major surgery. METHODS AND ANALYSIS: The GAP study is a multicentre, double-blind, randomised controlled trial in patients aged 18 years and over, undergoing different types of major surgery (cardiac, thoracic or abdominal). Patients will be randomised in a 1:1 ratio to receive either gabapentin (600 mg just before surgery and 600 mg/day for 2 days after surgery) or placebo in addition to usual pain management for each type of surgery. Patients will be followed up daily until hospital discharge and then at 4 weeks and 4 months after surgery. The primary outcome is length of hospital stay following surgery. Secondary outcomes include pain, total opioid use, adverse health events, health related quality of life and costs. ETHICS AND DISSEMINATION: This study has been approved by the Research Ethics Committee . Findings will be shared with participating hospitals and disseminated to the academic community through peer-reviewed publications and presentation at national and international meetings. Patients will be informed of the results through patient organisations and participant newsletters. TRIAL REGISTRATION NUMBER: ISRCTN63614165.

Impact on Health-Related Quality of Life of Video-Assisted Thoracoscopic Surgery for Lung Cancer.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) approaches are increasingly used in lung cancer surgery, but little is known about their impact on patients' health-related quality of life (HRQL). This prospective study measured recovery and HRQL in the year after VATS for non-small cell lung cancer (NSCLC) and explored the feasibility of HRQL data collection in patients undergoing VATS or open lung resection. PATIENTS AND METHODS: Consecutive patients referred for surgical assessment (VATS or open surgery) for proven/suspected NSCLC completed HRQL and fatigue assessments before and 1, 3, 6 and 12 months post-surgery. Mean HRQL scores were calculated for patients who underwent VATS (segmental, wedge or lobectomy resection). Paired t-tests compared mean HRQL between baseline and expected worst (1 month), early (3 months) and longer-term (12 months) recovery time points. RESULTS: A total of 92 patients received VATS, and 18 open surgery. Questionnaire response rates were high (pre-surgery 96-100%; follow-up 67-85%). Pre-surgery, VATS patients reported mostly high (good) functional health scores [(European Organisation for Research and Treatment of Cancer) EORTC function scores > 80] and low (mild) symptom scores (EORTC symptom scores < 20). One-month post-surgery, patients reported clinically and statistically significant deterioration in overall health and physical, role and social function (19-36 points), and increased fatigue, pain, dyspnoea, appetite loss and constipation [EORTC 12-26; multidimensional fatigue inventory (MFI-20) 3-5]. HRQL had not fully recovered 12 months post-surgery, with reduced physical, role and social function (10-14) and persistent fatigue and dyspnoea (EORTC 12-22; MFI-20 2.7-3.2). CONCLUSIONS: Lung resection has a considerable detrimental impact on patients' HRQL that is not fully resolved 12 months post-surgery, despite a VATS approach.

The rise of human factors: optimising performance of individuals and teams to improve patients' outcomes.

The improvement of surgical outcomes has been achieved working under the assumption that they are mainly the result of technical skills. This model, although correct, is not exhaustive and has left out many variables that affect outcomes, of which a number can be grouped under the label of non-technical skills, which is a subset of human factors. Non-technical skills are developed to facilitate a shared mental model between team members, teams and their operational environment. They include situation awareness, decision-making, communication, teamwork, leadership and performance-shaping factors. The importance of these non-technical skills has been highlighted during the investigations of severe accidents in many high-risk industries and healthcare. There is an almost untapped opportunity to improve outcomes focusing on non-technical skills because until recently there has been an under-investment of time and resources in this area compared with technical skills. This theoretical paper supports the adoption of a broader model of human performance as a function of technical and non-technical skills and the cultural and organisational context where these are at play. We also aim to highlight a pathway to increase the investment in non-technical skills following the most updated evidence.

Utilising the Delphi Process to Develop a Proficiency-based Progression Train-the-trainer Course for Robotic Surgery Training.

CONTEXT: As the role of robot-assisted surgery continues to expand, development of standardised and validated training programmes is becoming increasingly important. OBJECTIVE: To provide guidance on an optimised "train-the-trainer" (TTT) structured educational programme for surgical trainers, in which delegates learn a standardised approach to training candidates in skill acquisition. We aim to describe a TTT course for robotic surgery based on the current published literature and to define the key elements within a TTT course by seeking consensus from an expert committee formed of key opinion leaders in training. EVIDENCE ACQUISITION: The project was carried out in phases: a systematic review of the current evidence was conducted, a face-to-face meeting was held in Philadelphia, and then an initial survey was created based on the current literature and expert opinion and sent to the committee. Thirty-two experts in training, including clinicians, academics, and industry, contributed to the Delphi process. The Delphi process underwent three rounds of survey in total. Additions to the second- and third-round surveys were formulated based on the answers and comments from the previous rounds. Consensus opinion was defined as ≥80% agreement. EVIDENCE SYNTHESIS: There was 100% consensus that there was a need for a standardized TTT course in robotic surgery. A consensus was reached in multiple areas, including the following: (1) definitions and terminologies, (2) qualifications to attend, (3) course objectives, (4) precourse considerations, (5) requirement of e-learning, (6) theory and course content, and (7) measurement of outcomes and performance level verification. The resulting formulated curriculum showed good internal consistency among experts, with a Cronbach alpha of 0.90. CONCLUSIONS: Using the Delphi methodology, we achieved an international consensus among experts to develop and reach content validation for a standardised TTT curriculum for robotic surgery training. This defined content lays the foundation for developing a proficiency-based progression model for trainers in robotic surgery. This TTT curriculum will require further validation. PATIENT SUMMARY: As the role of robot-assisted surgery continues to expand, development of standardised and validated training programmes is becoming increasingly important. There is currently a lack of high-level evidence on how best to train trainers in robot-assisted surgery. We report a consensus view on a standardised "train-the trainer" curriculum focused on robotic surgery. It was formulated by training experts from the USA and Europe, combining current evidence for training with experts' knowledge of surgical training.

Digital pathology is a practical alternative to on-site intraoperative frozen section diagnosis in thoracic surgery.

AIMS: Telepathology uses digitised image transfer to allow off-site reporting of histopathology slides. This technology could facilitate the centralisation of pathology services, which may improve their quality and cost-effectiveness. The benefits may be most apparent in frozen section reporting, in which turnaround times (TATs) are vital. We moved from on-site to off-site telepathology reporting of thoracic surgery frozen section specimens in 2016. The aim of this study was to compare TATs before and after this service change. METHODS AND RESULTS: All thoracic frozen section specimens analysed 4 months prior and 4 months following the service change were included. Demographics, operation, sample type, time taken from theatre, time received by laboratory, time reported by laboratory, TAT, frozen section diagnosis, final histopathological diagnosis and final TNM staging were recorded. The results were analysed with spss statistical software version 24. In total, there were 65 samples from 59 patients; 34 before the change and 31 after the change. Specimens included 51 lung, six lymph node, three bronchial, three chest wall and two pleural biopsies. Before the change, the median TAT was 25 min [interquartile range (IQR) 20-33 min]. No diagnoses were deferred. No diagnoses were changed on subsequent paraffin analysis. After the change, with the use of digital pathology, the median TAT was 27.5 min (IQR 21.75-38.5 min). This difference was not significant (P = 0.581). Diagnosis was deferred in one case (3.23%). There was one (3.23%) mid-case technical failure resulting in the sample having to be transported by courier, resulting in a TAT of 106 min. No diagnoses were changed on subsequent paraffin analysis. CONCLUSIONS: There was no significant difference in reporting times between digital technology and an on-site service, although one sample was affected by a technical failure requiring physical transportation of the specimen for analysis. Our study was underpowered to detect differences in accuracy.

Outcomes from the Delphi process of the Thoracic Robotic Curriculum Development Committee.

OBJECTIVES: As the adoption of robotic procedures becomes more widespread, additional risk related to the learning curve can be expected. This article reports the results of a Delphi process to define procedures to optimize robotic training of thoracic surgeons and to promote safe performance of established robotic interventions as, for example, lung cancer and thymoma surgery. METHODS: In June 2016, a working panel was spontaneously created by members of the European Society of Thoracic Surgeons (ESTS) and European Association for Cardio-Thoracic Surgery (EACTS) with a specialist interest in robotic thoracic surgery and/or surgical training. An e-consensus-finding exercise using the Delphi methodology was applied requiring 80% agreement to reach consensus on each question. Repeated iterations of anonymous voting continued over 3 rounds. RESULTS: Agreement was reached on many points: a standardized robotic training curriculum for robotic thoracic surgery should be divided into clearly defined sections as a staged learning pathway; the basic robotic curriculum should include a baseline evaluation, an e-learning module, a simulation-based training (including virtual reality simulation, Dry lab and Wet lab) and a robotic theatre (bedside) observation. Advanced robotic training should include e-learning on index procedures (right upper lobe) with video demonstration, access to video library of robotic procedures, simulation training, modular console training to index procedure, transition to full-procedure training with a proctor and final evaluation of the submitted video to certified independent examiners. CONCLUSIONS: Agreement was reached on a large number of questions to optimize and standardize training and education of thoracic surgeons in robotic activity. The production of the content of the learning material is ongoing.

Pathological lymph node involvement is not a predictor of adverse outcomes in patients undergoing thoracoscopic lobectomy for lung cancer†.

OBJECTIVES: As the practice of video-assisted thoracoscopic surgery (VATS) lobectomy gains widespread acceptance, the complexity of procedures attempted increases and the stage of tumour that may be safely approached remains controversial. We examined the impact of nodal involvement with respect to perioperative outcomes after VATS lobectomy. METHODS: All patients listed for VATS lobectomy for non-small-cell lung cancer at our institution from 2012 to 2016 were analysed. Bronchoplastic or chest wall resections and tumours over 7 cm were considered a contraindication to a thoracoscopic approach. RESULTS: Of the 489 patients identified, 97 (19.8%) patients had pathological nodal involvement. The overall conversion rate was 6.1%, reoperation rate was 5.3% and readmission rate was 5.9%. Median hospital stay was 5 days, 30-day mortality was 0.6% and 90-day mortality was 1.6%. No significant difference was identified between the nodal-negative or -positive groups in terms of preoperative demographics, hospital stay, postoperative complications, conversion rate, reoperation rate or readmission rate. Univariate logistic regression identified gender, Thoracoscore, dyspnoea score, performance status, chronic obstructive pulmonary disease, previous stroke, preoperative lung function and non-adenocarcinoma as predictors of postoperative complications. A multivariate model including nodal status identified Thoracoscore (odds ratio 1.57, 95% confidence interval 1.16-2.18; P < 0.001) and preoperative transfer factor (odds ratio 0.97, 95% confidence interval 0.96-0.98; P < 0.001) as the only predictors of complications. CONCLUSIONS: In non-small-cell lung cancer patients with pathological hilar or mediastinal lymph node involvement, VATS lobectomy can be safely performed, as there does not appear to be an adverse effect on the incidence of perioperative complications, length of stay or readmissions.

The anterior approach to lymph node station 7.

We describe a novel video-assisted thoracic surgery (VATS) anterior approach to lymph node station 7 after VATS left lower lobectomy.

Isolated metastasis of testicular seminoma to extralobar pulmonary sequestration.

This case report describes a 46-year-old patient with a very unusual pattern of isolated metastasis to an extralobar pulmonary sequestration following orchidectomy for seminoma. The patient underwent uncomplicated video-assisted thoracoscopic resection of the metastasis, involving the whole of the sequestration mass.

Pain and recovery are comparable after either uniportal or multiport video-assisted thoracoscopic lobectomy: an observation study.

OBJECTIVES: Uniportal approaches to video-assisted thoracoscopic surgery (VATS) lobectomy have been described in significant series. Few comparison studies between the two techniques exist. The aim was to determine whether the uniportal technique had more favourable postoperative outcomes than the multiport technique. METHODS: All VATS lobectomies undertaken at a single university hospital during August 2012 to December 2013 were studied. Patients with preoperative opiate use or chronic pain were excluded. Patients were divided into those with uniportal and multiport approaches for analysis. All continuous data were assessed for normality, and analysed with the Mann-Whitney U-tests or t-tests as appropriate. Categorical data were analysed by Fisher's exact or χ(2) test for trend as appropriate. RESULTS: One hundred and twenty-nine VATS lobectomies were completed. Six were excluded and data were incomplete for 13, leaving 110 (15 uniportal, 95 multiport) for analysis. The demographics of the two groups were similar. There was no significant difference in the Thoracoscore or American Society of Anesthesiologists grades. The median morphine use in the first 24 postoperative hours was 19 mg in the uniportal group and 23 mg in the multiport group, P = 0.84. The median visual analogue pain score in the first 24 h was 0 in the uniportal group and 0 in the multiport group, P = 0.65. There was no difference in the duration of patient-controlled analgesia (P = 0.97), chest drain duration (P = 0.67) or hospital length of stay (P = 0.54). There was no inpatient mortality and no unplanned admission to critical care in either group. CONCLUSIONS: Uniportal VATS lobectomy is safe, and there is no appreciable negative impact on the hospital stay or morbidity. Patient-reported pain and morphine use in the first 24 h was low with either technique. Larger prospective studies are needed to quantify any benefit to a particular approach for VATS lobectomy.

Innate immune responses after resection for lung cancer via video-assisted thoracoscopic surgery and thoracotomy.

OBJECTIVE: Innate immune responses to pulmonary resection may be critical in the pathogenesis of important postoperative pulmonary complications and potentially longer-term survival. We sought to compare innate immunity of patients undergoing major pulmonary resection for bronchogenic carcinoma via video-assisted thoracoscopic surgery (VATS) and thoracotomy. METHODS: Bronchoalveolar lavage was conducted in the contralateral lung before staging bronchoscopy and mediastinoscopy and immediately after lung resection. Blood and exhaled nitric oxide were sampled preoperatively and at 6, 24, and 48 hours postoperatively. RESULTS: Forty patients were included (26 VATS and 14 thoracotomy). There was a lower systemic cytokine response from lung resection undertaken by VATS compared with thoracotomy [interleukin 6 (IL-6), analysis of variance (ANOVA) P = 0.026; IL-8, ANOVA P = 0.018; and IL-10, ANOVA P = 0.047]. The VATS patients had higher perioperative serum albumin levels (ANOVA P = 0.001). Lower levels of IL-10 were produced by lipopolysaccharide-stimulated blood monocytes from the VATS patients compared with the thoracotomy patients at 6 hours postoperatively (geometric mean ratio, 1.16; 95% confidence interval, 1.08-1.33; P = 0.011). No statistically significant differences in the neutrophil phagocytic capacity, overall leukocyte count, or differential leukocyte count were found between the surgical groups (ANOVA P > 0.05). No statistically significant differences in bronchoalveolar lavage fluid parameters were found. Exhaled nitric oxide levels fell postoperatively, which reached statistical significance at 48 hours (geometric mean ratio, 1.2; 95% confidence interval, 1.02-1.46; P = 0.029). There were no significant differences found between the surgical groups (ANOVA P = 0.331). CONCLUSIONS: Overall, a trend toward greater proinflammatory and anti-inflammatory responses is seen with lung resection performed via thoracotomy compared with VATS.

Early and mid-term outcomes of trans-sternal and video-assisted thoracoscopic surgery for thymoma.

OBJECTIVES: Video-assisted thoracoscopic surgery (VATS) for thymoma has uncertain safety and effectiveness in comparison with trans-sternal resection. This feasibility study compared short- and mid-term outcomes for patients undergoing these two procedures, highlights weaknesses in current research and makes recommendations for long-term technological evaluations in this field. METHODS: Consecutive thymoma cases between 2004 and 2010 were identified. Patients were divided into two groups according to surgical approach (Group I trans-sternal; Group II VATS) and comparisons were made between groups. The primary outcome was overall survival. Secondary outcomes included operative morbidity and mortality, hospital stay, recurrence rate and disease-free survival. RESULTS: Thirty-nine patients were included (Group I: n = 22 vs Group II: n = 17). There were no differences between groups at baseline for all measured covariates. No deaths occurred within 30 days of surgery. More patients in Group I developed complications (Group I: n = 10 vs Group II: n = 3; P = 0.093), while hospital stay was shorter in Group II (Group I: 6.4 ± 4.6 days vs Group II: 4.4 ± 1.8 days; P = 0.030). Five-year overall survival (Group I: 93.8 ± 6.1% vs Group II: 83.3 ± 11.2%; P = 0.425), 5-year disease-free survival (Group I: 71.0 ± 15.3% vs Group II: 83.3 ± 11.2%; P = 0.827) and recurrence rates at final follow-up (Group I: n = 2 vs Group II: n = 1; P = 0.363) were similar between the groups. CONCLUSION: VATS thymectomy for thymoma is feasible, safe and has comparable mid-term oncological outcomes to trans-sternal thymectomy. Future research is required to evaluate long-term oncological outcomes of VATS thymectomy for thymoma in national registries and randomized, controlled trials.

Uniportal video-assisted thoracic surgery: the lesser invasive thoracic surgery.

OBJECTIVES: We evaluated whether single-port video-assisted thoracic surgery is feasible without compromising outcomes, and whether the technique could be reproduced by a trainee. METHODS: In a 6-month period, 37 operations were performed by single-port video-assisted thoracic surgery. Of the 37 patients, 27 (73%) were male and the mean age was 45.1 ± 21 years. Twenty-three (62%) were operated on by consultants and 14 (38%) by trainees. The procedures included 19 (51.3%) operations for treatment of pneumothoraces, 8 (21.6%) metastasectomies, 7 (18.9%) lung biopsies, 2 (5.4%) empyema débridements, and 1 (2.7%) pleuropericardial window. RESULTS: Mean operative time was 51.8 ± 14.7 min. Patient-controlled analgesia infusion was used for 1.3 ± 1 days. Three (8.1%) patients needed an operative reintervention, but there was no intensive treatment unit admission or hospital mortality. Mean postoperative hospital stay was 3.3 ± 2.7 days. On follow-up, all patients had a tissue diagnosis and all lung nodules were R0 resections. Patients operated on by consultants and trainees had similar preoperative profiles and postoperative outcomes, except that those operated on by trainees used patient-controlled analgesia significantly longer (1.8 ± 1.48 vs. 1 ± 0.48 days; p = 0.03). CONCLUSION: Single-port video-assisted thoracic surgery can be performed and reproduced well without compromising outcomes. It is considered aesthetically better and may reduce analgesic requirements, but it might not reduce hospital stay.

Adopting a standardized anterior approach significantly increases video-assisted thoracoscopic surgery lobectomy rates.

OBJECTIVES: Video-assisted thoracoscopic surgery (VATS) lobectomy is associated with improved short-term outcomes compared with thoracotomy. Definition of the hilar structures is crucial to safe VATS lobectomy. Several VATS approaches have been described. We report the effect of three surgeons in our institution undertaking standardized anterior approach (SAA) training on the proportion of isolated lobectomies subsequently completed by VATS. Predictors of successful VATS lobectomy were analysed. METHODS: Three consultant surgeons undertook SAA training at two different time points. Two were performing VATS lobectomy prior to SAA training. Training involved a 2-day visit to an established SAA unit. Lobectomies performed by these surgeons between April 2011 and December 2012 (20 months), before and after training, were recorded prospectively. Bilobectomies, sleeve resections, pneumonectomies and chest wall resections were excluded. VATS lobectomy proportions before and after training were compared. Independent predictors of completion by VATS rather than thoracotomy were identified by multivariable logistic regression. RESULTS: One hundred and sixty-three isolated lobectomies were performed, 97 of these by VATS (59.5%). The mean age was 68.8 (± 10.5) years. Pathology was lung cancer in 137 (84.0%), other primary malignancy in 10 (6.1%), pulmonary metastases in 8 (4.9%) and benign in 8 (4.9%). The VATS lobectomy rate rose from 22.2% before SAA training to 77.3% after, P < 0.001. The effect was significant for both existing and adopting VATS lobectomy surgeons, P = 0.002 to <0.001. The median hospital stay was 4 days after VATS and 5 after thoracotomy, P < 0.001. There were 5 in-hospital deaths after thoracotomy and none after VATS lobectomy, unadjusted P = 0.01. In the final logistic regression model, SAA training was the strongest predictor of successful VATS lobectomy (odds ratio 15.16; 95% confidence interval 6.39, 35.96). CONCLUSIONS: Formal training and adoption of the SAA approach were associated with a more than 3-fold increase in our VATS lobectomy rate. The effect was immediate and sustained. This may reflect easier identification of the major structures from the anterior view. In addition, standardization of surgical techniques and perioperative protocols may facilitate efficient team working. VATS lobectomy was associated with a shorter median hospital stay. Units seeking to increase their VATS lobectomy rate should consider group adoption of the SAA approach.