De la intención al comportamiento: modelo analítico del comportamiento de riesgo moral del médico basado en la teoría del comportamiento planificado / From intention to behavior: analytical model of doctor's moral hazard behavior-based on planned behavior theory / Da intenção ao comportamento: modelo analítico do comportamento moral de risco de médicos baseado na teoria do comportamento planejado

Resumen Basado en el concepto de comportamiento de riesgo moral del médico y el modelo teórico de comportamiento planificado, este artículo construye un modelo teórico del comportamiento de riesgo moral del médico y analiza en detalle los principales factores que influyen en el comportamiento de riesgo moral del médico, incluidas las actitudes conductuales, subjetivas normas y control conductual percibido. En combinación con los resultados de la encuesta por cuestionario, este artículo utiliza un modelo de ecuación estructural y un análisis factorial para verificar las hipótesis. Los resultados muestran que en el modelo teórico de la conducta de riesgo moral del médico, las intenciones de riesgo moral de los médicos se ven afectadas por tres variables independientes: actitudes conductuales, normas subjetivas y control conductual percibido. Como variable intermedia, las intenciones de riesgo moral tienen un efecto mediador en el comportamiento de riesgo moral de los médicos. Todos los coeficientes de trayectoria cumplen los requisitos y se verifican todos los supuestos del modelo. El modelo teórico del comportamiento de riesgo moral del médico establecido en este estudio puede explicar eficazmente la ley de ocurrencia del comportamiento de riesgo moral del médico y predecir este comportamiento de acuerdo con la situación real de varios factores influyentes. Esto proporciona una guía teórica eficaz para el siguiente paso para llevar a cabo mejor la investigación relevante sobre el riesgo moral del médico basada en la perspectiva de la gestión, especialmente el establecimiento de estrategias de prevención y control para el comportamiento de riesgo moral del médico.

Abstract Based on the concept of doctor's moral hazard behavior and the theoretical model of planned behavior, this paper constructs a theoretical model of doctor's moral hazard behaviorm and analyzes the main influencing factors of doctor's moral hazard behavior in detail, including behavioral attitudes, subjective norms and perceived behavioral control. Combined with the results of questionnaire survey, this paper uses structural equation model and factor analysis to verify the hypotheses. The results show that in the theoretical model of doctor's moral hazard behavior, doctors' moral risk intentions are affected by three independent variables: behavioral attitudes, subjective norms and perceived behavioral control. As an intermediary variable, moral risk intentions have a mediating effect on doctors' moral hazard behavior. All path coefficients meet the requirements, and all assumptions of the model are verified. The theoretical model of doctor's moral hazard behavior established in this study can effectively explain the occurrence law of doctor's moral hazard behavior and can predict doctor's moral hazard behavior according to the actual situation of various influencing factors. This provides an effective theoretical guidance for the next step to better carry out the relevant research on doctor's moral hazard based on the management perspective, especially the establishment of prevention and control strategies for doctor's moral hazard behavior.

Resumo Baseado no conceito de comportamento moral de risco de médicos e o modelo teórico do comportamento planejado, este artigo constrói um modelo teórico de comportamento de risco moral de médicos e analisa os fatores principais que influenciam o comportamento moral de risco de médicos em detalhes, incluindo atitudes comportamentais, normas subjetivas e controle comportamental percebido. Combinado com os resultados de levantamentos com questionários, esse artigo usa o modelo de equação estrutural e análise fatorial para verificar as hipóteses. Os resultados mostram que no modelo teórico do comportamento de risco moral de médicos, as intenções de risco moral de médicos são afetadas por três variáveis independentes: atitudes comportamentais, normas subjetivas e controle comportamental percebido. Como uma variável intermediária, intenções de risco moral tem um efeito mediador no comportamento de risco moral de médicos. Todos os coeficientes de caminho cumprem os requisitos e todas as suposições do modelo são comprovadas. O modelo teórico do comportamento de risco moral de médicos estabelecidos nesse estudo podem efetivamente explicar a lei de ocorrência do comportamento de risco moral de médicos e pode predizer o comportamento de risco moral de médicos de acordo com a situação real de vários fatores de influência. Isto fornece um guia teórico efetivo para os próximos passos para melhor conduzir pesquisas relevantes sobre risco moral de médicos baseadas na perspectiva de gestão, especialmente o estabelecimento de estratégias de prevenção e controle para o comportamento de risco moral de médicos.

Treatment of complications after laparoscopic intersphincteric resection for low rectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To summarize the perioperative and postoperative complications follow laparoscopic intersphincteric resection (LapISR) in the treatment of low rectal cancer and their management.</p><p><b>METHODS</b>An observational study was conducted in 73 consecutive patients who underwent LapISR for low rectal cancer between June 2011 and February 2016 in our hospital. The clinicopathological parameters, perioperative and postoperative complications, and clinical outcomes were collected from a prospectively maintained database. Perioperative and postoperative complications were defined as any complication occurring within or more than 3 months after the primary operation, respectively.</p><p><b>RESULTS</b>Forty-nine(67.1%) cases were male and 24(32.9%) were female with a median age of 61(25 to 79) years. The median distance from distal tumor margin to anal verge was 4.0(1.0 to 5.5) cm. The median operative time was 195 (120 to 360) min, median intra operative blood loss was 100 (20 to 300) ml, median number of harvested lymph nodes was 14(3 to 31) per case. All the patients underwent preventive terminal ileum loop stoma. No conversion or hospital mortality was presented. The R0 resection rate was 98.6% with totally negative distal resection margin. A total of 34 complication episodes were recorded in 21(28.8%) patients during perioperative period, and among which 20.6%(7/34) was grade III(-IIII( according to Dindo system. Anastomosis-associated morbidity (16.4%,12/73) was the most common after LapISR, including mucosa ischemia in 9 cases(12.3%), stricture in 7 cases (9.6%, 4 cases secondary to mucosa necrosis receiving anal dilation), grade A fistula in 3 cases (4.1%) receiving conservative treatment and necrosis in 1 case (1.4%) receiving permanent stoma. After a median follow up of 21(3 to 60) months, postoperative complications were recorded in 12 patients (16.4%) with 16 episodes, including anastomotic stenosis (8.2%), rectum segmental stricture (5.5%), ileus (2.7%), partial anastomotic dehiscence (1.4%), anastomotic fistula (1.4%), rectovaginal fistula (1.4%) and mucosal prolapse (1.4%). These patients received corresponding treatments, such as endoscopic transanal resection, anal dilation, enema, purgative, permanent stoma, etc. according to the lesions. Six patients (8.2%) required re-operation intervention due to postoperative complications.</p><p><b>CONCLUSION</b>Anastomosis-associated morbidity is the most common after LapISR in the treatment of low rectal cancer in perioperative and postoperative periods, which must be strictly managed with suitable methods.</p>

Comparison of oncology outcomes and anal function among laparoscopic partial, subtotal and total intersphincteric resection for low rectal cancers / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To compare the oncology outcomes and anal function among laparoscopic partial, subtotal and total intersphincteric resection(ISR) for low rectal cancers.</p><p><b>METHODS</b>From June 2011 to February 2016, a total of 79 consecutive patients with low rectal cancers underwent laparoscopic ISR with hand-sewn coloanal anastomosis at our department. According to the distal tumor margin, partial ISR (internal sphincter resection at the dentate line) was used to treat tumors with distance <1 cm from the anal sphincter (n=28), subtotal ISR was adopted for the tumors locating between the dentate line and intersphincteric groove (n=34), and total ISR (resection at the dentate line) was applied in the treatment of intra-anal tumors (n=17). Anal function was evaluated by a standardized gastrointestinal questionnaire, Wexner incontinence score and Kirwan's classification. Metaphase oncological results and postoperative anal function were compared among three groups, and.</p><p><b>RESULTS</b>Other than the distance of tumor low margin to dentate line (P=0.000) and serum CEA level (P=0.040), no significant differences were noted in baseline data among 3 groups (all P>0.05). The median follow up was 21(8-61) months. The 3-year disease-free survival rates in laparoscopic partial, subtotal and total ISR groups were 91.1%, 88.9%, 88.2% (P=0.901) and the 3-year local relapse-free survival rates were 91.1%, 72.9%, 80.2%(P=0.658), whose all differences were not significant. Thirty-eight patients who did not receive neoadjuvant chemoradiotherapy and underwent ileostomy closure for at least 24 months completed the evaluation of anal function, including 14 cases in partial group, 15 cases in subtotal group and 9 cases in total group. Of 38 patients, 73.7%(28/38) was classified as good function (Wexner incontinence score ≤10) and no patient adopted a colostomy because of severe fecal incontinence(Kirwan classification=grade 5). Furthermore, there were no significant differences in Wexner incontinence score and Kirwan classification among 3 groups (all P>0.05). However, patients with chronic anastomotic stoma stenosis showed worse anal function than those without stenosis [Wexner incontinence score: 18(9-20) vs 6(0-18), P=0.000; Kirwan grading: 3(2-4) vs. 2(1-4), P=0.002].</p><p><b>CONCLUSIONS</b>As the ultimate sphincter-saving technique, laparoscopic ISR can result in better oncologic outcomes and better anal function for patients with low rectal cancers. The different procedures of ISR may not affect the efficacy, but chronic anastomotic stoma stenosis deteriorates incontinence status.</p>