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1.
Surg Endosc ; 2021 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-34782967

RESUMO

BACKGROUND: Prolonged operative duration has been associated with increased post-operative morbidity in numerous surgical subspecialties; however, data are limited in operations for colon cancer specifically and existing literature makes unwarranted methodological assumptions of linearity. We sought to assess the effects of extended operative duration on perioperative outcomes in those undergoing segmental colectomy for cancer using a methodologically sound approach. METHODS: We conducted a retrospective cohort study of patients undergoing segmental colectomy for cancer between 2014 and 2018, logged in the National Surgical Quality Improvement Program datasets. Our primary outcome was a composite of any complication within 30 days; secondary outcomes included length of stay and discharge disposition. Our main factor of interest was operative duration. RESULTS: We analyzed 26,380 segmental colectomy cases, the majority of which were approached laparoscopically (64.95%) and were right sided (62.93%). Median operative duration was 152 (95% CI 112-206) minutes. On multivariable regression, increased operative duration was linearly associated with any complication (OR = 1.003, 95% CI 1.003-1.003, p < 0.0001) in the overall cohort, as was length of stay (p < 0.0001). All subgroups except for the laparoscopic left colectomy group were linearly associated with operative duration. In the laparoscopic left colectomy group, an inflection point in the odds of any complication was found at 176 min (OR = 1.39, 95% CI 1.20-1.61, p < 0.0001). CONCLUSIONS: This study suggests that the risk of perioperative complications increases linearly with increasing operative duration, where each additional 30 min increases the odds of complication by 10%. In those undergoing laparoscopic left colectomy, the risk of complications sharply increases after ~ 3 h, suggesting that surgeons should aim to complete these procedures within 3 h where possible.

2.
Surg Endosc ; 2021 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-34471981

RESUMO

BACKGROUND: There is a paucity of evidence surrounding the issue of delays on the day of surgery with respect to both causes and consequences. We sought to determine whether patients whose operations started late were at increased risk of post-operative complications. METHODS: We conducted a retrospective cohort study of 1420 first-of-the-day common general surgical procedures, dividing these into "on-time start" (OTS) and "late-start" (LS) cases. Our primary outcomes were minor and major complication rate; our secondary objective was to identify factors predicting LS. Groups were compared using univariable and multivariable analysis. RESULTS: LS rate was 55.3%. On univariable analysis, LS had higher rates of major and minor complications (7.3% vs. 3.5%, p = 0.002; 3.8% vs. 1.6%, p = 0.011). On multivariable analysis, LS was not associated with increased odds of any complications. Minor complications were predicted by operative duration [OR = 1.005 (1.002-1.008)], female sex [OR = 1.78 (1.037-3.061)], and undergoing an ileostomy closure procedure [OR = 10.60 (2.791-40.246)], and were reduced in those undergoing surgery on Wednesdays [OR = 0.38 (0.166-0.876)]. Major complications were predicted by operative duration [OR = 1.007 (1.003-1.011)] and ASA class [OR = 6.73 (1.505-30.109)]. Multivariable analysis using LS as an outcome identified that anesthesia time [OR = 1.35 (1.031-1.403)], insulin-dependent diabetes [OR = 1.91 (1.128-3.246)], and dyspnea upon moderate exertion [OR = 2.52 (1.423-4.522)] were predictive of LS. CONCLUSIONS: Most cases in our study started late. While this has significant efficiency and economic costs, it is not associated with adverse patient outcomes. This topic remains incompletely described. Further research is needed to improve efficiency and patient experience by investigating the causes of operative delays.

3.
Surg Open Sci ; 5: 1-5, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-34337371

RESUMO

Background: Low ligation of the inferior mesenteric artery with preservation of the left colic artery may decrease the risk of colorectal anastomotic ischemia compared to high ligation at its origin. Low ligation leaves apical nodes in situ and is therefore paired with apical lymphadenectomy. We sought to compare relevant oncologic outcomes between high ligation and low ligation plus apical lymphadenectomy in rectosigmoid resection for colorectal cancer. Methods: We conducted a retrospective cohort study. Patients receiving a rectosigmoid resection for cancer between January 2012 and July 2018 were included. Patients with metastatic disease and those who underwent low ligation without apical lymphadenectomy were excluded. Our primary outcome was nodal yield/metastasis. Secondary outcomes included perioperative complications, local recurrence, and overall survival. Results: Eighty-four patients underwent high ligation and 89 low ligation plus apical lymphadenectomy (median follow-up 20 months). In the low-ligation group, a median of 2 (interquartile range = 1-3) apical nodes was resected; 4.1% were malignant, increasing pathologic stage in 25% of these patients. There were no differences in nodal yield, complications, anastomotic leak, local recurrence, or overall survival. Conclusion: No differences were identified between high ligation and low ligation plus apical lymphadenectomy with respect to relevant clinical outcomes. Prospective trial data are needed to robustly establish the oncologic benefit and safety of the low ligation plus apical lymphadenectomy technique.

4.
Curr Oncol ; 28(3): 2065-2078, 2021 05 29.
Artigo em Inglês | MEDLINE | ID: mdl-34072615

RESUMO

While adjuvant treatment of colon cancers that penetrate the serosa (T4) have been well-established, neoadjuvant strategies have yet to be formally evaluated. Our objective was to perform a scoping review of eligibility criteria, treatment regimens, and primary outcomes for neoadjuvant approaches to T4 colon cancer. A librarian-led, systematic search of MEDLINE, Embase, Cochrane Library, Web of Science, and CINAHL up to 11 February 2020 was performed. Primary research evaluating neoadjuvant treatment in T4 colon cancer were included. Screening and data abstraction were performed in duplicate; analyses were descriptive or thematic. A total of twenty studies were included, most of which were single-arm, single-center, and retrospective. The primary objectives of the literature to date has been to evaluate treatment feasibility, tumor response, disease-free survival, and overall survival in healthy patients. Conventional XELOX and FOLFOX chemotherapy were the most commonly administered interventions. Rationale for selecting a specific regimen and for treatment eligibility criteria were poorly documented across studies. The current literature on neoadjuvant strategies for T4 colon cancer is overrepresented by single-center, retrospective studies that evaluate treatment feasibility and efficacy in healthy patients. Future studies should prioritize evaluating clear selection criteria and rationale for specific neoadjuvant strategies. Validation of outcomes in multi-center, randomized trials for XELOX and FOLFOX have the most to contribute to the growing evidence for this poorly managed disease.


Assuntos
Neoplasias do Colo , Terapia Neoadjuvante , Quimioterapia Adjuvante , Neoplasias do Colo/tratamento farmacológico , Intervalo Livre de Doença , Humanos , Estudos Retrospectivos
5.
Colorectal Dis ; 23(8): 2146-2153, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-33999494

RESUMO

AIM: The timing of ileostomy reversal has been the subject of controversy, with researchers investigating the safety of early versus late stoma closure. Anecdotally, a longer duration of faecal diversion is associated with a greater incidence of postoperative ileus. We sought to investigate the association between duration of diversion and postoperative ileus. METHOD: We conducted an institutional retrospective cohort study on 173 patients undergoing ileostomy closure between 2012 and 2018. Our primary outcome was ileus; secondary outcomes included postoperative complications and descriptive factors. We investigated the association between duration of diversion and ileus using several analyses to ensure that time was treated appropriately as a continuous, nonlinear variable. RESULTS: In all, 20.2% of patients had an ileus. Multivariate analysis did not identify a significant association between any independent predictors and ileus, although there was a trend towards increased risk of ileus with increasing duration of diversion. When treated as a categorical variable, a duration of diversion >328 days independently increased the odds of ileus (OR = 3.25, P = 0.033). Duration of diversion was associated with days to first flatus and to first diet (P = 0.025 and P = 0.004, respectively). When patients received nasogastric intubation, the mean duration of intubation was 3.2 days. CONCLUSION: Greater duration of diversion was associated with a trend towards increased risk of ileus; this risk tripled when diversion lasted more than 328 days.


Assuntos
Íleus , Obstrução Intestinal , Colostomia , Humanos , Ileostomia/efeitos adversos , Íleus/epidemiologia , Íleus/etiologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos
6.
Eur J Surg Oncol ; 47(9): 2390-2397, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34034943

RESUMO

INTRODUCTION: Resection for isolated distant recurrence of colon cancer is well accepted. Resection for locoregionally recurrent colon cancer (LRCC) is not well studied. We evaluated the long-term outcomes of curative-intent resection for LRCC. METHODS: All patients undergoing curative-intent resection for LRCC at three specialized cancer centers affiliated with the University of Toronto were identified (1993-2017). Follow-up included serial clinical assessment, colonoscopy, CEA, and cross-sectional imaging. Overall survival (OS), cancer-specific survival (CSS) and time to re-recurrence were estimated using Kaplan-Meier method and cumulative incidence function. The association between resection margins and outcome was assessed with Cox models. RESULTS: 117 patients were included in the study cohort. Median follow-up was 53 months (IQR: 34-101). OS was 75% (95% CI: 68-84) at 5 years, and 69% (95% CI: 59-79) at 10 years. CSS was 78% (95% CI: 70-86) at 5 years and 72% (95% CI: 63-83) at 10 years. The rate of re-recurrence was 22% (95% CI: 14-31) at 5 years, and 27% (95% CI: 16-39) at 10 years. Negative resection margin (R0) was associated with improved OS (HR 3.33, 95% CI: 1.85-6.00, p < 0.01). There were no postoperative deaths; complications with Clavien-Dindo grade > II occurred in 12% of patients. Perioperative chemotherapy was used in 63% of patients and radiotherapy in 37%. CONCLUSION: In selected patients with LRCC, excellent OS, CSS and low re-recurrence rates were observed, and R0 resection predicted better outcomes. These findings support consideration of resection for LRCC in fit patients after review at a multidisciplinary cancer conference.

7.
J Med Ethics ; 2021 May 21.
Artigo em Inglês | MEDLINE | ID: mdl-34021059

RESUMO

The COVID-19 pandemic has strained healthcare resources the world over, requiring healthcare providers to make resource allocation decisions under extraordinary pressures. A year later, our understanding of COVID-19 has advanced, but our process for making ethical decisions surrounding resource allocation has not. During the first wave of the pandemic, our institution uniformly ramped-down clinical activity to accommodate the anticipated demands of COVID-19, resulting in resource waste and inefficiency. In preparation for the second wave, we sought to make such ramp down decisions more prudently and ethically. We report the development of a tool that can be used to make fair and ethical decisions in times of resource scarcity. We formed an interprofessional team to develop and use this tool to ensure that a diverse range of stakeholder perspectives were represented in this development process. This team, called the clinical activity recovery team, established institutional objectives that were combined with well-established procedural values, substantive ethical principles and decision-making criteria by using a variation on the well-known accountability for reasonableness ethical framework. The result of this is a stepwise, semiquantitative, ethical decision tool that can be applied to resource allocation challenges in order to reach fair and ethically defensible decisions. This ethical decision tool can be applied in various contexts and may prove useful at both the institutional and the departmental level; indeed this is how it is applied at our centre. As the second wave of COVID-19 strains healthcare resources, this tool can help clinical leaders to make fair decisions.

8.
Front Oncol ; 11: 629207, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33777780

RESUMO

Background: Experimental data highlight the potential benefits and health system cost savings related to surgical prehabilitation; however, adequately powered randomized controlled trial (RCT) data remain nascent. Emerging prehabilitation services may be informed by early RCT data but can be limited in informing real-world program development. Pragmatic trials emphasize external validity and generalizability to understand and advise intervention development and implementation in clinical settings. This paper presents the methodology of a pragmatic prehabilitation trial to complement emerging phase III clinical trials and inform implementation strategies. Methods: This is a pilot pragmatic clinical trial conducted in a large academic hospital in Toronto, Ontario, Canada to assess feasibility of clinical implementation and derive estimates of effectiveness. Feasibility data include program referral rates, enrolment and attrition, intervention adherence and safety, participant satisfaction, and barriers and facilitators to programming. The study aims to receive 150 eligible referrals for adult, English-speaking, preoperative oncology patients with an identified indication for prehabilitation (e.g., frailty, deconditioning, malnutrition, psychological distress). Study participants undergo a baseline assessment and shared-decision making regarding the intervention setting: either facility-based prehabilitation or home-based prehabilitation. In both scenarios, participants receive an individualized exercise prescription, stress-reduction psychological support, nutrition counseling, and protein supplementation, and if appropriate, smoking cessation program referrals. Secondary objectives include estimating intervention effects at the week prior to surgery and 30 and 90 days postoperatively. Outcomes include surgical complications, postoperative length of stay, mortality, hospital readmissions, physical fitness, psychological well-being, and quality of life. Data from participants who decline the intervention but consent for research-related access to health records will serve as comparators. The COVID-19 pandemic required the introduction of a 'virtual program' using only telephone or internet-based communication for screening, assessments, or intervention was introduced. Conclusion: This pragmatic trial will provide evidence on the feasibility and viability of prehabilitation services delivered under usual clinical conditions. Study amendments due to the COVID-19 pandemic are presented as strategies to maintain prehabilitation research and services to potentially mitigate the consequences of extended surgery wait times.

9.
Artigo em Inglês | MEDLINE | ID: mdl-33660225

RESUMO

PURPOSE: The impact of body mass index (BMI) on outcomes after open or laparoscopic surgery for rectal cancer remains unclear. The objective of this retrospective cohort study was to examine the interaction of body mass index and surgical modality (i.e., laparoscopy versus open) with respect to short-term clinical outcomes in patients with rectal cancer. METHODS: The ACS-NSQIP database (2012-2016) was reviewed for patients undergoing open or laparoscopic surgery for rectal cancer. The primary outcome was 30-day all-cause morbidity. Logistic regression and Cox proportional hazard models were used for analysis. RESULTS: A total of 16,145 patients were grouped into open (N = 6759, 42%) and laparoscopic (N  = 9386, 58%) cohorts. Patients with higher BMI (p < 0.001) and those undergoing open surgery (p < 0.001) were at increased risk of all-cause morbidity. There was no significant change in the odds ratio of experiencing all-cause morbidity between open and laparoscopic surgery with increasing BMI (p = 0.572). Median length of stay was significantly shorter in the laparoscopy group (4 days vs. 6 days; p < 0.001), at the cost of increased operative time (239 min vs. 210 min, p < 0.001). The difference in operative time between laparoscopy and open surgery did not increase with rising BMI (i.e., ∆37 min vs. ∆39 min at BMI 25 kg/m2 vs 50 kg/m2, respectively, p = 0.491). CONCLUSION: BMI may not be a strong modifier for surgical approach with respect to short-term clinical outcomes in patients with obesity and rectal cancer. Laparoscopic surgery was associated with improved short-term clinical outcomes, without much change in the absolute difference in operative time compared with open surgery, even at higher BMIs.

10.
Dis Colon Rectum ; 64(3): 293-300, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33555709

RESUMO

BACKGROUND: There is emerging evidence of the oncological safety of minimally invasive surgery in T4 colorectal cancer; however, such support is lacking in N2 disease. OBJECTIVE: This study aimed to compare oncological and perioperative outcomes of surgical resection for N2 colorectal cancer using an open versus minimally invasive approach. DESIGN: We conducted a retrospective cohort study using the National Surgical Quality Improvement Program's generic and targeted colectomy data sets. SETTINGS: Data about surgery for N2 colorectal cancer were obtained regarding North American hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program. PATIENTS: All patients undergoing elective surgical resection for N2 colorectal cancer in participating hospitals between 2014 and 2018 were selected. INTERVENTIONS: Surgical resection of N2 colorectal cancer was performed. MAIN OUTCOME MEASURES: Our primary outcome was nodal yield. Secondary outcomes included perioperative complications and mortality. RESULTS: A total of 1837 patients underwent open and 3907 patients underwent minimally invasive surgery colectomies for N2 colorectal cancer (n = 5744). Median nodal yield was 20 (interquartile range, 15-27) in the open group and 21 (interquartile range, 16-28) in the minimally invasive group (p < 0.0001); however, nodal harvest between the 2 groups was not significantly different on multivariate analysis. Perioperative complications were higher on univariate analysis in the open surgery group, with respect to key outcomes including anastomotic leak and death (p < 0.001). LIMITATIONS: This study is limited by its retrospective design and by the fact that the staging data collected by the National Surgical Quality Improvement Program are pathological rather than clinical; however, prior studies found a 97% concordance between pathological and clinical N2 determination. CONCLUSIONS: Minimally invasive surgery approaches to colorectal cancer with N2 disease result in equivalent nodal harvests compared with open approaches. Our group supports the use of a minimally invasive approach in advanced nodal stage colorectal cancer in the appropriately selected patient. See Video Abstract at http://links.lww.com/DCR/B417. LOS ABORDAJES QUIRRGICOS MNIMAMENTE INVASIVOS SON SEGUROS Y APROPIADOS EN EL CNCER COLORRECTAL N: ANTECEDENTES:Existe evidencia emergente de la seguridad oncológica de la cirugía mínimamente invasiva en el cáncer colorrectal T4; sin embargo, semenjante apoyo falta en la enfermedad N2.OBJETIVO:comparar los resultados oncológicos y perioperatorios de la resección quirúrgica para el cáncer colorrectal N2 utilizando un abordaje abierto versus mínimamente invasivo.DISEÑO:Realizamos un estudio de cohorte retrospectivo utilizando los conjuntos de datos de colectomía genéricos y específicos del Programa Nacional de Mejoramiento de la Calidad Quirúrgica.AJUSTE:Hospitales de Norte America que participan en el Programa Nacional de Mejoramiento de la Calidad Quirúrgica del Colegio Americano de Cirujanos.PACIENTES:Todos los pacientes sometidos a resección quirúrgica electiva por cáncer colorrectal N2 en los hospitales participantes entre 2014 y 2018.INTERVENCIONES:Resección quirúrgica de cáncer colorrectal N2.PRINCIPALES MEDIDAS DE VOLORACION:Nuestro resultado principal fue el rendimiento nodal. Los resultados secundarios incluyeron complicaciones perioperatorias y mortalidad.RESULTADOS:1837 pacientes fueron sometidos a cirugía abierta y 3907 pacientes fueron sometidos a colectomías de cirugía mínimamente invasiva por cáncer colorrectal N2 (n = 5744). La mediana del rendimiento nodal fue 20 (IQR 15-27) en el grupo abierto y 21 (IQR 16-28) en el grupo mínimamente invasivo (p <0,0001); sin embargo, el rendimiento nodal entre los dos grupos no fue significativamente diferente en el análisis multivariado. Las complicaciones perioperatorias fueron mayores en el análisis univariado en el grupo de cirugía abierta, con respecto a los resultados clave, incluida la fuga anastomótica y la muerte (p <0,001).LIMITACIONES:Este estudio está limitado por su diseño retrospectivo y por el hecho de que los datos de estadificación recopilados por NSQIP son patológicos más que clínicos; sin embargo, estudios previos encontraron una concordancia del 97% entre la determinación patológica y clínica de N2.CONCLUSIONES:Los enfoques de cirugía mínimamente invasiva para el cáncer colorrectal con enfermedad N2 dan rendimientos nodales equivalentes a abordajes abiertos. Nuestro grupo apoya el uso de abordaje mínimamente invasivo en el cáncer colorrectal avanzado en estadio ganglionar en el paciente adecuadamente seleccionado. Consulte Video Resumenhttp://links.lww.com/DCR/B417.


Assuntos
Colectomia/estatística & dados numéricos , Neoplasias Colorretais/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Fístula Anastomótica/epidemiologia , Estudos de Casos e Controles , Colectomia/métodos , Neoplasias Colorretais/patologia , Interpretação Estatística de Dados , Feminino , Humanos , Linfonodos/patologia , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/estatística & dados numéricos , Estadiamento de Neoplasias/métodos , Período Perioperatório/mortalidade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Segurança , Resultado do Tratamento
11.
Surgery ; 170(2): 493-498, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33608150

RESUMO

BACKGROUND: Survey-based studies are often the basis of policy changes; however, the methodologic quality of such research can be questionable. Methodologic reviews of survey-based studies have been conducted in other medical fields, but the surgical literature has not been assessed. METHODS: All citations published in 9 major surgical journals from 2002 to 2019 were screened for studies administering surveys to health care professionals. Descriptive and methodologic data were collected by 2 reviewers who also assessed the transparency and quality of the methodology. Agreement between reviewers was assessed using a weighted κ-statistic. Survey quality metrics were measured, descriptive statistics were calculated, and regression analysis was used to assess the association between subjective overall study quality and objective quality metrics. RESULTS: We included 271 articles in our analysis; the weighted-κ for reviewer quality assessment was 0.69 and for transparency assessment was 0.71. Deficiencies were identified in questionnaire development methodology and reporting, in which the median number of developmental steps reported was 1 (of 8) and in the reporting of incomplete/missing data where 63% of studies failed to report how incomplete questionnaires were managed; 70% of studies failed to report missing data. Overall subjective quality was positively associated with objective quality metrics. CONCLUSION: The deficiencies identified in the surgical literature highlight the need for improvement in the conduct and reporting of survey-based research, both in the surgical literature and more broadly. Adoption of a standardized reporting guideline for survey-based research may ameliorate the deficiencies identified by this study and other investigations.


Assuntos
Cirurgia Geral , Pesquisa Qualitativa , Inquéritos e Questionários , Humanos , Reprodutibilidade dos Testes , Projetos de Pesquisa
12.
Surg Endosc ; 2021 Jan 27.
Artigo em Inglês | MEDLINE | ID: mdl-33502618

RESUMO

BACKGROUND: Anastomotic leak (AL) is a common complication after colectomy with a relatively high failure to rescue rate (FTR), or death after major complications. There is emerging evidence to suggest an early AL may be associated with increased technical difficulty. Whether the timing of an AL is associated with higher FTR has not been established. METHODS: Patients who underwent a colectomy between 2012 and 2017 were identified from the American College of Surgeons National Quality Improvement Program (ACS NSQIP database). The primary outcome was FTR after AL. The predictor variable used was day of post-operative leak (POD) categorized into early (POD ≤ 3), intermediate (3 < POD ≤ 20) and late (20 < POD ≤ 30) AL. These POD groups were compared to generate hypotheses to explain any association observed between timing of AL and FTR. RESULTS: Of 135,539 identified patients, 4613 patients experienced an AL (3.4%) with an overall FTR of 6.4%. FTR differed by timing of AL: early AL was found to have a FTR of 28/195 (12.6%), with a FTR in intermediate AL of 152/2550 (5.6%) and 3/356 (0.8%) in late AL patients (p < 0.0001). When compared by timing of AL, patients differed by sex, pre-operative bowel preparation, de-functioning ostomy rates and re-operation rates (p < 0.05). Controlling for age, ASA, sex, emergency status, operative approach, indication, de-functioning ostomy, re-operation and concurrent procedure, an early AL was found to have a 2.3-fold increased risk of FTR (95% CI 1.38-3.84, p = 0.001), with a late AL having a 0.15-fold decreased risk (95% CI 0.04-0.49, p = 0.002), both compared to an intermediate AL. CONCLUSION: Early ALs, occurring within three days of surgery, may carry a significant risk of FTR. Given the findings identified here, this may support the use of early detection algorithms and interventions of AL to minimize the risk of FTR.

14.
Ann Surg Oncol ; 28(5): 2779-2787, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33098049

RESUMO

IMPORTANCE: Failure to rescue (FTR), or death after major complications, has emerged as a marker of hospital-level quality of care. OBJECTIVE: To evaluate the predictive performance of the ACS-NSQIP modified frailty index (mFI) in determining FTR following an anastomotic leak (AL) after a colectomy for colorectal cancer. DESIGN: Retrospective cohort study. SETTING: Multicenter interrogation of the 2012-2016 American College of Surgeons (ACS) colectomy procedure targeted National Surgical Quality Improvement Program (NSQIP) database. PATIENTS AND METHODS: A total of 50,944 patients who underwent colectomy for colorectal cancer. EXPOSURE: Frailty as measured by: (1) Age, ASA, and emergency status (model 1), (2) Age, ASA, emergency status, and mFI (model 2), (3) ACS-NSQIP mortality prediction (model 3). MAIN OUTCOME AND MEASURE: Primary outcome was FTR after AL. RESULTS: A total of 1755 patients experienced an AL (3.46%) with a FTR rate of 6.44%. The mean age was 65.6 years (95% CI 65.28-65.58 years), median ASA was 3 (IQR 2-3), 51 patients (2.92%) were partially or totally dependent, 366 (20.86%) were diabetic, 105 (5.98%) had a history of chronic obstructive pulmonary disease (COPD), 32 (1.82%) had a history of congestive heart disease (CHD), and 966 (55.04%) were on hypertensive treatment. The performance of model 1 (AUROC 0.77; 95% CI 0.72-0.81), model 2 (AUROC 0.77; 95% CI 0.73-0.82), and model 3 (AUROC 0.79; 95% CI 0.75-0.83) to predict FTR was not different (p = 0.44). CONCLUSIONS AND RELEVANCE: Age and ASA remain the most reliable predictors of failure to rescue anastomotic leak after colectomy for colorectal cancer. Addition of the modified frailty index, or all variables collected by NSQIP, did not significantly improve predictive performance.


Assuntos
Neoplasias do Colo , Fragilidade , Idoso , Fístula Anastomótica/etiologia , Colectomia , Neoplasias do Colo/cirurgia , Fragilidade/diagnóstico , Humanos , Complicações Pós-Operatórias , Estudos Retrospectivos , Fatores de Risco
15.
J Surg Oncol ; 123(2): 470-478, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33141434

RESUMO

BACKGROUND: Technical and clinical differences in resection of obstructed and non-obstructed colon cancers may result in differences in lymph node retrieval. The objective of this study is to compare the lymph node harvest following resection of obstructed and nonobstructed colon cancer patients. METHODS: A retrospective analysis utilizing the 2014-2018 NSQIP colectomy targeted data set was conducted. One-to-one coarsened exact matching (CEM) was utilized between patients undergoing resection for obstructed and non-obstructed colon cancer. The primary outcome was the adequacy of lymph node retrieval (LNR, ≥12 nodes). RESULTS: CEM resulted in 9412 patients. Patients with obstructed tumors were more likely to have inadequate LNR (13.3% vs 8.2%, p < .001) compared to those with nonobstructed tumors. Multivariate analysis demonstrated that patients with obstructing tumors had worse LNR compared to non-obstructed tumors (odds ratio [OR]: 0.74, 95% confidence interval [CI]: 0.62-0.87; p < .005). Increased age (OR: 0.99, 95% CI: 0.098-0.99), presence of preoperative sepsis (OR: 0.70, 95% CI: 0.055-0.90), left-sided and sigmoid tumors compared to right-sided (OR: 0.64, 95% CI: 0.51-0.81; OR: 0.69, 95% CI: 0.58-0.82, respectively), and open surgical resection compared to an minimally invasive surgical approach were associated with inadequate LNR (p < .05). CONCLUSION: This study demonstrated that resection for obstructing colon cancer compared to non-obstructed colon cancer is associated with increased odds of inadequate lymph node harvest.


Assuntos
Colectomia/métodos , Neoplasias do Colo/cirurgia , Obstrução Intestinal/fisiopatologia , Excisão de Linfonodo/estatística & dados numéricos , Linfonodos/cirurgia , Idoso , Neoplasias do Colo/patologia , Feminino , Seguimentos , Humanos , Linfonodos/patologia , Masculino , Prognóstico , Estudos Retrospectivos
16.
Arch Pathol Lab Med ; 145(3): 365-370, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-32649836

RESUMO

CONTEXT.­: Laparoscopic sleeve gastrectomy (LSG) has quickly become the bariatric surgical procedure of choice for patients with obesity who have failed medical management. Laparoscopic sleeve gastrectomy results in a gastric remnant that is routinely subject to pathologic examination. OBJECTIVE.­: To perform a histologic and cost-benefit analysis of gastric remnants post-LSG. DESIGN.­: All LSG cases performed at University Health Network, Toronto, Ontario, Canada, between 2010 and 2019 were reviewed. Specimens that underwent routine histopathologic assessment and ancillary immunohistochemical analysis were analyzed. Baseline patient characteristics and surgical outcomes were obtained from our internal database. The total cost of specimen gross preparation, examination, sampling, and producing and reporting a hematoxylin-eosin slide was calculated. RESULTS.­: A total of 572 patients underwent LSG during the study period and had their specimens examined histologically. A mean of 4.87 blocks generating 4 hematoxylin-eosin slides was produced. The most common histologic findings reported in LSG specimens ranged from no pathologic abnormalities identified together with proton pump inhibitor-related change. A minority of cases demonstrated clinically actionable histologic findings, of which Helicobacter pylori infection was the most common. The total cost for the complete pathologic analysis of these cases amounted to CaD $66 383.10 (US $47 080.21) with a mean of CaD $116.05 (US $82.40) per case. A total of CaD $62 622.75 (US $44 413.30) was spent on full examination of cases that had no further postoperative clinical impact. CONCLUSIONS.­: There is a broad spectrum of pathologic findings in LSG specimens, ranging from clinically nonactionable to more clinically actionable. The vast majority of histologic findings had no clinical impact, with only a minority of cases being clinically significant. This study therefore recommends that LSG specimens be subject to gross pathologic examination in the vast majority of cases. However, sections should be submitted for microscopic analysis if grossly evident lesions are present and if there is a clinical/known history of clinically actionable findings.


Assuntos
Gastrectomia/economia , Infecções por Helicobacter/patologia , Helicobacter pylori/isolamento & purificação , Laparoscopia/economia , Obesidade Mórbida/patologia , Adulto , Cirurgia Bariátrica , Análise Custo-Benefício , Feminino , Infecções por Helicobacter/diagnóstico , Infecções por Helicobacter/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/diagnóstico , Obesidade Mórbida/cirurgia , Ontário
17.
Ann Surg ; 272(2): e118-e124, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32675513

RESUMO

OBJECTIVE: Our objective was to review the literature surrounding the risks of viral transmission during laparoscopic surgery and propose mitigation measures to address these risks. SUMMARY BACKGROUND DATA: The SARS-CoV-2 pandemic has caused surgeons the world over to re-evaluate their approach to surgical procedures given concerns over the risk of aerosolization of viral particles and exposure of operating room staff to infection. International society guidelines advise against the use of laparoscopy; however, the evidence on this topic is scant and recommendations are based on the perceived most cautious course of action. METHODS: We conducted a narrative review of the existing literature surrounding the risks of viral transmission during laparoscopic surgery and balance these risks against the benefits of minimally invasive approaches. We also propose mitigation measures to address these risks that we have adopted in our institution. RESULTS AND CONCLUSION: While it is currently assumed that open surgery minimizes operating room staff exposure to the virus, our findings reveal that this may not be the case. A well-informed, evidence-based opinion is critical when making decisions regarding which operative approach to pursue, for the safety and well-being of the patient, the operating room staff, and the healthcare system at large. Minimally invasive surgical approaches offer significant advantages with respect to both patient care, and the mitigation of the risk of viral transmission during surgery, provided the appropriate equipment and expertise are present.


Assuntos
Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/transmissão , Controle de Infecções/métodos , Transmissão de Doença Infecciosa do Paciente para o Profissional , Laparoscopia , Procedimentos Cirúrgicos Minimamente Invasivos , Salas Cirúrgicas , Pneumonia Viral/epidemiologia , Pneumonia Viral/transmissão , Betacoronavirus , COVID-19 , Tomada de Decisões , Humanos , Pandemias , Seleção de Pacientes , Equipamento de Proteção Individual , SARS-CoV-2
18.
Surg Endosc ; 34(9): 3748-3753, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32504263

RESUMO

INTRODUCTION: Transanal total mesorectal excision (taTME) is a novel approach to surgery for rectal cancer. The technique has gained significant popularity in the surgical community due to the promising ability to overcome technical difficulties related to the access of the distal pelvis. Recently, Norwegian surgeons issued a local moratorium related to potential issues with the safety of the procedure. Early adopters of taTME in Canada have recognized the need to create guidelines for its adoption and supervision. The objective of the statement is to provide expert opinion based on the best available evidence and authors' experience. METHODS: The procedure has been performed in Canada since 2014 at different institutions. In 2016, the first Canadian taTME congress was held in the city of Toronto, organized by two of the authors. In early 2019, a multicentric collaborative was established [The Canadian taTME expert Collaboration] which aimed at ensuring safe performance and adoption of taTME in Canada. Recently surgeons from 8 major Canadian rectal cancer centers met in the city of Toronto on December 7 of 2019, to discuss and develop a position statement. There in person, meeting was followed by 4 rounds of Delphi methodology. RESULTS: The generated document focused on the need to ensure a unified approach among rectal cancer surgeons across the country considering its technical complexity and potential morbidity. The position statement addressed four domains: surgical setting, surgeons' requirements, patient selection, and quality assurance. CONCLUSIONS: Authors agree transanal total mesorectal excision is technically demanding and has a significant risk for morbidity. As of now, there is uncertainty for some of the outcomes. We consider it is possible to safely adopt this operation and obtain adequate results, however for this purpose it is necessary to meet specific requirements in different domains.


Assuntos
Consenso , Laparoscopia/normas , Protectomia/normas , Neoplasias Retais/cirurgia , Reto/cirurgia , Cirurgiões/normas , Cirurgia Endoscópica Transanal/normas , Canadá , Humanos , Laparoscopia/métodos , Protectomia/métodos , Cirurgia Endoscópica Transanal/métodos
19.
J Clin Pathol ; 73(10): 618-623, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32591353

RESUMO

BACKGROUND: Bariatric surgical procedures are employed when there is a failure of lifestyle modification in arresting obesity. Laparoscopic sleeve gastrectomy (LSG) is quickly becoming the bariatric surgical procedure of choice. LSG results in a gastric remnant that is subject to pathological examination. The objective of this paper is to review the literature in regard to histological findings identified in gastric remnants post-LSG and identify the most pertinent histological findings. MATERIALS AND METHODS: A literature search was performed to identify relevant case series. Data gathered from relevant case series then underwent statistical analysis. RESULTS: The most common histological findings in an LSG specimen were clinically indolent findings such as no pathological abnormalities identified followed by non-specific gastritis. A minority of cases demonstrated clinically actionable findings for which Helicobacter pylori represented the majority of these findings. CONCLUSION: There is a broad spectrum of pathological findings in LSG specimens, ranging from clinically indolent to clinically actionable. The most common histological findings are clinically indolent and only a small portion are of clinical significance and, hence, actionable.


Assuntos
Obesidade Mórbida/patologia , Obesidade Mórbida/cirurgia , Estômago/patologia , Adulto , Cirurgia Bariátrica , Feminino , Gastrectomia , Humanos , Laparoscopia , Masculino , Pessoa de Meia-Idade
20.
Can J Surg ; 63(3): E208-E210, 2020 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-32356948

RESUMO

Summary: In the decade since its inception, the World Health Organization's surgical safety checklist has fundamentally changed the conduct of surgery the world over. A critical component of the checklist - the "pause" or "time-out" - requires all operating room staff to stop other activities and together review critical information about the case to ensure that nothing is missed. Surgical trainees in Canada are transitioning to a competency-based medical education model; a core aspect of this model requires trainees to advocate for their own learning goals. We propose the use of a detailed and formalized preoperative pause as a means to enable superior and more targeted intraoperative learning for surgical trainees.


Assuntos
Atitude do Pessoal de Saúde , Lista de Checagem , Educação Baseada em Competências/métodos , Educação de Pós-Graduação em Medicina/métodos , Ortopedia/educação , Canadá , Humanos , Aprendizagem , Salas Cirúrgicas
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