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1.
Isr Med Assoc J ; 22(1): 13-16, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31927799

RESUMO

BACKGROUND: During Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) the surgeon operates exclusively through a single vaginal entry point, leaving no external scarring. OBJECTIVES: To evaluate the learning curve of vNOTES hysterectomy by experienced gynecologists based on surgical times and short-term outcomes. METHODS: A retrospective study was conducted of the first 25 vNOTES hysterectomy surgeries performed from July to December 2018 at Rambam Health Care Campus by a single surgeon. The primary outcome was hysterectomy time. Secondary outcomes included intra-operative bleeding, length of hospitalization, postoperative pain, and need for analgesia. Socio-demographic and clinical data were retrieved from patient electronic medical charts. RESULTS: Median age was 64.5 years (range 40-79). Median hysterectomy time was 38 minutes (range 30-49) from the first cut until completion. Comparisons between median hysterectomy time in the first 10 hysterectomies and in the 15 subsequent procedures demonstrated a significant decrease in median total time: 45 minutes (range 41-49) vs. 32 minutes (range 30-38), respectively (P = 0.024). The median estimated intraoperative blood loss decreased from 100 ml (range 70-200) in the first 10 hysterectomies to 40 ml (range 20-100) in the subsequent procedures (P = 0.011). CONCLUSIONS: vNOTES hysterectomy is feasible by an experienced gynecologist, with an exponential improvement in surgical performance in a short period as expressed by the improvement in hysterectomy time, low complication rates, negligible blood loss, minimal post-surgical pain, fast recovery, and short hospitalization. vNOTES allows easier and safer access to adnexal removal compared to conventional vaginal surgery.


Assuntos
Ginecologia/educação , Histerectomia Vaginal/educação , Curva de Aprendizado , Cirurgia Endoscópica por Orifício Natural/educação , Adulto , Idoso , Feminino , Humanos , Histerectomia Vaginal/métodos , Pessoa de Meia-Idade , Cirurgia Endoscópica por Orifício Natural/métodos , Duração da Cirurgia , Estudos Retrospectivos , Resultado do Tratamento
2.
Bone Joint J ; 102-B(1): 117-124, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31888372

RESUMO

AIMS: It is unknown whether kinematic alignment (KA) objectively improves knee balance in total knee arthroplasty (TKA), despite this being the biomechanical rationale for its use. This study aimed to determine whether restoring the constitutional alignment using a restrictive KA protocol resulted in better quantitative knee balance than mechanical alignment (MA). METHODS: We conducted a randomized superiority trial comparing patients undergoing TKA assigned to KA within a restrictive safe zone or MA. Optimal knee balance was defined as an intercompartmental pressure difference (ICPD) of 15 psi or less using a pressure sensor. The primary endpoint was the mean intraoperative ICPD at 10° of flexion prior to knee balancing. Secondary outcomes included balance at 45° and 90°, requirements for balancing procedures, and presence of tibiofemoral lift-off. RESULTS: A total of 63 patients (70 knees) were randomized to KA and 62 patients (68 knees) to MA. Mean ICPD at 10° flexion in the KA group was 11.7 psi (SD 13.1) compared with 32.0 psi in the MA group (SD 28.9), with a mean difference in ICPD between KA and MA of 20.3 psi (p < 0.001). Mean ICPD in the KA group was significantly lower than in the MA group at 45° and 90°, respectively (25.2 psi MA vs 14.8 psi KA, p = 0.004; 19.1 psi MA vs 11.7 psi KA, p < 0.002, respectively). Overall, participants in the KA group were more likely to achieve optimal knee balance (80% vs 35%; p < 0.001). Bone recuts to achieve knee balance were more likely to be required in the MA group (49% vs 9%; p < 0.001). More participants in the MA group had tibiofemoral lift-off (43% vs 13%; p < 0.001). CONCLUSION: This study provides persuasive evidence that restoring the constitutional alignment with KA in TKA results in a statistically significant improvement in quantitative knee balance, and further supports this technique as a viable alternative to MA. Cite this article: Bone Joint J. 2020;102-B(1):117-124.


Assuntos
Artroplastia do Joelho/métodos , Prótese do Joelho , Osteoartrite do Joelho/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Fenômenos Biomecânicos , Feminino , Humanos , Curva de Aprendizado , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Osteoartrite do Joelho/fisiopatologia , Planejamento de Assistência ao Paciente , Cuidados Pré-Operatórios , Implantação de Prótese/métodos , Amplitude de Movimento Articular/fisiologia , Resultado do Tratamento
5.
Int Braz J Urol ; 45(6): 1122-1128, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31808399

RESUMO

INTRODUCTION: To evaluate the influence of previous experience as bedside assistants on patient selection, perioperative and pathological results in robot assisted laparoscopic radical prostatectomy. MATERIALS AND METHODS: The first 50 cases of two robotic surgeons were reviewed retrospectively. Group 1 consisted of the first 50 cases of the surgeon with previous experience as a robotic bedside assistant between September 2016-July 2018, while group 2 included the first 50 cases of the surgeon with no bedside assistant experience between February 2009-December 2009. Groups were examined in terms of demographics, prostate volume, presence of median lobe, prostate specific antigen (PSA), preoperative Gleason score, positive core number, clinical stage, console surgery time, estimated blood loss, postoperative Gleason score, pathological stage, positive surgical margin rate, postoperative complications, length of hospital stay and biochemical recurrence rate. RESULTS: Previous abdominal surgery and the presence of median lobe hypertrophy rates were higher in Group 1 than in Group 2 (20% vs. 4%, p=0.014; 24% vs. 6%, p=0.012; respectively). In addition, patients in Group 1 were in a higher clinical stage than those in Group 2 (cT2: 70% vs. 28%, p=0.001). Median console surgery time and median length of hospital stay was significantly shorter in Group 1 than in Group 2 (170 min vs. 240 min, p=0.001; 3 vs. 4, p=0.022; respectively). Clavien grade 3 complication rate was higher in Group 2 but was statistically insignificant. CONCLUSION: Our findings might reflect that previous bedside assistant experience led to an increase in self-confidence and the ability to manage troubleshooting and made it more likely for surgeons to start with more difficult cases with more challenging patients. It is recommended that novice surgeons serve as bedside assistants before moving on to consoles.


Assuntos
Competência Clínica , Prostatectomia/educação , Procedimentos Cirúrgicos Robóticos/educação , Idoso , Humanos , Curva de Aprendizado , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Duração da Cirurgia , Prostatectomia/métodos , Neoplasias da Próstata/patologia , Neoplasias da Próstata/cirurgia , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/métodos , Autoimagem , Estatísticas não Paramétricas , Fatores de Tempo , Resultado do Tratamento
6.
Int Braz J Urol ; 45(6): 1136-1143, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31808401

RESUMO

PURPOSE: To prospectively evaluate the association of adherent perinephric fat (APF) on perioperative outcomes of robotic-assisted partial nephrectomy (RAPN) following elimination of the surgical learning curve. MATERIALS AND METHODS: 305 consecutive RAPNs performed by a single experienced surgeon were analyzed. The fi rst 100 RAPNs were considered the learning curve and therefore excluded. APF was defined as the necessity of subcapsular renal dissection to mobilize the tumor from surrounding perinephric fat. Perioperative outcomes were evaluated including operative time, warm ischemia time (WIT), postoperative complications, length of stay, margins, ischemia, and complications score (MIC), estimated blood loss (EBL), and change in pre-operative to postoperative day 1 (POD 1) laboratory values. After correction for multiple comparisons, P values ≤0.0045 were considered statistically signifi cant but associations with P values ≤0.05 were also mentioned in the study results. RESULTS: Fifty-eight (28.3%) patients had APF. Patients with APF had longer operative times compared to those without APF (median, 213 vs. 192 minutes, P <0.001). There was some evidence of higher increase in change in creatinine from preoperative to POD 1 among those with APF compared to those without APF, although this was not statistically signifi cant (median, 0.2 vs. 0.1mg/dL, P=0.03). There were no other statistically significant associations between presence of APF and perioperative outcomes. CONCLUSIONS: APF is associated with increased operative time but no change in other perioperative outcomes. Surgeon experience does not affect perioperative outcomes associated with APF.


Assuntos
Tecido Adiposo Branco/cirurgia , Competência Clínica , Curva de Aprendizado , Nefrectomia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Índice de Massa Corporal , Feminino , Taxa de Filtração Glomerular , Humanos , Masculino , Pessoa de Meia-Idade , Nefrectomia/efeitos adversos , Duração da Cirurgia , Período Perioperatório , Complicações Pós-Operatórias , Estudos Prospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Estatísticas não Paramétricas , Resultado do Tratamento , Adulto Jovem
7.
Bone Joint J ; 101-B(12): 1585-1592, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31786991

RESUMO

AIMS: Arthroplasty skills need to be acquired safely during training, yet operative experience is increasingly hard to acquire by trainees. Virtual reality (VR) training using headsets and motion-tracked controllers can simulate complex open procedures in a fully immersive operating theatre. The present study aimed to determine if trainees trained using VR perform better than those using conventional preparation for performing total hip arthroplasty (THA). PATIENTS AND METHODS: A total of 24 surgical trainees (seven female, 17 male; mean age 29 years (28 to 31)) volunteered to participate in this observer-blinded 1:1 randomized controlled trial. They had no prior experience of anterior approach THA. Of these 24 trainees, 12 completed a six-week VR training programme in a simulation laboratory, while the other 12 received only conventional preparatory materials for learning THA. All trainees then performed a cadaveric THA, assessed independently by two hip surgeons. The primary outcome was technical and non-technical surgical performance measured by a THA-specific procedure-based assessment (PBA). Secondary outcomes were step completion measured by a task-specific checklist, error in acetabular component orientation, and procedure duration. RESULTS: VR-trained surgeons performed at a higher level than controls, with a median PBA of Level 3a (procedure performed with minimal guidance or intervention) versus Level 2a (guidance required for most/all of the procedure or part performed). VR-trained surgeons completed 33% more key steps than controls (mean 22 (sd 3) vs 12 (sd 3)), were 12° more accurate in component orientation (mean error 4° (sd 6°) vs 16° (sd 17°)), and were 18% faster (mean 42 minutes (sd 7) vs 51 minutes (sd 9)). CONCLUSION: Procedural knowledge and psychomotor skills for THA learned in VR were transferred to cadaveric performance. Basic preparatory materials had limited value for trainees learning a new technique. VR training advanced trainees further up the learning curve, enabling highly precise component orientation and more efficient surgery. VR could augment traditional surgical training to improve how surgeons learn complex open procedures. Cite this article: Bone Joint J 2019;101-B:1585-1592.


Assuntos
Artroplastia de Quadril/educação , Educação de Pós-Graduação em Medicina/métodos , Ortopedia/educação , Treinamento por Simulação/métodos , Realidade Virtual , Adulto , Competência Clínica , Feminino , Seguimentos , Humanos , Curva de Aprendizado , Londres , Masculino , Desempenho Psicomotor , Método Simples-Cego
9.
Zhongguo Gu Shang ; 32(12): 1173-1176, 2019 Dec 25.
Artigo em Chinês | MEDLINE | ID: mdl-31870082

RESUMO

The posterior condylar fracture of the tibial plateau refers to the fracture of the posterior 1/3 area of the tibial plateau. Compared with other clinical types such as Schatzker and AO, the three-column theory is more widely used in the diagnosis and treatment of the posterior condylar fracture of the tibial plateau. There are advantages and disadvantages in learning curve, intraoperative risk and therapeutic effect of minimally invasive methods such as posterior and lateral related approaches, circular external fixator and balloon dilatation, which are commonly used in open surgery. There is no consensus on the best surgical method. This article reviews the diagnosis, classification and treatment of posterior condylar fracture of tibial plateau.


Assuntos
Fraturas da Tíbia , Fixadores Externos , Fixação Interna de Fraturas , Humanos , Curva de Aprendizado , Tíbia , Fraturas da Tíbia/diagnóstico , Fraturas da Tíbia/terapia
10.
Chirurgia (Bucur) ; 114(5): 622-629, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31670638

RESUMO

Since its first description in 1992, laparoscopic adrenalectomy has become the standard of treatment for most benign and low grade small adrenal tumors but due to the low incidence of adrenal disease, it remains a rarely performed intervention outside referral or excellence centers. Although laparoscopic surgery had a positive impact on complications of adrenalectomy, surgical risk should be thoroughly assessed when it comes to secreting or large tumors. This is a retrospective analysis of laparoscopic adrenalectomies performed in the first 4 years of practice 2007-2010 - the early experience including the learning curve of the senior surgeon, and our late experience from 2016 to 2019. All interventions were performed by a single team led by a senior surgeon with extensive experience in advanced laparoscopic surgery, using the lateral transperitoneal approach. In total, 82 cases were included, out of 153 laparoscopic adrenalectomies performed between 2007 and 2019. Only one conversion was recorded during the early experience and two laparoscopic reinterventions were needed for hemostasis and drainage. Non-secreting adenoma was the most frequent indication for surgery (26 cases) followed by Cushing's Syndrome (22 cases) while adrenocortical carcinoma was diagnosed in 3 cases. Significant differences were found between the two periods regarding operative time and length of postoperative hospital stay (p 0.001). With growing experience in laparoscopic transperitoneal adrenalectomy, less complications and shorter operative time and postoperative hospital stay are to be expected.


Assuntos
Neoplasias das Glândulas Suprarrenais/cirurgia , Adrenalectomia/métodos , Adrenalectomia/estatística & dados numéricos , Humanos , Laparoscopia , Curva de Aprendizado , Tempo de Internação , Duração da Cirurgia , Peritônio/cirurgia , Estudos Retrospectivos , Medição de Risco
11.
Arch Esp Urol ; 72(9): 904-914, 2019 Nov.
Artigo em Espanhol | MEDLINE | ID: mdl-31697250

RESUMO

OBJECTIVES: To describe a roadmap of the most representative milestones and considerations in the validation of surgical simulators, especially those of laparoscopic surgery. And additionally, help determine when in this process a simulator can be considered as validated. METHODS: A non-systematic review was carried out searching terms like simulation, validation, training, assessment, skills and learning curve, as well as providing the experience accumulated by our center. RESULTS: An ideal classical validation process should consist of the following steps: fidelity, verification/calibration/ reliability, subjective and objective strategies. Baseline tests of fidelity and verification/calibration/ technological reliability are not always detailed in the simulation literature. A simulator can be considered validated if, at least, satisfactorily completed any of the two main objective strategies, that is, constructive and/or criterion validity. CONCLUSIONS: The methodologies to validate simulators as useful and reliable for the improvement of psychomotor/ technical skills are widely analyzed, although there is a variety of approaches depending on the scientific reference consulted, not being implemented equally in all works. This apparent arbitrariness should be considered in advance because it can lead the researcher to misunderstandings, especially when the simulator will be regarded as valid.


Assuntos
Laparoscopia , Treinamento por Simulação , Competência Clínica , Simulação por Computador , Humanos , Laparoscopia/métodos , Curva de Aprendizado , Reprodutibilidade dos Testes
12.
Semin Vasc Surg ; 32(1-2): 48-67, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31540657

RESUMO

The evolving demands of surgical training have led to the successful implementation of skills examinations in the areas of laparoscopic and endoscopic surgery. Currently, there is no similar formal skills assessment in vascular surgery, despite endovascular intervention replacing open surgery in treatment of many vascular conditions. The adoption of less invasive techniques to treat aneurysm and occlusive disease has resulted in new training paradigms and technical challenges for trainees. The duty hour restriction for trainees and declining numbers of complex open vascular interventions have added to the challenges of vascular surgery training. Simulation is a promising avenue for both skills training and assessment. The ability to evaluate the fundamental skills of trainees would be an important step to ensure a degree of uniformity in trainees' technical abilities. The role of simulation-based training in acquiring, testing, and refining these skills is still in its infancy in the vascular surgery training paradigm. This article aims to impart a deeper understanding of the conditions for developing and implementing the fundamentals of vascular and endovascular surgery, and to provide guidance regarding the role of simulation-based training in a rapidly evolving specialty. There are various forms of simulation available, including benchtop models, high-fidelity simulators, and virtual-reality simulators, and each requires a different method of proficiency assessment. Both open surgery and endovascular skills can be assessed and the application of successful implementation in academic vascular surgery training program is presented.


Assuntos
Certificação , Instrução por Computador/métodos , Educação de Pós-Graduação em Medicina/métodos , Internato e Residência , Treinamento por Simulação/métodos , Cirurgiões/educação , Procedimentos Cirúrgicos Vasculares/educação , Certificação/normas , Competência Clínica , Instrução por Computador/normas , Currículo , Educação de Pós-Graduação em Medicina/normas , Humanos , Curva de Aprendizado , Treinamento por Simulação/normas , Cirurgiões/normas , Procedimentos Cirúrgicos Vasculares/normas
13.
BMC Surg ; 19(1): 134, 2019 Sep 11.
Artigo em Inglês | MEDLINE | ID: mdl-31510984

RESUMO

BACKGROUND: Laparoscopic adrenalectomy (LA) is currently recognized as the gold standard for the treatment of most adrenal lesions, with a high safety and feasibility profile. This study aimed to present the extensive experience of a specialized endocrine surgeon in LA in a relatively large series of patients. METHODS: A total of 116 LAs performed from June 2009 to 2018 were evaluated in terms of adrenal pathologies, perioperative management, complications, conversions, tumor size, operative time, and learning curve. The learning curve was assessed using the cumulative sum (CUSUMOT) technique. RESULTS: Of 116 LAs, 107 (92.2%) were completed successfully, 77 (72%) of which were for Cushing's syndrome (n = 43, 55.8%), pheochromocytoma (n = 26, 33.8%), and Conn's syndrome (n = 8, 10.4%). Conversion was required in 9 cases (7.8%), the most common cause being limited space complicating dissection (n = 3). The mean operative time for successful LAs (unilateral 85, bilateral 22) was 74.7 min (range 40-210 min) and the mean hospital stay was 1.7 days (range 1-5 days). Gender, tumor size and body mass index were found to have no significant relationship with the operative time (p > 0.05). Postoperative normalization in hormone profiles was obtained in all patients but one. Aside from grade-I port-site infections in four patients (3.7%), no postoperative major complications and 30-day mortality were observed. On the CUSUMOT graph, the learning period covered the first 34 operations. CONCLUSIONS: Laparoscopic adrenalectomy is safe and advantageous, but requires a dedicated team involving experienced endocrine surgeons who have achieved competency after completion of the learning curve.


Assuntos
Neoplasias das Glândulas Suprarrenais/cirurgia , Adrenalectomia/métodos , Síndrome de Cushing/cirurgia , Hiperaldosteronismo/cirurgia , Feocromocitoma/cirurgia , Adulto , Idoso , Feminino , Humanos , Laparoscopia/métodos , Curva de Aprendizado , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Adulto Jovem
14.
Khirurgiia (Mosk) ; (9): 44-51, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31532166

RESUMO

OBJECTIVE: To determine validity and adequacy of the assessment of experience acquisition in video-assisted hemithyroidectomy, to compare surgical outcomes at the learning stage and in delayed period. MATERIAL AND METHODS: Experience acquisition was studied via assessment of the duration of video-assisted hemithyroidectomy in 67 patients who were operated by the same surgeon. Time of surgery was analyzed through between-group comparison of surgical outcomes. These groups were defined arbitrarily, in exponential fashion, using the logarithm method and moving average. Risks of failure regarding duration of surgery and postoperative complications were investigated using CUSUM analysis. RESULTS: Minimum period of experience accumulation in video-assisted hemithyroidectomy (26 procedures) was determined using logarithmic analysis, maximum period (66 interventions) - using CUSUM analysis. Other approaches also showed sharp nature of the learning curve.CUSUM analysis of failures at the learning stage showed 2-fold decrease of their probability after 66 operations. However, even experience acquisitiondoes not exclude risk of failures in hemithyroidectomy. CONCLUSION: Arbitrary division of the cohort of patients seems to be unreasonable because clear number of operations necessary to achieve sustainable results does not follow it.Mathematical methods adequately reflect experience accumulation and allow determining the required number of interventions for stable results and minimum complication rate.


Assuntos
Curva de Aprendizado , Doenças da Glândula Tireoide/cirurgia , Tireoidectomia/métodos , Cirurgia Vídeoassistida/métodos , Estudos de Coortes , Humanos , Tireoidectomia/efeitos adversos , Tireoidectomia/estatística & dados numéricos , Cirurgia Vídeoassistida/efeitos adversos , Cirurgia Vídeoassistida/estatística & dados numéricos
15.
Curr Urol Rep ; 20(10): 59, 2019 Sep 02.
Artigo em Inglês | MEDLINE | ID: mdl-31478111

RESUMO

PURPOSE OF REVIEW: The purpose of this review is to summarize the most current literature regarding the most important aspects to consider when developing a center of excellence for prostate imaging and biopsy. RECENT FINDINGS: Multiparametric MRI (mp-MRI) has changed the way we diagnose and treat prostate cancer. This imaging modality allows for more precise identification of areas suspicious in terms of harboring prostate cancer, enabling performance of targeted mp-MRI-guided biopsies that have been demonstrated to yield superior cancer detection rates. Centers worldwide are increasingly adopting this technology. However, obtaining results comparable with those findings published in the literature can be challenging. The imaging and biopsy process entails the need for a multidisciplinary team including a dedicated radiologist, urologist, and pathologist. Adequate mp-MRI interpretation for accurate lesion identification, acquaintance with the biopsy technique selected, and precise characterization of Gleason Score/Grade Groupings are equal determinants of accurate biopsy results. Furthermore, all specialists are required to attain appropriate learning curves to ensure optimal results. In this review, we characterize crucial aspects to consider when developing a center of excellence for prostate imaging and biopsy as well as insights regarding how to implement them.


Assuntos
Instalações de Saúde/normas , Biópsia Guiada por Imagem/normas , Imagem por Ressonância Magnética/métodos , Neoplasias da Próstata/diagnóstico por imagem , Biópsia/métodos , Biópsia/normas , Humanos , Biópsia Guiada por Imagem/métodos , Curva de Aprendizado , Masculino , Gradação de Tumores , Equipe de Assistência ao Paciente/normas , Desenvolvimento de Programas/normas , Neoplasias da Próstata/patologia , Estados Unidos
16.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(8): 792-795, 2019 Aug 25.
Artigo em Chinês | MEDLINE | ID: mdl-31422621

RESUMO

So far, D2 lymphadenectomy has been recognized as the key one of the procedures in curative resection for gastric cancer. In summary, the standardized implementation of D2 lymphadenectomy can contribute to both surgical quality and patients' prognosis. Lymph node dissection, as an important basis for local surgical treatment of gastric cancer, involves certain technical risks due to complex adjacent relationship and anatomical variation of organs or blood vessels, and so on. There is a certain incidence of side injuries in D2 lymphadenectomy for a surgeon, regardless of the experience of learning curve. Complying with specification of surgical procedures and summarizing the vital points of lymph node dissection in each curative gastrectomy for gastric cancer is the principal method to reduce or avoid the occurrence of relevant complications after surgery.


Assuntos
Gastrectomia/normas , Excisão de Linfonodo/efeitos adversos , Excisão de Linfonodo/normas , Neoplasias Gástricas/cirurgia , Gastrectomia/efeitos adversos , Gastrectomia/métodos , Humanos , Curva de Aprendizado , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Prognóstico , Neoplasias Gástricas/patologia
18.
Zentralbl Chir ; 144(4): 408-418, 2019 Aug.
Artigo em Alemão | MEDLINE | ID: mdl-31412418

RESUMO

Transanal total mesorectal excision (TaTME) is an innovative and technically demanding surgical approach for the treatment of rectal cancer. This review summarises the international consensus statements on prerequisites and training requirements for safe implementation of this complex procedure. Recommendations will be discussed on the basis of the published surveys from dedicated training centres. Furthermore, experience is shared on mentored TaTME cadaveric courses (video) and an initial clinical series of 102 TaTMEs. The procedure should be performed primarily by postgraduate colorectal surgeons. Initially, a structured training program at designated training centers is mandatory. Cadaver training and proctoring are the central elements required to ensure safe implementation of TaTME in clinical practice. However, validation of TaTME training concepts needs further work. Evaluation of the first pioneering series indicates a learning phase with at least 40 operations. Above the cut-off, lower complication rates and acceptable quality of specimen are achieved. In our series, morbidity decreased significantly (Clavien-Dindo ≥ III: 29 vs. 9%). With the indication for TaTME, we find a median of 6 risk factors (4 - 8) for an unfavourable outcome after abdominal TME alone. Only high volume centres with a concentration of appropriately selected patients could aim for a proposed TaTME frequency of 20 per year. Structured training programs for TaTME are justified and must be completed before implementation in clinical practice. The case volume effect for the learning curve and individual patient selection are crucial and support the concentration of the new method in high volume centres.


Assuntos
Neoplasias Retais , Cirurgia Endoscópica Transanal , Cadáver , Humanos , Curva de Aprendizado , Reto
20.
Med Sci Monit ; 25: 5903-5919, 2019 Aug 08.
Artigo em Inglês | MEDLINE | ID: mdl-31392971

RESUMO

BACKGROUND For early-stage cervical cancers, radical hysterectomy (RH) with pelvic lymphadenectomy has been the standard care. This study compared the learning curves and intra-, peri-, and post-operative outcomes for 3-dimensional laparoscopic RH (3D-LRH) and robotic-assisted (RA)-LRH by a surgeon highly skilled in 2-dimensional (2D)-LRH for treatment of early-stage cervical cancer. MATERIAL AND METHODS Two hundred and thirty-nine patients with early-stage cervical cancer (FIGO stage: Ia2-IIa2) admitted to Shanghai Obstetrics and Gynecology Hospital, Fudan University were recruited into this prospective study: 54, 85, and 100 patients underwent 2D-, 3D-, and RA-LRH, respectively and were followed up. Patients' demographic, clinical, and operative information was retrieved and compared. CUSUM (cumulative summation) analysis using a benchmark derived from previously performed 2D-LRHs. RESULTS Both 3D- and RA-LRH had a steep learning curve. 3D-LRH was superior to 2D- and RA-LRH in terms of significantly shorter operating time. For all approaches, the operating time was associated with the uterus size of the patient and was not affected by other parameters. All approaches of LRH yielded comparable radicality and operative results other than operative time. CONCLUSIONS Both 3D- and RA-LRH approaches had similar radicality, and intra-operative and post-operative complication rates, however, 3D-LRH had the shortest operating time and lowest amount of blood loss. After reaching proficiency, RA-LRH had comparable operating time with that of 2D-LRH, and might be even shorter in cases where surgeon has acquired more experience. In countries where labor costs are low; 3D-LRH might be preferable to 2D- and RA-LRH for early-stage cervical cancer.


Assuntos
Histerectomia/métodos , Laparoscopia/métodos , Neoplasias do Colo do Útero/cirurgia , Adenocarcinoma/patologia , Adulto , Benchmarking/métodos , Carcinoma de Células Escamosas/patologia , China , Feminino , Humanos , Curva de Aprendizado , Excisão de Linfonodo/métodos , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Duração da Cirurgia , Complicações Pós-Operatórias , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos , Neoplasias do Colo do Útero/patologia
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