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BACKGROUND: Associations between procedure volumes and outcomes can inform minimum volume standards and the regionalization of health services. Robot-assisted surgery continues to expand globally; however, data are limited regarding which hospitals should be using the technology. STUDY DESIGN: Using administrative health data for all residents of Ontario, Canada, this retrospective cohort study included adult patients who underwent a robot-assisted radical prostatectomy (RARP), total robotic hysterectomy (TRH), robot-assisted partial nephrectomy (RAPN), or robotic portal lobectomy using 4 arms (RPL-4) between January 2010 and September 2021. Associations between yearly hospital volumes and 90-day major complications were evaluated using multivariable logistic regression models adjusted for patient characteristics and clustering at the level of the hospital. RESULTS: A total of 10,879 patients were included, with 7567, 1776, 724, and 812 undergoing a RARP, TRH, RAPN, and RPL-4, respectively. Yearly hospital volume was not associated with 90-day complications for any procedure. Doubling of yearly volume was associated with a 17-min decrease in operative time for RARP (95% confidence interval [CI] - 23 to - 10), 8-min decrease for RAPN (95% CI - 14 to - 2), 24-min decrease for RPL-4 (95% CI - 29 to - 19), and no significant change for TRH (- 7 min; 95% CI - 17 to 3). CONCLUSION: The risk of 90-day major complications does not appear to be higher in low volume hospitals; however, they may not be as efficient with operating room utilization. Careful case selection may have contributed to the lack of an observed association between volumes and complications.
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Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos , Nefrectomia , Complicações Pós-Operatórias , Prostatectomia , Procedimentos Cirúrgicos Robóticos , Humanos , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Masculino , Feminino , Estudos Retrospectivos , Pessoa de Meia-Idade , Ontário , Prostatectomia/métodos , Nefrectomia/métodos , Idoso , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Duração da Cirurgia , Histerectomia/métodos , Histerectomia/estatística & dados numéricos , AdultoRESUMO
BACKGROUND: Robot-assisted surgery has been rapidly adopted. It is important to define the learning curve to inform credentialling requirements, training programs, identify fast and slow learners, and protect patients. This study aimed to characterize the hospital learning curve for common robot-assisted procedures. STUDY DESIGN: This cohort study, using administrative health data for Ontario, Canada, included adult patients who underwent a robot-assisted radical prostatectomy (RARP), total robotic hysterectomy (TRH), robot-assisted partial nephrectomy (RAPN), or robotic portal lobectomy using four arms (RPL-4) between 2010 and 2021. The association between cumulative hospital volume of a robot-assisted procedure and major complications was evaluated using multivariable logistic models adjusted for patient characteristics and clustering at the hospital level. RESULTS: A total of 6814 patients were included, with 5230, 543, 465, and 576 patients in the RARP, TRH, RAPN, and RPL-4 cohorts, respectively. There was no association between cumulative hospital volume and major complications. Visual inspection of learning curves demonstrated a transient worsening of outcomes followed by subsequent improvements with experience. Operative time decreased for all procedures with increasing volume and reached plateaus after approximately 300 RARPs, 75 TRHs, and 150 RPL-4s. The odds of a prolonged length of stay decreased with increasing volume for patients undergoing a RARP (OR 0.87; 95% CI 0.82-0.92) or RPL-4 (OR 0.77; 95% CI 0.68-0.87). CONCLUSION: Hospitals may adopt robot-assisted surgery without significantly increasing the risk of major complications for patients early in the learning curve and with an expectation of increasing efficiency.
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Procedimentos Cirúrgicos Robóticos , Masculino , Adulto , Feminino , Humanos , Procedimentos Cirúrgicos Robóticos/métodos , Estudos de Coortes , Curva de Aprendizado , Prostatectomia/efeitos adversos , Hospitais , Ontário , Resultado do TratamentoRESUMO
OBJECTIVE: The aim of this study was to determine if robotic-assisted lobectomy (RPL-4) is cost-effective and offers improved patient-reported health utility for patients with early-stage non-small cell lung cancer when compared with video-assisted thoracic surgery lobectomy (VATS-lobectomy). BACKGROUND: Barriers against the adoption of RPL-4 in publicly funded health care include the paucity of high-quality prospective trials and the perceived high cost of robotic surgery. METHODS: Patients were enrolled in a blinded, multicentered, randomized controlled trial in Canada, the United States, and France, and were randomized 1:1 to either RPL-4 or VATS-lobectomy. EuroQol 5 Dimension 5 Level (EQ-5D-5L) was administered at baseline and postoperative day 1; weeks 3, 7, 12; and months 6 and 12. Direct and indirect costs were tracked using standard methods. Seemingly Unrelated Regression was applied to estimate the cost effect, adjusting for baseline health utility. The incremental cost-effectiveness ratio was generated by 10,000 bootstrap samples with multivariate imputation by chained equations. RESULTS: Of 406 patients screened, 186 were randomized, and 164 analyzed after the final eligibility review (RPL-4: n=81; VATS-lobectomy: n=83). Twelve-month follow-up was completed by 94.51% (155/164) of participants. The median age was 68 (60-74). There were no significant differences in body mass index, comorbidity, pulmonary function, smoking status, baseline health utility, or tumor characteristics between arms. The mean 12-week health utility score was 0.85 (0.10) for RPL-4 and 0.80 (0.19) for VATS-lobectomy ( P =0.02). Significantly more lymph nodes were sampled [10 (8-13) vs 8 (5-10); P =0.003] in the RPL-4 arm. The incremental cost/quality-adjusted life year of RPL-4 was $14,925.62 (95% CI: $6843.69, $23,007.56) at 12 months. CONCLUSION: Early results of the RAVAL trial suggest that RPL-4 is cost-effective and associated with comparable short-term patient-reported health utility scores when compared with VATS-lobectomy.
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Carcinoma Pulmonar de Células não Pequenas , Neoplasias Pulmonares , Procedimentos Cirúrgicos Robóticos , Carcinoma de Pequenas Células do Pulmão , Humanos , Idoso , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Carcinoma Pulmonar de Células não Pequenas/patologia , Neoplasias Pulmonares/cirurgia , Neoplasias Pulmonares/patologia , Procedimentos Cirúrgicos Robóticos/métodos , Análise Custo-Benefício , Estudos Prospectivos , Carcinoma de Pequenas Células do Pulmão/cirurgia , Cirurgia Torácica Vídeoassistida/métodos , Pneumonectomia/métodosRESUMO
BACKGROUND: Lung cancer resection is associated with high rates of prolonged hospital stay. It is presumed that preconditioning with aerobic exercise can shorten the postoperative duration of hospital stay, but this has not yet been demonstrated in trials after lung cancer surgery. The aim of this study was to perform a RCT to determine whether Move For Surgery (MFS), a home-based and wearable technology-enhanced preconditioning program before lung cancer surgery, is associated with a lower incidence of prolonged hospital stay when compared to usual preoperative care. METHODS: Patients undergoing lung resection for early-stage non-small cell lung cancer were enrolled before surgery into this blinded, single-site RCT, and randomized to either the MFS or control group in a 1 : 1 ratio. Patients in the MFS group were given a wearable activity tracker, and education about deep breathing exercises, nutrition, sleep hygiene, and smoking cessation. Participants were motivated/encouraged to reach incrementally increasing fitness goals remotely. Patients in the control group received usual preoperative care. The primary outcome was the difference in proportion of patients with hospital stay lasting more than 5 days between the MFS and control groups. RESULTS: Of 117 patients screened, 102 (87.2 per cent) were eligible, enrolled, and randomized (51 per trial arm). The majority (95 of 102, 93.1 per cent) completed the trial. Mean(s.d.) age was 67.2(8.8) years and there were 55 women (58 per cent). Type of surgery and rates of thoracotomy were not different between arms. The proportion of patients with duration of hospital stay over 5 days was 3 of 45 (7 per cent) in the MFS arm compared to 12 of 50 (24 per cent) in the control arm (P = 0.021). CONCLUSION: MFS, a home-based and wearable technology-enhanced preconditioning program before lung cancer surgery, decreased the proportion of patients with a prolonged hospital stay. Registration number: NCT03689634 (http://www.clinicaltrials.gov).
After lung cancer surgery, many patients are admitted to hospital for a prolonged amount of time. It is believed that exercises undertaken before surgery can shorten the stay in hospital, but this has not yet been studied. This study aimed to find out whether Move For Surgery (MFS), a home-based exercise (preconditioning) program using wearable technology before lung cancer surgery, can decrease the number of patients who are admitted to hospital for a prolonged amount of time. Patients with lung cancer were invited to enter this trial 34 weeks before surgery. They were randomly put into the MFS or control group. Patients in the MFS group were given a wearable activity tracker, and education about deep breathing exercises, nutrition, sleep hygiene, and quitting smoking. Participants were encouraged to reach increasing fitness goals each week. Patients in the control group underwent usual preoperative care. The difference between the MFS and control groups in the proportion of patients with duration of stay in hospital exceeding 5 days was studied. There were 102 participants in total, 51 in each group. The majority (95 of 102, 93.1 per cent) completed the trial. The average age of participants was 67 years, and 58 per cent were women. Type of surgery and number of open operations were no different between groups. The proportion of patients with duration of stay greater than 5 days was 3 of 45 (7 per cent) in the MFS group compared with 12 of 50 (24 per cent) in the control group. Therefore, MFS before lung cancer surgery was shown to decrease the number of patients admitted to hospital for a prolonged amount of time.
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OBJECTIVE: Thymectomy has been utilized as a treatment for Myasthenia Gravis (MG) for many decades, with both open and minimally invasive surgical (MIS) techniques currently used. Although MIS has shown improved short-term results, long-term effects remain uncertain. This systematic review and meta-analysis aim to compare the post-operative and long-term outcomes of MIS versus open thymectomy in MG patients. METHODS: MEDLINE, EMBASE and CENTRAL databases were searched from inception till January 2022 for keywords related to MG and open or MIS thymectomy. Primary outcome was complete stable remission (CSR), and secondary outcomes were clinical improvement, complications, length of stay, operation time, and blood loss. Grading of recommendations, assessment, development, and evaluation was used to assess the certainty of evidence. RESULTS: 26 studies with 3588 patients were included in the analysis. At 1, 3 and 5 years, there was no statistical difference noted in CSR between open versus MIS thymectomy. However, CSR was improved at 1 year for MIS thymectomy in non-thymomatous MG (P = 0.03). There was no significant difference in rates of partial clinical improvement between techniques at 1-year. Although analyses on length of hospital stay and blood loss showed improvement following MIS thymectomy, operative time was shorter for open thymectomy. CONCLUSION: This is the first systematic review and meta-analysis assessing long-term effects of MIS versus open thymectomy in MG patients. Given the lack of significant differences noted, either MIS or open thymectomy can be performed, based on surgeon preference. Further high-level, long-term research should be conducted to determine the benefit of each technique.
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Miastenia Gravis , Timectomia , Humanos , Timectomia/métodos , Miastenia Gravis/cirurgia , Miastenia Gravis/etiologia , Indução de Remissão , Tempo de Internação , Procedimentos Cirúrgicos Minimamente Invasivos , Resultado do Tratamento , Estudos RetrospectivosRESUMO
INTRODUCTION: Robotic surgery has integrated into the healthcare system despite limited evidence demonstrating its clinical benefit. Our objectives were (i) to describe secular trends and (ii) patient- and system-level determinants of the receipt of robotic as compared to open or laparoscopic surgery. METHODS: This population-based retrospective cohort study included adult patients who, between 2009 and 2018 in Ontario, Canada, underwent one of four commonly performed robotic procedures: radical prostatectomy, total hysterectomy, thoracic lobectomy, partial nephrectomy. Patients were categorized based on the surgical approach as robotic, open, or laparoscopic for each procedure. Multivariable regression models were used to estimate the temporal trend in robotic surgery use and associations of patient and system characteristics with the surgical approach. RESULTS: The cohort included 24,741 radical prostatectomy, 75,473 total hysterectomy, 18,252 thoracic lobectomy, and 4608 partial nephrectomy patients, of which 6.21% were robotic. After adjusting for patient and system characteristics, the rate of robotic surgery increased by 24% annually (RR 1.24, 95%CI 1.13-1.35): 13% (RR 1.13, 95%CI 1.11-1.16) for robotic radical prostatectomy, 9% (RR 1.09, 95%CI 1.05-1.13) for robotic total hysterectomy, 26% (RR 1.26, 95%CI 1.06-1.50) for thoracic lobectomy and 26% (RR 1.26, 95%CI 1.13-1.40) for partial nephrectomy. Lower comorbidity burden, earlier disease stage (among cancer cases), and early career surgeons with high case volume at a teaching hospital were consistently associated with the receipt of robotic surgery. CONCLUSION: The use of robotic surgery has increased. The study of the real-world clinical outcomes and associated costs is needed before further expanding use among additional providers and hospitals.
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Laparoscopia , Procedimentos Cirúrgicos Robóticos , Robótica , Masculino , Adulto , Feminino , Humanos , Procedimentos Cirúrgicos Robóticos/métodos , Estudos Retrospectivos , Laparoscopia/métodos , Hospitais de Ensino , OntárioRESUMO
While randomized controlled trials (RCTs) are regarded as one of the highest forms of clinical research, the robustness of their P values can be difficult to ascertain. Defined as the minimum number of patients in a study arm that would need to be changed from a non-event to event for the findings to lose significance, the Fragility Index is a method for evaluating results from these trials. This study aims to calculate the Fragility Index for trials evaluating perioperative esophagectomy-related interventions to determine the strength of RCTs in this field. MEDLINE and EMBASE were searched for RCTs related to esophagectomy that reported a significant dichotomous outcome. Two reviewers independently screened articles and performed the data extractions with risk of bias assessment. The Fragility Index was calculated using a two-tailed Fisher's exact test. Bivariate correlation was conducted to evaluate associations between the Fragility Index and study characteristics. 41 RCTs were included, and the median sample size was 80 patients [Interquartile range (IQR) 60-161]. Of the included outcomes, 29 (71%) were primary, and 12 (29%) were secondary. The median Fragility Index was 1 (IQR 1-3), meaning that by changing one patient from a non-event to event, the results would become non-significant. Fragility Index was correlated with P value, number of events, and journal impact factor. The RCTs related to esophagectomy did not prove to be robust, as the significance of their results could be changed by altering the outcome status of a handful of patients in one study arm.
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Esofagectomia , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Tamanho da Amostra , Esofagectomia/efeitos adversosRESUMO
OBJECTIVE: The aim of this study was to analyze esophageal cancer patients who previously underwent neoadjuvant therapy followed by a curative resection to determine whether additional adjuvant therapy is associated with improved survival outcomes. SUMMARY BACKGROUND DATA: Neoadjuvant therapy followed by surgery is the standard of care for locally advanced esophageal cancer, whereas adjuvant therapy is typically employed for patients with residual disease. However, the role of adjuvant therapy after a curative resection is still uncertain. METHODS: MEDLINE, EMBASE, and CENTRAL databases were searched for studies comparing patients with esophageal cancer who underwent neoadjuvant therapy and curative resection with and without adjuvant therapy. Primary outcome was overall survival (OS), and random effects meta-analysis was conducted where appropriate. Grading of recommendations, assessment, development, and evaluation was used to assess the certainty of evidence. RESULTS: Ten studies involving 6462 patients were included. When compared to patients who received neoadjuvant therapy and esophagectomy alone, adjuvant therapy groups experienced a significant decrease in mortality by 48% at 1âyear (Risk Ratio (RR) 0.52, 95% confidence interval [CI] 0.41-0.65, P < 0.001, moderate certainty). This reduction in mortality was carried through to 5-year follow-up (RR 0.91, 95% CI 0.86-0.96, P < 0.001, moderate certainty). The difference between the adjuvant therapy and the control group was uncertain regarding the secondary outcomes. CONCLUSION: Adjuvant therapy after neoadjuvant treatment and esophagectomy with negative resection margins provide an improved OS at 1 and 5âyears with moderate to high certainty of evidence, but the benefit for disease-free survival and locoregional/distal recurrence remain uncertain due to limited reporting of these outcomes.
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Quimioterapia Adjuvante , Neoplasias Esofágicas/terapia , Esofagectomia , Terapia Neoadjuvante , Neoplasias Esofágicas/mortalidade , Neoplasias Esofágicas/cirurgia , Humanos , Recidiva Local de Neoplasia , Recidiva , Análise de SobrevidaRESUMO
BACKGROUND: Robotic surgery was integrated into some healthcare systems despite there being few well designed, real-world studies on safety or benefit. This study compared the safety of robotic with laparoscopic, thoracoscopic, and open approaches in common robotic procedures. METHODS: This was a population-based, retrospective study of all adults who underwent prostatectomy, hysterectomy, pulmonary lobectomy, or partial nephrectomy in Ontario, Canada, between 2008 and 2018. The primary outcome was 90-day total adverse events using propensity score overlap weights, and secondary outcomes were minor or major morbidity/adverse events. RESULTS: Data on 24 741 prostatectomy, 75 473 hysterectomy, 18 252 pulmonary lobectomy, and 6608 partial nephrectomy operations were included. Relative risks for total adverse events in robotic compared with open surgery were 0.80 (95 per cent c.i. 0.74 to 0.87) for radical prostatectomy, 0.44 (0.37 to 0.52) for hysterectomy, 0.53 (0.44 to 0.65) for pulmonary lobectomy, and 0.72 (0.54 to 0.97) for partial nephrectomy. Relative risks for total adverse events in robotic surgery compared with a laparoscopic/thoracoscopic approach were 0.94 (0.77 to 1.15), 1.00 (0.82 to 1.23), 1.01 (0.84 to 1.21), and 1.23 (0.82 to 1.84) respectively. CONCLUSION: The robotic approach is associated with fewer adverse events than an open approach but similar to a laparoscopic/thoracoscopic approach. The benefit of the robotic approach is related to the minimally-invasive approach rather than the platform itself.
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Laparoscopia , Procedimentos Cirúrgicos Robóticos , Adulto , Feminino , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Masculino , Nefrectomia/efeitos adversos , Nefrectomia/métodos , Ontário , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversosRESUMO
Robotic-assisted thoracoscopic surgery (RTS) is safe and effective, but is associated with high capital and operating costs that are not reimbursed by the Canadian government. Currently, patients have access to RTS only when it is supported by research or philanthropic funds. In a recent study, we assessed the extent of patient-reported satisfaction with RTS, whether patients would have been willing to pay out of pocket for it, and what factors were associated with patients' willingness to pay. Many patients (290 of 411 [70.56%]) stated that they would have paid the additional $2000 to supplement the government health care coverage to have access to RTS. Factors found to be significantly associated with participants' willingness to pay were an annual income of $60 000 or more (p = 0.034), private insurance coverage (p = 0.007), overall experience with RTS rated as 8 or higher out of 10 (p < 0.001), and overall postoperative postdischarge experience rated as satisfying or very satisfying (p = 0.004).
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Procedimentos Cirúrgicos Robóticos , Cirurgia Torácica , Assistência ao Convalescente , Canadá , Financiamento Pessoal , Humanos , Alta do PacienteRESUMO
BACKGROUND: Emergency department (ED) visits and readmissions after thoracic surgery are a major health care problem. We hypothesized that the addition of a novel post-discharge mobile app specific to thoracic surgery to an existing home care program would reduce ED visits and readmissions compared to a home care program alone. METHODS: We conducted a prospective cohort study of patients undergoing major lung resection for malignant disease between November 2016 and May 2018. Patients received either home care alone (control group) or home care plus a patient-input mobile app (intervention group). Primary outcomes were 30-day readmission and ED visit rates. Secondary outcomes included reasons for ED visits and readmissions, perioperative complications, 30-day mortality, anxiety (assessed with the Generalized Anxiety Disorder-7 Scale [GAD-7]) and app-related adverse events. We compared outcomes between the 2 groups, analyzing the data on an intention-to-treat basis. RESULTS: Despite the greater number of open surgery and anatomic resections in the intervention cohort, patients in that group were less likely than those in the control group to visit the ED within 30 days of discharge (24.0% v. 38.8%, p = 0.02). Thirty-day readmission rates were similar between the intervention and control groups (10.1% v. 12.2%, p = 0.6). In a subset of patients, there was no difference between the 2 groups in the proportion of patients with a GAD-7 score of 0 (control group 79.8%, intervention group 79.5%, p = NS), which indicated a similar absence of postdischarge anxiety and depression symptoms in the 2 cohorts. CONCLUSION: The addition of a mobile app to a home care program after thoracic surgery was associated with a reduced frequency of ED visits, in spite of the higher proportions of thoracotomies and anatomic resections in the app cohort. More studies are needed to evaluate the full effect of this new, emerging technology.
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Aplicativos Móveis , Readmissão do Paciente , Humanos , Alta do Paciente , Assistência ao Convalescente , Estudos Prospectivos , Serviço Hospitalar de Emergência , Estudos de Coortes , Tecnologia , PulmãoRESUMO
BACKGROUND: Prolonged air leaks are increasingly treated in the outpatient setting, with patients discharged with chest tubes in place. We evaluated the incidence and risk factors associated with readmission, empyema development and further interventions in this patient population. METHODS: We undertook a retrospective cohort analysis of all patients from 4 tertiary academic centres (January 2014 to December 2017) who were discharged home with a chest tube after lung resection for a postoperative air leak lasting more than 5 days. We analyzed demographics, patient factors, surgical details, hospital readmission, reintervention, antibiotics at discharge, empyema and death. RESULTS: Overall, 253 of 2794 patients were analyzed (9.0% of all resections), including 30 of 759 from centre 1 (4.0%), 67 of 857 from centre 2 (7.8%), 9 of 247 from centre 3 (3.6%) and 147 of 931 from centre 4 (15.8%) (p < 0.001). Our cohort consisted of 56.5% men, and had a median age of 69 (range 19-88) years. Despite similar initial lengths of stay (p = 0.588), 49 patients (19.4%) were readmitted (21%, 0%, 23% and 11% from centres 1 to 4, respectively, p = 0.029), with 18 (36.7%) developing empyema, 11 (22.4%) requiring surgery and 3 (6.1%) dying. Only chest tube duration was a significant predictor of readmission (p < 0.001) and empyema development (p = 0.003), with a nearly threefold increased odds of developing empyema when the chest tube remained in situ for more than 20 days. CONCLUSION: Discharge with chest tube after lung resection is associated with serious adverse events. Given the high risk of empyema development, removal of chest tubes should be considered, when appropriate, within 20 days of surgery. Our data suggest a potential need for proactive postdischarge outpatient management programs to diminish risk of morbidity and death.
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Tubos Torácicos , Alta do Paciente , Adulto , Assistência ao Convalescente , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Tempo de Internação , Pulmão , Masculino , Pessoa de Meia-Idade , Pneumonectomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Estudos Retrospectivos , Adulto JovemRESUMO
Kidney transplant (KT) outcomes from high kidney donor profile index (KDPI ≥85%) donors with acute kidney injury (AKI) remain underreported. KT from 172 high KDPI Acute Kidney Injury Network (AKIN) stage 0-1 donors and 76 high KDPI AKIN stage 2-3 donors from a single center were retrospectively assessed. The AKIN 2-3 cohort had more delayed graft function (71% vs. 37%, p < .001). At one year, there were no differences in the estimated glomerular filtration rate (44 ± 17 vs. 46 ± 18, p = .42) or fibrosis on protocol biopsy (ci, p = .85). Donor terminal creatinine (p = .59) and length of delayed graft function (p = .39) did not impact one-year eGFR. There were more primary nonfunction (PNF) events in the high KDPI AKIN 2-3 group (5.3% vs. 0.6%, p = .02). With a median follow-up of 3.8 years, one-year death-censored graft failure was 3.5% for AKIN 0-1 and 14.5% for AKIN 2-3 (HR 2.40, 95% CI 1.24-4.63, p = .01). Although AKIN stage 2-3 high KDPI kidneys had comparable one-year eGFR to AKIN stage 0-1 high KDPI kidneys, there were more PNF occurrences and one-year death-censored graft survival was reduced. Given these findings, additional precautions should be undertaken when assessing and utilizing kidneys from severe AKI high KDPI donors.
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Injúria Renal Aguda , Doadores de Tecidos , Sobrevivência de Enxerto , Humanos , Rim , Estudos RetrospectivosRESUMO
BACKGROUND: Currently, consensus on the effectiveness of incentive spirometry (IS) following cardiac, thoracic, and upper abdominal surgery has been based on randomized controlled trials (RCTs) and systematic reviews of lower methodological quality. To improve the quality of the research and to account for the effects of IS following thoracic surgery, in addition to cardiac and upper abdominal surgery, we performed a meta-analysis with thorough application of the Grading of Recommendations Assessment, Development and Evaluation scoring system and extensive reference to the Cochrane Handbook for Systematic Reviews of Interventions. OBJECTIVE: The objective of this study was to determine, with rigorous methodology, whether IS for adult patients (18 years of age or older) undergoing cardiac, thoracic, or upper abdominal surgery significantly reduces30-day post-operative pulmonary complications (PPCs), 30-day mortality, and length of hospital stay (LHS) when compared to other rehabilitation strategies. METHODS: The literature was searched using Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, and Web of Science for RCTs between the databases' inception and March 2019. A random-effect model was selected to calculate risk ratios (RRs) with 95% confidence intervals (CIs). RESULTS: Thirty-one RCTs involving 3,776 adults undergoing cardiac, thoracic, or upper abdominal surgery were included. By comparing the use of IS to other chest rehabilitation strategies, we found that IS alone did not significantly reduce 30-day PPCs (RR = 1.00, 95% CI: 0.88-1.13) or 30-day mortality (RR = 0.73, 95% CI: 0.42-1.25). Likewise, there was no difference in LHS (mean difference = -0.17,95% CI: -0.65 to 0.30) between IS and the other rehabilitation strategies. None of the included trials significantly impacted the sensitivity analysis and publication bias was not detected. CONCLUSIONS: This meta-analysis showed that IS alone likely results in little to no reduction in the number of adult patients with PPCs, in mortality, or in the LHS, following cardiac, thoracic, and upper abdominal surgery.
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Motivação , Terapia Respiratória , Abdome/cirurgia , Adolescente , Adulto , Humanos , Tempo de Internação , Complicações Pós-Operatórias/prevenção & controle , Terapia Respiratória/métodos , Espirometria/métodosRESUMO
Background: Ultrasonographic features can be used to predict mediastinal lymph node malignancy during endobronchial ultrasonography. Despite the validity of using these features for this purpose, the features are not being widely used in clinical practice. This may be attributable to the absence of educational programs that teach clinicians how to identify the features. To address this knowledge gap, we developed an online educational module to teach clinicians how to correctly interpret ultrasonographic features. Methods: The module was designed using corrective feedback and test-enhanced learning theories and distributed to clinicians in relevant specialties. The efficacy of the program was determined by comparing the percentages of correctly identified ultrasonographic features as each clinician progressed through the module. Participants were also asked to self-rate their confidence during the module. Analysis of variance was conducted, and a learning curve and descriptive statistics were generated. Results: Twenty-two of the 29 participants (76%) completed the module. Analysis of variance indicated that the percentage of correctly identified features increased significantly as clinicians completed the module (p = 0.004); this finding is supported by the positive slope of the learning curve. Even though they initially reported some difficulty with identifying certain features, their confidence increased as they progressed through the module. When asked, 86% of participants reported that they found the educational module helpful and 90% reported that they would recommend it to others. Conclusion: Participating clinicians were receptive to the interactive educational module. It enhances clinician skill and confidence in interpreting ultrasonographic features. The results of this study provide the foundation needed to test the validity of the educational module in clinical settings and to further explore clinician preferences for educational programs.
Contexte: Les caractéristiques échographiques permettent de prédire la malignité des ganglions lymphatiques médiastinaux durant l'échographie endobronchique. Malgré leur validité à cette fin, ces caractéristiques ne sont pas très utilisées dans la pratique clinique. Cela pourrait être attribuable à l'absence de programmes de formation pour enseigner aux médecins comment repérer ces caractéristiques. Pour répondre à cette lacune au plan des connaissances, nous avons conçu un module de formation en ligne pour enseigner aux médecins comment interpréter correctement les caractéristiques échographiques. Méthodes: Le module a été conçu selon les théories de rétroaction corrective et d'apprentissage par test et a été distribué aux médecins des spécialités concernées. L'efficacité du programme a été déterminée en comparant les pourcentages de caractéristiques échographiques correctement identifiées à mesure que chaque médecin progressait d'une étape à l'autre du module. Les participants ont aussi été invités à autoévaluer leur degré de confiance pendant la réalisation du module. On a ensuite procédé à une analyse de la variance et on a généré une courbe d'apprentissage et des statistiques descriptives. Résultats: Vingt-deux participants sur 29 (76 %) ont mené le module à terme. L'analyse de la variance a indiqué que le pourcentage de caractéristiques correctement identifiées augmentait significativement à mesure que les médecins finalisaient leur module (p = 0,004); cette observation est confirmée par la courbe d'apprentissage positive. Même s'ils avaient initialement fait état de certaines difficultés à identifier des caractéristiques, leur degré de confiance a augmenté au fur et à mesure qu'ils avançaient. Quatre-vingt-six pour cent des participants ont indiqué avoir trouvé le module utile et 90 % ont dit qu'ils le recommanderaient. Conclusion: Les médecins participants ont bien accueilli ce module éducatif interactif : il améliore les habiletés et le degré de confiance des médecins en leur capacité d'interpréter les caractéristiques échographiques. Les résultats de cette étude servent de point de départ pour tester la validité du module en milieu clinique et pour continuer d'explorer les préférences des médecins en ce qui concerne les programmes de formation.
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Broncoscopia , Competência Clínica , Educação a Distância , Educação Médica , Endossonografia , Linfonodos/diagnóstico por imagem , Mediastino/diagnóstico por imagem , Pneumologistas , Cirurgiões , Neoplasias Torácicas/diagnóstico por imagem , Adulto , Competência Clínica/normas , Educação a Distância/métodos , Educação a Distância/organização & administração , Educação a Distância/normas , Educação Médica/métodos , Educação Médica/organização & administração , Educação Médica/normas , Endossonografia/métodos , Humanos , Internato e Residência , Corpo Clínico HospitalarRESUMO
BACKGROUND: Robotic surgery was introduced as a platform for minimally invasive lung resection in Canada in October 2011. We present the first Canadian series of robotic pulmonary resection for lung cancer. METHODS: Prospective databases at 2 institutions were queried for patients who underwent robotic resection for lung cancer between October 2011 and June 2015. To examine the effect of learning curves on patient and process outcomes, data were organized into 3 temporal tertiles, stratified by surgeon. RESULTS: A total of 167 consecutive patients were included in the study. Median age was 66 (range 27-88) years, and 46.1% (n = 77) of patients were men. The majority of patients (n = 141, 84%) underwent robotic lobectomy. Median duration of surgery was 270 (interquartile range [IQR] 233-326) minutes, and median length of stay (LOS) was 4 (IQR 3-6) days. Twelve patients (7%) were converted to thoracotomy. Total duration of surgery and console time decreased significantly (p < 0.001) across tertiles, with a steady decline until case 20, followed by a plateau effect. Across tertiles, there was no significant difference in LOS, number of lymph node stations removed, or perioperative complications. CONCLUSION: The results of this case series are comparable to those reported in the literature. A prospective study to examine the outcomes and cost of robotic pulmonary resection compared with video-assisted thoracoscopic surgery should be done in the context of the Canadian health care system. We have presented the first consecutive case series of robotic lobectomy in Canada. Outcomes compare favourably to other series in the literature.
CONTEXTE: C'est en octobre 2011 que la chirurgie robotisée a fait son entrée au Canada comme approche à la résection pulmonaire minimalement effractive. Nous présentons à notre connaissance la première série canadienne sur la résection pulmonaire robotisée pour le cancer du poumon. MÉTHODES: Nous avons interrogé les bases de données prospectives de 2 établissements pour recenser les patients ayant subi une résection robotisée pour un cancer du poumon entre octobre 2011 et juin 2015. Nous avons organisé les données en 3 tertiles temporels et nous les avons stratifiées par chirurgien pour mesurer l'effet des courbes d'apprentissage sur les résultats enregistrés chez les patients et du point de vue des procédés. RÉSULTATS: En tout, 167 patients consécutifs ont été inclus dans l'étude. L'âge médian était de 66 ans (entre 27 et 88 ans) et 46,1 % (n = 77) étaient des hommes. La majorité des patients (n = 141, 84 %) ont subi une lobectomie robotisée. La durée moyenne des interventions a été de 270 minutes (intervalle interquartile [IIQ] 96) et la durée médiane des séjours a été de 4 jours (IIQ 3). L'intervention s'est transformée en thoracotomie chez 12 patients (7 %). La durée totale de la chirurgie et le temps passé à la console ont diminué significativement (p < 0,001) selon les différents tertiles, avec un déclin constant jusqu'au cas no 20, suivi d'un effet de plateau. Entre les tertiles, on n'a noté aucune différence significative pour ce qui est de la durée des séjours hospitaliers, du nombre de chaînes ganglionnaires excisées ou des complications périopératoires. CONCLUSION: Les résultats de cette série de cas sont comparables à ceux qui sont rapportés dans la documentation. Une étude prospective, dans le but de comparer les résultats et le coût des résections pulmonaires robotisées à ceux des chirurgies thoracoscopiques vidéo-assistées, s'imposerait dans le contexte des soins de santé canadiens. Nous avons présenté la première série de cas consécutifs de lobectomies robotisées au Canada. Les résultats se comparent favorablement à ceux d'autres séries décrites dans la documentation.
Assuntos
Pneumopatias/cirurgia , Avaliação de Processos e Resultados em Cuidados de Saúde/estatística & dados numéricos , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Toracoscopia/estatística & dados numéricos , Toracotomia/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Canadá , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Toracoscopia/efeitos adversos , Toracotomia/efeitos adversosRESUMO
INTRODUCTION: The purpose of this study was to determine the proportion of symptomatic recurrence following initial non-operative management of gallstone disease in the elderly and to test possible predictors. METHODS: This is a single institution retrospective chart review of patients 65 years and older with an initial hospital visit (V1) for symptomatic gallstone disease, over a 4-year period. Patients with initial "non-operative" management were defined as those without surgery at V1 and without elective surgery at visit 2 (V2). Baseline characteristics included age, sex, Charlson comorbidity index (CCI), diagnosis, and interventions (ERCP or cholecystostomy) at V1. Outcomes assessed over 1 year were as follows: recurrence (any ER/admission visit following V1), surgery, complications, and mortality. A survival analysis using a Cox proportional hazards model was performed to assess predictors of recurrence. RESULTS: There were 195 patients initially treated non-operatively at V1. Mean age was 78.3 ± 7.8 years, 45.6% were male, and the mean CCI was 2.1 ± 1.9. At V1, 54.4% had a diagnosis of biliary colic or cholecystitis, while 45.6% had a diagnosis of cholangitis, pancreatitis, or choledocholithiasis. 39.5% underwent ERCP or cholecystostomy. Excluding 10 patients who died at V1, 31.3% of patients had a recurrence over the study period. Among these, 43.5% had emergency surgery, 34.8% had complications, and 4.3% died. Median time to first recurrence was 2 months (range 6 days-4.8 months). Intervention at V1 was associated with a lower probability of recurrence (HR 0.3, CI [0.14-0.65]). CONCLUSION: One-third of elderly patients will develop a recurrence following non-operative management of symptomatic biliary disease. These recurrences are associated with significant rates of emergency surgery and morbidity. Percutaneous or endoscopic therapies may decrease the risk of recurrence.
Assuntos
Coledocolitíase/terapia , Cálculos Biliares/terapia , Idoso , Idoso de 80 Anos ou mais , Colangiopancreatografia Retrógrada Endoscópica/estatística & dados numéricos , Colangite/cirurgia , Colecistite/cirurgia , Colecistostomia/estatística & dados numéricos , Coledocolitíase/complicações , Coledocolitíase/mortalidade , Feminino , Cálculos Biliares/complicações , Cálculos Biliares/mortalidade , Gastroenteropatias/cirurgia , Humanos , Masculino , Pancreatite/cirurgia , Modelos de Riscos Proporcionais , Recidiva , Estudos Retrospectivos , Análise de SobrevidaRESUMO
BACKGROUND: Catheter-associated urinary tract infections (CAUTIs) are the most common device-associated healthcare-acquired infections and pose a significant burden on patients and healthcare systems worldwide. However, there is a paucity of data on CAUTI epidemiology and microbiology in the Middle East and North Africa (MENA) region, including Lebanon. METHODS: This 14-year retrospective cohort study was conducted at a tertiary care center in Lebanon. It analyzed data on all adult patients diagnosed with CAUTI between January 2009 and December 2022 in intensive care units (ICUs) and between June 2011 and December 2022 in regular units. Incidence rates, urinary catheter utilization ratios, and microbiological profiles were collected and analyzed. RESULTS: A total of 620 CAUTI cases were identified during the study period. The overall CAUTI rate was 2.4 per 1000 catheter-days, with higher rates in ICUs (3.2 per 1000 catheter-days) compared to regular units (1.4 per 1000 catheter-days). No significant changes in the rates were noted despite implementing many interventions. The most common pathogens were Gram-negative bacteria, with Escherichia coli, Pseudomonas aeruginosa, and Klebsiella pneumoniae being predominant. Multidrug-resistant organisms represented 48% of all isolates. Enterobacterales were largely extended-spectrum ß-lactamase (ESBL) producing, and most Acinetobacter baumannii isolates showed multidrug resistance. CONCLUSIONS: This study provides important insights into CAUTI epidemiology and microbiology in a tertiary care center in Lebanon, addressing the knowledge gap in this area in the MENA region. Despite implementing prevention measures, CAUTI rates remained stable over the 14-year period. The findings highlight the need for continuous improvement in infection prevention practices, diagnostic stewardship, and antimicrobial stewardship, especially given the rising threat of antimicrobial resistance. These results can serve as a guide for the development of targeted preventive strategies to reduce the burden of CAUTIs, particularly in low- and middle-income countries where antimicrobial resistance is a major issue.
Assuntos
Anti-Infecciosos , Infecções Relacionadas a Cateter , Infecção Hospitalar , Infecções Urinárias , Adulto , Humanos , Infecções Relacionadas a Cateter/prevenção & controle , Centros de Atenção Terciária , Estudos Retrospectivos , Líbano/epidemiologia , Infecções Urinárias/microbiologia , Unidades de Terapia Intensiva , Catéteres/efeitos adversos , Infecção Hospitalar/microbiologiaRESUMO
Background: We lack data on the effectiveness of education and the patient's attitude toward different deceased donor kidney types. A prospective study was performed to evaluate patient attitudes, baseline knowledge, and effectiveness of our kidney transplant education process. We also analyzed the knowledge retention of our waitlist patients. Design: We prospectively surveyed a patient cohort using a paired analysis pre and post education with initial evaluation visit. Knowledge retention among waitlist patients was assessed with annual waitlist visit. Results: One hundred four patients received paired surveys to assess the baseline knowledge and effectiveness of education. Forty-three patients received a single survey with their annual waitlist evaluation to assess knowledge retention. Paired survey showed mixed results, with no statistically significant improvement in the kidney donor profile index domain. Significant improvement was seen in the hepatitis C virus-positive donor domain and the Public Health Service (PHS) increased-risk donor domain. For the waitlist cohort, overall knowledge retention ranged from excellent to fair, with a decline in knowledge for the PHS increased-risk donor domain. Conclusion: Our study suggests that the education intervention regarding different deceased donor kidney types is effective overall and transplant candidates retain the knowledge while waiting for transplant.
Assuntos
Transplante de Rim , Doadores de Tecidos , Humanos , Estudos Prospectivos , Transplante de Rim/métodos , Escolaridade , RimRESUMO
OBJECTIVE: To determine whether targeted sampling (TS), which omits biopsy of triple- normal lymph nodes (LNs) on positron emission tomography, computed tomography, and endobronchial ultrasound (EBUS), is noninferior to systematic sampling (SS) of mediastinal LNs during EBUS for staging of patients with early-stage non-small cell lung cancer (NSCLC). METHODS: Patients who are clinical nodal (cN)0-N1 with suspected NSCLC eligible for EBUS based on positron emission tomography/computed tomography were enrolled in this prospective, multicenter trial. During EBUS, all patients underwent TS and then crossed over to SS, whereby at least 3 mediastinal LN stations (4R, 4L, 7) were routinely sampled. Gold standard of comparison was pathologic results. Based on the previous feasibility trial, a noninferiority margin of 6% was established for difference in missed nodal metastasis (MNM) incidence between TS and SS. The McNemar test on paired proportions was used to determine MNM incidence for each sampling method. Analysis was per-protocol using a level of significance of P < .05. RESULTS: Between November 2020 and April 2022, 91 patients were enrolled at 6 high-volume Canadian tertiary care centers. A total of 256 LNs underwent TS and SS. Incidence of MNM was 0.78% in SS and 2.34% in TS, with an absolute difference of 1.56% (95% confidence interval, -0.003% to 4.1%; P = .13). This falls within the noninferiority margin. A total of 6/256 LNs from 4 patients who were not sampled by TS were found to be malignant when sampled by SS. CONCLUSIONS: In high-volume thoracic endosonography centers, TS is not inferior to SS in nodal staging of early-stage NSCLC. This results in change of clinical management for a minority of patients.