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Endometrioid ovarian adenocarcinoma is a common subtype of epithelial ovarian cancer that can arise on a background of endometriosis. Maximal cytoreductive effort with an aim to remove all macroscopic disease (achieve R0) is the single independent prognostic factor for survival. Complex multidisciplinary surgeries may be required in order to achieve this.
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OBJECTIVE: To develop guidelines for a faculty training program in nontechnical skill assessment in surgery. BACKGROUND: Nontechnical skills in the operating room are critical for patient safety. The successful integration of these skills into workplace-based assessment is dependent upon the availability of faculty who are able to teach and assess them. At present, no guidelines exist regarding the training requirements for such faculty in surgical contexts. METHODS: The development of the guidelines was carried out in several stages: stage 1-a detailed literature review on current training for nontechnical skill assessors; stage 2-semistructured interviews with a multidisciplinary panel (consisting of clinicians and psychologists/human factors specialists) of experts in surgical nontechnical skills; and stage 3-interview findings fed into an Expert Consensus Panel (ECP) Delphi approach to establish consensus regarding training requirements for faculty assessing nontechnical skills in surgery. RESULTS: The ECP agreed that training in nontechnical skill assessment should be delivered by a multidisciplinary team consisting of clinicians and psychologists/human factors specialists. The ECP reached consensus regarding who should be targeted to be trained as faculty (including proficiency and revalidation requirements). Consensus was reached on 7 essential training program content elements (including training in providing feedback/debriefing) and 8 essential methods of evaluating the effectiveness of a "train-the-trainers" program. CONCLUSIONS: This study provides evidence-based guidelines that can be used to guide the development and evaluation of programs to educate faculty in the training and assessment of nontechnical skills. Uptake of these guidelines could accelerate the development of surgical expertise required for safe and high-quality patient care.
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Competência Clínica , Educação Médica Continuada/normas , Educação de Pós-Graduação em Medicina , Docentes de Medicina , Cirurgia Geral/educação , Técnica Delphi , Educação Médica Continuada/métodos , Humanos , Entrevistas como Assunto , Desenvolvimento de Programas/normas , Avaliação de Programas e Projetos de Saúde/normas , Reino UnidoRESUMO
OBJECTIVE: To investigate the nature of process failures in postoperative care, to assess their frequency and preventability, and to explore their relationship to adverse events. BACKGROUND: Adverse events are common and are frequently caused by failures in the process of care. These processes are often evaluated independently using clinical audit. There is little understanding of process failures in terms of their overall frequency, relative risk, and cumulative effect on the surgical patient. METHODS: Patients were observed daily from the first postoperative day until discharge by an independent surgeon. Field notes on the circumstances surrounding any nonroutine or atypical event were recorded. Field notes were assessed by 2 surgeons to identify failures in the process of care. Preventability, the degree of harm caused to the patient, and the underlying etiology of process failures were evaluated by 2 independent surgeons. RESULTS: Fifty patients undergoing major elective general surgery were observed for a total of 659 days of postoperative care. A total of 256 process failures were identified, of which 85% were preventable and 51% directly led to patient harm. Process failures occurred in all aspects of care, the most frequent being medication prescribing and administration, management of lines, tubes, and drains, and pain control interventions. Process failures accounted for 57% of all preventable adverse events. Communication failures and delays were the main etiologies, leading to 54% of process failures. CONCLUSIONS: Process failures are common in postoperative care, are highly preventable, and frequently cause harm to patients. Interventions to prevent process failures will improve the reliability of surgical postoperative care and have the potential to reduce hospital stay.
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Procedimentos Cirúrgicos do Sistema Digestório , Procedimentos Cirúrgicos Eletivos , Erros Médicos/estatística & dados numéricos , Avaliação de Processos e Resultados em Cuidados de Saúde , Cuidados Pós-Operatórios/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Cirurgia Geral/normas , Hospitais de Ensino/normas , Hospitais de Ensino/estatística & dados numéricos , Hospitais Urbanos/normas , Hospitais Urbanos/estatística & dados numéricos , Humanos , Relações Interprofissionais , Londres , Masculino , Erros Médicos/efeitos adversos , Erros Médicos/prevenção & controle , Pessoa de Meia-Idade , Segurança do Paciente , Cuidados Pós-Operatórios/efeitos adversos , Cuidados Pós-Operatórios/métodos , Cuidados Pós-Operatórios/estatística & dados numéricos , Estudos ProspectivosRESUMO
PURPOSE: This review summarizes the published methods of colonic EFTR, examining data on feasibility and safety. Due to the introduction of bowel cancer screening programs, there is an increasing incidence of complex colonic polyps and early colonic cancer that requires segmental colectomy. Traditional radical surgery is associated with significant morbidity, and there is a need for alternative treatments. METHODS: Systematic literature search identified articles describing EFTR techniques of colon, published between 1990 and 2012. Complication rates, anastomotic bursting pressures, procedure duration, specimen size and quality, and postmortem findings were analyzed. RESULTS: Five research groups reported four EFTR techniques using endoscopic stapling devices, T-tags, compression closure, or laparoscopic assistance for defect closure before or after specimen resection. A total of 113 procedures were performed in 99 porcine models, with an overall success rate of 89 and 4 % mortality. The intraoperative complication rate was 22 % (0-67 %). Post-resection closure methods more commonly resulted in failure to close the defect (5-55 %) and a high incidence of abnormal findings at postmortem examination (84 %). Significant heterogeneity was observed in procedure duration (median or mean 3-233 min) and size of the excised specimen (median or mean 1.7-3.6 cm). Anastomotic bursting pressures and specimen quality were poorly documented. CONCLUSIONS: The technique of EFTR is developing, but the inability to close the resection defect reliably is a major obstacle. The review highlights the challenges that need to be addressed in future preclinical studies.
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Colectomia/métodos , Neoplasias do Colo/cirurgia , Colonoscopia/métodos , Laparoscopia/métodos , Fístula Anastomótica , Animais , Colectomia/instrumentação , Pólipos do Colo/cirurgia , Colonoscópios , Colonoscopia/efeitos adversos , Desenho de Equipamento , Estudos de Viabilidade , Humanos , Modelos Animais , Complicações Pós-Operatórias/etiologia , Grampeadores Cirúrgicos , Grampeamento Cirúrgico/métodos , Suínos , Técnicas de Fechamento de Ferimentos/instrumentaçãoRESUMO
Key Clinical Message: Radical gynecology oncology surgeries are feasible in patients refusing blood transfusion, when performed with careful preoperative (with hemoglobin optimization and patients' counseling), intraoperative (with hemostasis and stepwise devascularization, hemodilution, and autologous cell salvage) and postoperative (considering iron infusion or erythropoietin) planning with a multidisciplinary team involvement. Abstract: We describe the case of a female Jehovah's Witness patient in her 60s undergoing pelvic exenteration, focusing on the preoperative, intraoperative, and postoperative measures that allowed an uncomplicated surgery without blood transfusion. Blood transfusions are common in the surgical management of gynecology oncology patients, up to 93% of patients undergoing pelvic exenteration may require blood products. However, increasingly more patients are cautious in receiving blood products, either for fear of potential risks or for religious believes. It is therefore vital to optimize the management of these patients in order to avoid blood transfusions. In this case, we summarize the management of a lady in her 60s who underwent laparotomy, pelvic exenteration, Bricker colicureterostomy, and end colostomy formation for recurrent endometrial carcinoma, despite previous total abdominal hysterectomy and bilateral salpingo-oophorectomy followed by brachytherapy, chemotherapy, and external beam radiotherapy for high-grade serous carcinoma. Preoperatively, an advance decision to refuse blood products was discussed to ascertain all the options that were suitable. As her preoperative hemoglobin was acceptable (127 g/L), no further intervention was required. Intraoperatively, blood loss was effectively minimized with meticulous hemostasis, stepwise pelvic devascularization, intraoperative hemodilution, and cell salvage. Despite these interventions, total blood loss was 1030 mL and postoperative hemoglobin was 113 g/L. Postoperative measures therefore included intravenous iron infusion, minimization of phlebotomy, and optimization of cardiopulmonary status. Erythropoietin was also considered, but was not necessary as patient responded to the previous measures well and was successfully discharged after an uncomplicated recovery. Only few cases of total pelvic exenteration have been described in the literature for Jehovah's Witness patients. However, our case shows that laparotomy and pelvic exenteration is feasible in patients refusing blood products, if performed under a multidisciplinary team and with careful preoperative, intraoperative, and postoperative planning, also in the setting of previous radical hysterectomy and co-adjuvant therapy.
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Aim: The coronavirus pandemic has significantly disrupted the way we deliver healthcare worldwide. We have been flexible and creative in order to continue providing elective colorectal cancer operations and to restart services for benign cases during the recovery period of the pandemic. In this paper, we describe the impact of coronavirus on our elective services and how we have implemented new patient pathways to allow us to continue providing patient care. Patients and Methods: Data on major colorectal elective resections were prospectively collected in an Enhanced Recovery After Surgery (ERAS) database. Data on the number of proctology cases and telemed appointments were collected from the hospital theatre information management system and electronic patient record system, respectively. Results: During the pandemic, there was a complete shift towards cancer cases, with benign services and proctology cases being placed on hold. Hospital length of stay was reduced. We implemented earlier hospital discharge and more intense telephone follow-up after elective major surgery. This has not resulted in an increase in postoperative complications, nor any increase in readmission to hospital. During the recovery phase, we have introduced a higher proportion of telemed consultations, including one-stop telemed proctology clinics, resulting in straight to tests or investigations. Conclusion: We have created a streamlined multidisciplinary pathway to reinstate our elective colorectal services as soon as possible and to minimise potential harm caused to patients whose treatment have been delayed. We anticipate many of these changes will be permanently incorporated into our clinical practice once the pandemic is over.
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INTRODUCTION: Emergency general surgery (EGS) is responsible for 80-90% of surgical in-hospital deaths and the early management of these unwell patients is critical to improving outcomes. Unfortunately care for EGS patients is often fragmented and important care processes are frequently omitted. METHODS: This study aimed to define a group of important processes during EGS admission and assess their reliability. Literature review and semi-structured interviews were used to define a draft list of processes, which was refined and validated using the Delphi consensus methodology. A prospective cohort study of the 22 included processes was performed in 315 patients across 5 acute hospitals. RESULTS: Prospective study of the 22 selected processes demonstrated omission of 1130/5668 (19.9%) processes. Only 6 (1.9%) patients had all relevant processes performed correctly. Administration of oxygen to hypoxic patients (82/129, 64%), consultant review (202/313, 65%) and administration of antibiotics within 3 h for patients with severe sepsis (41/60, 68%) were performed particularly poorly. There were significant differences in the mean number of omissions per patient between hospitals ( ANOVA: F = 11.008, p < 0.001) and this was strongly correlated with hospitals' median length of stay (Spearman's rho = 0.975, p = 0.005). CONCLUSIONS: Reliability of admissions processes in this study was poor, with significant variability between hospitals. It is likely that improvements in process reliability would enhance EGS patients' outcomes. This will require engagement of the entire surgical team and the implementation of multiple interventions to improve the effectiveness of the admission phase of care.
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Serviço Hospitalar de Emergência/normas , Tratamento de Emergência/mortalidade , Avaliação de Resultados em Cuidados de Saúde , Admissão do Paciente , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Estudos de Coortes , Tratamento de Emergência/estatística & dados numéricos , Feminino , Humanos , Tempo de Internação , Londres , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reprodutibilidade dos Testes , Estudos Retrospectivos , Medicina EstatalRESUMO
BACKGROUND: Clinical handover (handoff, sign out) is frequently implicated as a cause of adverse events in hospitalised patients. Complex social interactions such as handover are subject to the teamwork skills of the participants and there is increasing evidence that the quality of teamwork in handover affects outcome. Teamwork skills have been assessed in one-to-one handovers but the applicability of these measurement tools to healthcare team shift handovers remains unproven. This study aimed to assess the feasibility of measurement of teamwork skills in shift handover and the applicability of adapted teamwork skills rating scales to a shift handover environment. METHODS: Morning surgical shift handovers were assessed for completeness of information transfer, duration, interruptions and handover attendance. Handover teamwork skills were evaluated using two validated rating scales, adapted from one-to-one handovers and intra-operative teamwork skill measurement. RESULTS: 50 handovers, including 306 patients were observed. Communication checklist completion was 97% but the quality of teamwork skills varied widely between handovers. There was very good concurrent validity between the two teamwork skill rating scales (Spearman's rho = 0.67, p < 0.001). There was no significant correlation between content completion, duration, interruptions or attendance and teamwork skill ratings. CONCLUSIONS: Teamwork skills vary widely between handovers and can be consistently scored using both rating scales. It is feasible to use adapted teamwork skill rating scales in shift handover and they appear to measure different constructs to traditional handover measures such as interruptions and communication checklist completion. The assessment of teamwork skills is a necessary complement to the assessment of completeness of information transfer when evaluating the overall quality of handover.
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Continuidade da Assistência ao Paciente/normas , Equipe de Assistência ao Paciente/normas , Transferência da Responsabilidade pelo Paciente/normas , Centro Cirúrgico Hospitalar/normas , Hospitalização , Humanos , Disseminação de Informação , Assistência Perioperatória/normas , Estudos Prospectivos , Recursos HumanosRESUMO
Males often play a critical role in offspring care but the time and energy invested in looking after young can potentially limit their ability to seek out additional mating opportunities. Recent studies, however, suggest that a conflict between male parental effort and mating effort may not always be inevitable, especially if breeding occurs near the nest, or if parental behaviours are under sexual selection. Accordingly, we set out to experimentally investigate male care and courtship in the desert goby Chlamydogobius eremius, a nest-guarding fish with exclusive paternal care. Despite courtship occurring near the nest, we found that when egg-tending males were given the opportunity to attract additional females, they fanned their eggs less often, engaged in shorter fanning bouts, and spent more of their time outside their nests courting. Our findings highlight the importance of understanding the circumstances under which reproductive tradeoffs are expected to occur and how these, in turn, operate to influence male reproductive decisions.
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Clima Desértico , Comportamento de Nidação , Perciformes , Comportamento Sexual Animal , Animais , Feminino , Masculino , Óvulo , Fatores de TempoRESUMO
BACKGROUND: Laparoscopic antireflux surgery is an accepted treatment for persistent gastroesophageal reflux but about 4% of patients will eventually require revision surgery. METHODS: We searched The Cochrane Collaboration, Medline, and EMBASE databases, augmented by Google Scholar and PubMed related articles from January 1, 1990, to November 22, 2010. Twenty studies met the inclusion criteria, reporting on 930 surgeries. RESULTS: The mean surgical duration was 166 minutes and conversion to open revision fundoplication was required in 7% of cases. Complications were reported in 14% of cases and the mean length of stay varied between 1.2 and 6 days. A good to excellent result was reported for 84% of surgeries and 5% of patients required a further revisional procedure. CONCLUSIONS: Laparoscopic revision antireflux surgery appears to be feasible and safe, but subject to somewhat greater risk of conversion, higher morbidity, longer hospital stay, and poorer outcomes than primary laparoscopic fundoplication.