To critically assess centralization policies for highly specialized surgeries in Europe and North America and propose recommendations.
Most countries are increasingly forced to maintain quality ...medicine at a reasonable cost. An all-inclusive perspective, including health care providers, payers, society as a whole and patients, has ubiquitously failed, arguably for different reasons in environments. This special article follows 3 aims: first, analyze health care policies for centralization in different countries, second, analyze how centralization strategies affect patient outcome and other aspects such as medical education and cost, and third, propose recommendations for centralization, which could apply across continents.
Conflicting interests have led many countries to compromise for a health care system based on factors beyond best patient-oriented care. Centralization has been a common strategy, but modalities vary greatly among countries with no consensus on the minimal requirement for the number of procedures per center or per surgeon. Most national policies are either partially or not implemented. Data overwhelmingly indicate that concentration of complex care or procedures in specialized centers have positive impacts on quality of care and cost. Countries requiring lower threshold numbers for centralization, however, may cause inappropriate expansion of indications, as hospitals struggle to fulfill the criteria. Centralization requires adjustments in training and credentialing of general and specialized surgeons, and patient education.
There is an obvious need in most areas for effective centralization. Unrestrained, purely "market driven" approaches are deleterious to patients and society. Centralization should not be based solely on minimal number of procedures, but rather on the multidisciplinary treatment of complex diseases including well-trained specialists available around the clock. Audited prospective database with monitoring of quality of care and cost are mandatory.
To define the prognostic value of different histological subtypes of colorectal cancer.
Most colorectal cancers are classical adenocarcinomas (AC). Less frequent subtypes include mucinous ...adenocarcinomas (MAC) and signet-ring cell carcinomas (SC). In contrast to established prognostic factors such as TNM and grading, the histological subtype has no therapeutical consequences so far, although it may reflect different biological behavior.
Between 1982 and 2012, a total of 3479 consecutive patients underwent surgery for primary colorectal cancer (AC, MAC, or SC). Clinical, histopathological, and survival data were analyzed.
Of all 3479 patients, histological subtype was AC in 3074 cases (88%), MAC in 375 cases (11%), and SC in 30 cases (0.9%). MAC (51%, P < 0.001) and SC (50%, P = 0.029) occurred more frequently in right-sided tumors than AC (28%). Compared with AC, tumor stages and histological grading were higher in MAC and SC (P < 0.001 for each). Rates of angioinvasion were lower in MAC than in AC (5% vs 9%, P = 0.011). Rates of lymphatic invasion were higher in SC than in AC (67% vs 25%, P < 0.001). Five-year cause-specific survival was 67 ± 1% for AC, 61 ± 3% for MAC, and 21 ± 8% for SC (P < 0.001 for difference between the groups). In multivariable analysis, survival did not differ significantly between AC and MAC after correction for tumor stage. However, SC remained an independent prognostic factor associated with worse survival (hazard ratio = 2.5, 95% confidence interval = 1.6-3.8, P < 0.001).
MAC and SC are histological subtypes of colorectal cancer with different characteristics than classical AC. Both are diagnosed in more advanced tumor stages, but the dismal prognosis of SC seems to be caused by its intrinsic tumor biology.
Objectives
Incisional hernia, a serious complication after laparotomy, is associated with high morbidity and costs. This trial examines the value of prophylactic intraperitoneal onlay mesh to reduce ...the risk of incisional hernia after a median follow-up time of 5.3 years.
Methods
We conducted a parallel group, open-label, single center, randomized controlled trial (NCT01003067). After midline incision, the participants were either allocated to abdominal wall closure according to Everett with a PDS-loop running suture reinforced by an intraperitoneal composite mesh strip (Group
A
) or the same procedure without the additional mesh strip (Group
B
).
Results
A total of 276 patients were randomized (Group
A
= 131; Group
B
= 136). Follow-up data after a median of 5.3 years after surgery were available from 183 patients (Group
A
= 95; Group
B
= 88). Incisional hernia was diagnosed in 25/95 (26%) patients in Group
A
and in 46/88 (52%) patients in Group
B
(risk ratio 0.52; 95% CI 0.36–0.77;
p
< 0.001). Eighteen patients with asymptomatic incisional hernia went for watchful waiting instead of hernia repair and remained free of symptoms after of a median follow-up of 5.1 years. Between the second- and fifth-year follow-up period, no complication associated with the mesh could be detected.
Conclusion
The use of a composite mesh in intraperitoneal onlay position significantly reduces the risk of incisional hernia during a 5-year follow-up period.
Trial registration number
Ref. NCT01003067 (clinicaltrials.gov).
Grape (Vitis vinifera cv Silvaner) vine plants were cultivated under shaded conditions in the absence of ultraviolet (UV) radiation in a greenhouse, and subsequently placed outdoors under three ...different light regimes for 7 d. Different light regimes were produced by filters transmitting natural radiation, or screening out the UV-B (280-315 nm), or screening out the UV-A (315-400 nm) and the UV-B spectral range. During exposure, synthesis of UV-screening phenolics in leaves was quantified using HPLC: All treatments increased concentrations of hydroxycinnamic acids but the rise was highest, reaching 230% of the initial value, when UV radiation was absent. In contrast, UV-B radiation specifically increased flavonoid concentrations resulting in more than a 10-fold increase. Transmittance in the UV of all extracted phenolics was lower than epidermal UV transmittance determined fluorimetrically, and the two parameters were curvilinearly related. It is suggested that curvilinearity results from different absorption properties of the homogeneously dissolved phenolics in extracts and of the non-homogeneous distribution of phenolics in the epidermis. UV-B-dependent inhibition of maximum photochemical yield of photosystem II (PSII), measured as variable fluorescence of dark-adapted leaves, recovered in parallel to the buildup of epidermal screening for UV-B radiation, suggesting that PSII is protected against UV-B damage by epidermal screening. However, UV-B inhibition of CO2 assimilation rates was not diminished by efficient UV-B screening. We propose that protection of UV-B inactivation of PSII is observed because preceding damage is efficiently repaired while those factors determining UV-B inhibition of CO2 assimilation recover more slowly.
Background
Incisional hernias still are a major concern after laparotomy and are causing substantial morbidity. This study examines the feasibility, safety and incisional hernia rate of the use of a ...prophylactic intraperitoneal onlay mesh stripe (IPOM) to prevent incisional hernia following midline laparotomy.
Methods
This prospective, randomized controlled trial randomly allocated patients undergoing median laparotomy either to mass closure of the abdominal wall with a PDS-loop running suture reinforced by an intraperitoneal composite mesh stripe (Group A) or to the same procedure without the additional mesh stripe (Group B). Primary endpoint was the incidence of incisional hernias at 2 years following midline laparotomy. Secondary endpoints are were the feasibility, the safety of the mesh stripe implantation including postoperative pain, and the incidence of incisional hernias at 5 years.
Results
A total of 267 patients were included in this study. Follow-up data 2 years after surgery was available from 210 patients (Group A = 107; Group B = 103). An incisional hernia was diagnosed in 18/107 (17%) patients in Group A and in 40/103 (39%) patients in Group B (
p
< 0.001). A surgical operation due to an incisional hernia was conducted for 12/107 (11%) patients in Group A and for 24/103 (23%) patients in Group B (
p
= 0.039). In both groups, minor and major complications as well as postoperative pain are reported with no statistically significant difference between the groups, even in contaminated situations.
Conclusions
This first randomized clinical trial indicates that the placement of a non-absorbable IPOM-stripe with prophylactic intention may significantly reduce the risk for a midline incisional hernia.
Trial registration
Ref. NCT01003067 (clinicaltrials.gov)
Aim
The prevalence and definition of diastasis recti abdominis (DRA) is under debate. This retrospective cross-sectional study evaluated the interrectal distance and the prevalence of DRA in computed ...tomography (CT) in an asymptomatic population.
Materials and methods
Patients undergoing CT scans for suspected appendicitis or kidney stones from 01/2016 to 12/2018 were screened retrospectively to participate. A study population with equal distribution according to gender and age (18–90 years) was generated (
n
= 329 patients) and the interrectal distance was measured at six reference points.
Results
DRA (defined as > 2 cm at 3 cm above the umbilicus) was present in 57% of the population. The 80th percentile of the interrectal distance was 10 mm at the xiphoid (median 3 mm, 95% confidence interval (CI) 0–19 mm), 27 mm halfway from xiphoid to umbilicus (median 17 mm, 95% CI 0–39 mm), 34 mm at 3 cm above the umbilicus (median 22 mm, 95% CI 0–50 mm), 32 mm at the umbilicus (median 25 mm, 95% CI 0–45 mm), 25 mm at 2 cm below the umbilicus (median 14 mm, 95% CI 0–39 mm), and 4 mm halfway from umbilicus to pubic symphysis (median 0 mm, 95% CI 0–19 mm). In the multivariate analysis, higher age (
p
= 0.001), increased body mass index (
p
< 0.001), and parity (
p
< 0.037) were independent risk factors for DRA, while split xiphoid, tobacco abuse, and umbilical hernia were not.
Conclusion
The prevalence of DRA is much higher than commonly estimated (57%). The IRD 3 cm above the umbilicus may be considered normal up to 34 mm. To avoid over-treatment, the definition of DRA should be revised.
Purpose
The aim of this study was to investigate whether metastatic colorectal cancer (Union for International Cancer Control stage IV disease) represents a risk factor for anastomotic leakage after ...colorectal surgery without major hepatic resection.
Methods
This retrospective cohort study was based on an existing prospective colorectal database of all consecutive colorectal resections undertaken at the authors’ institution from July 2002 to July 2012 (
n
= 2104). All patients with colorectal resection and primary anastomosis for colorectal cancer were identified (
n
= 500). A temporary loop ileostomy was constructed in low rectal anastomosis up to 6 cm from the anal verge (
n
= 128 cases, 26 %). A routine contrast enema was undertaken at the occasion of other prospective studies in 254 patients. UICC stage IV disease was present in 94 patients (19 %), while 406 patients (81 %) had UICC stage I–III disease.
Results
The overall anastomotic leak rate was 2.6 % (13/500), 2.2 % (11/500) for both clinical and radiological leaks, and 0.8 % (2/254) for radiological leaks only. Four were managed conservatively and nine (1.8 %) required revision laparotomy. In the case of UICC stage IV disease, the anastomotic leak rate was 6.3 % (6/94), while in the case of UICC stage I–III disease the leak rate was 1.7 % (7/406). UICC stage IV disease odds ratio (OR) 4.4, 95 % confidence interval (CI) 1.3–14.4;
p
= 0.015 and diabetes (OR 5.7, 95 % CI 1.7–18.7;
p
= 0.004) were independent risk factors for anastomotic leakage after colorectal surgery.
Conclusions
Patients with stage IV colorectal cancer have an increased anastomotic leak rate after colorectal surgery. Whether this is due to an impaired immune system remains speculative.
Introduction: Intestinal spirochetosis is sometimes found by chance in histological specimen of routine endoscopies. There are only a few cases described in the literature that spirochetosis of the ...appendix was mimicking acute appendicitis. We present a case of pseudoappendicitis with the histological finding of spirochetes and review the current literature. Case Presentation: A 72-year-old woman presented with pain of the lower right abdomen and previous systemic corticoid therapy. In clinical examination, there was a tenderness and pain in the right lower quadrant, and inflammation values were elevated. An abdominal computed tomography scan revealed no obvious inflammation of the appendix. A diagnostic laparoscopy was performed and revealed a macroscopically uninflamed appendix which was removed. Histology revealed spirochetosis of the appendix but no typical signs of appendicitis. The patient was treated with antibiotics for 5 days and was discharged without abdominal pain. In a clinical control 6 weeks later, the abdominal pain had disappeared and the patient was in good clinical condition. Discussion: Intestinal spirochetosis is randomly found in histological specimen during routine endoscopies, even in asymptomatic patients. There are only a few cases described with spirochetosis of the appendix causing pain and mimicking appendicitis; hence, this entity is an important differential diagnosis of pain in the right lower quadrant of the abdomen.
Background
The landscape of surgical training has been subject to many changes over the past 15 years. This study examines resident satisfaction, determinants of satisfaction, demographics, working ...hours and the teaching rate of common operations in a longitudinal fashion with the aim to identify trends, shortcomings and possible ways to improve the current training system.
Methods
The Swiss Medical Association administers an annual survey to all Swiss residents to evaluate the quality of postgraduate medical training (yearly respondents: 687–825, response rate: 68–72%). Teaching rates for general surgical procedures were obtained from the Swiss association for quality management in surgery.
Results
During the study period (2003–2018), the number of surgical residents (408–655 (+61%)) and graduates in general surgery per year (42–63 (+50%)) increased disproportionately to the Swiss population. While the 52 working hour restriction was introduced in 2005 reported average weekly working hours did not decline (59.9–58.4 h (−3%)). Workplace satisfaction (6 being highest) rose from 4.3 to 4.6 (+7%). Working climate and leadership culture were the main determinants for resident satisfaction. The proportion of taught basic surgical procedures fell from 24.6 to 18.9% (−23%).
Conclusions
The number of residents and graduates in general surgery has risen markedly. At the same time, the proportion of taught operations is diminishing. Despite the introduction of working hour restrictions, the self-reported hours never reached the limit. The low teaching rate combined with the increasing resident number represents a major challenge to the maintenance of the current training quality.
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