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Counting the cost of cancer surgery for advanced and metastatic disease
doi: 10.1002/bjs.8695pmid: 22318744
Putting cancer surgery into context is vital
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doi: 10.1002/bjs.8695pmid: 22318744
Putting cancer surgery into context is vital
doi: 10.1002/bjs.7819pmid: 22287115
A glimpse into the future of surgery
doi: 10.1002/bjs.8697pmid: 22307828
BackgroundProctocolectomy with ileal pouch-anal anastomosis (IPAA) has been developed and refined since its introduction in the late 1970s. Nonetheless, it is a procedure associated with significant morbidity. The aim of this review was to provide a structured approach to the challenges that surgeons and physicians encounter in the management of intraoperative, postoperative and reoperative problems associated with ileoanal pouches.MethodsThe review was based on relevant studies identified from an electronic search of MEDLINE, Embase and PubMed databases from 1975 to April 2011. There were no language or publication year restrictions. Original references in published articles were reviewed.ResultsAlthough the majority of patients experience long-term success with an ileoanal pouch, significant morbidity surrounds IPAA. Surgical intervention is often critical to achieve optimal control of the situation.ConclusionA structured management plan will minimize the adverse consequences of the problems associated with pouches.
Tan, C J; Dasari, B V M; Gardiner, K
doi: 10.1002/bjs.8689pmid: 22261931
BackgroundUse of self-expanding metallic stents (SEMS) as a bridge to surgery has been suggested as an alternative management for acute malignant left-sided colonic obstruction, as emergency surgery has a high risk of morbidity and mortality. This meta-analysis evaluated high-quality evidence comparing preoperative SEMS with emergency surgery.MethodsRelevant randomized clinical trials (RCTs) were identified from the Cochrane Central Register of Controlled Trials, MEDLINE, Embase and PubMed (1990–2011). Primary outcomes were primary anastomosis, stoma and in-hospital mortality rates. Secondary outcomes included anastomotic leak, 30-day reoperation and surgical-site infection rates.ResultsFour RCTs with 234 patients were included. Technical and clinical success rates for stenting were 70·7 per cent (82 of 116) and 69·0 per cent (80 of 116) respectively. The clinical perforation rate was 6·9 per cent (8 of 116) and the silent perforation rate 14 per cent (11 of 77). SEMS intervention resulted in significantly higher successful primary anastomosis (risk ratio (RR) 1·58, 95 per cent confidence interval 1·22 to 2·04; P < 0·001) and lower overall stoma (RR 0·71, 0·56 to 0·89; P = 0·004) rates. There was no difference in primary anastomosis, permanent stoma, in-hospital mortality, anastomotic leak, 30-day reoperation and surgical-site infection rates. Three trials were stopped prematurely, one because the emergency surgery group had a significantly increased anastomotic leak rate, and two others because of stent-related complications and increased 30-day morbidity following SEMS management.ConclusionTechnical and clinical success rates for stenting were lower than expected. SEMS is associated with a high incidence of clinical and silent perforation. However, as a bridge to surgery, SEMS has higher successful primary anastomosis and lower overall stoma rates, with no significant difference in complications or mortality.
Jones, R P; Jackson, R; Dunne, D F J; Malik, H Z; Fenwick, S W; Poston, G J; Ghaneh, P
doi: 10.1002/bjs.8667pmid: 22261895
BackgroundThe evidence surrounding optimal follow-up after liver resection for colorectal metastases remains unclear. A significant proportion of recurrences occur in the early postoperative period, and some groups advocate more intensive review at this time.MethodsA systematic review of literature published between January 2003 and May 2010 was performed. Studies that described potentially curative primary resection of colorectal liver metastases that involved a defined follow-up protocol and long-term survival data were included. For meta-analysis, studies were grouped into intensive (more frequent review in the first 5 years after resection) and uniform (same throughout) follow-up.ResultsThirty-five studies were identified that met the inclusion criteria, involving 7330 patients. Only five specifically addressed follow-up. Patients undergoing intensive early follow-up had a median survival of 39·8 (95 per cent confidence interval 34·3 to 45·3) months with a 5-year overall survival rate of 41·9 (34·4 to 49·4) per cent. Patients undergoing routine follow-up had a median survival of 40·2 (33·4 to 47·0) months, with a 5-year overall survival rate of 38·4 (32·6 to 44·3) months.ConclusionEvidence regarding follow-up after liver resection is poor. Meta-analysis failed to identify a survival advantage for intensive early follow-up.
doi: 10.1002/bjs.7798pmid: 22287099
BackgroundWith higher-throughput data acquisition and processing, increasing computational power, and advancing computer and mathematical techniques, modelling of clinical and biological data is advancing rapidly. Although exciting, the goal of recreating or surpassing in silico the clinical insight of the experienced clinician remains difficult. Advances toward this goal and a brief overview of various modelling and statistical techniques constitute the purpose of this review.MethodsA review of the literature and experience with models and physiological state representation and prediction after injury was undertaken.ResultsA brief overview of models and the thinking behind their use for surgeons new to the field is presented, including an introduction to visualization and modelling work in surgical care, discussion of state identification and prediction, discussion of causal inference statistical approaches, and a brief introduction to new vital signs and waveform analysis.ConclusionModelling in surgical critical care can provide a useful adjunct to traditional reductionist biological and clinical analysis. Ultimately the goal is to model computationally the clinical acumen of the experienced clinician.
Patterson, B O; Holt, P J; Cleanthis, M; Tai, N; Carrell, T; Loosemore, T M
doi: 10.1002/bjs.7763pmid: 22190106
BackgroundOver the past 50 years the management of vascular trauma has changed from mandatory surgical exploration to selective non-operative treatment, where possible. Accurate, non-invasive, diagnostic imaging techniques are the key to this strategy. The purpose of this review was to define optimal first-line imaging in patients with suspected vascular injury in different anatomical regions.MethodsA systematic review was performed of literature relating to radiological diagnosis of vascular trauma over the past decade (2000–2010). Studies were included if the main focus was initial diagnosis of blunt or penetrating vascular injury and more than ten patients were included.ResultsOf 1511 titles identified, 58 articles were incorporated in the systematic review. Most described the use of computed tomography angiography (CTA). The application of duplex ultrasonography, magnetic resonance imaging/angiography and transoesophageal echocardiography was described, but significant drawbacks were highlighted for each. CTA displayed acceptable sensitivity and specificity for diagnosing vascular trauma in blunt and penetrating vascular injury within the neck and extremity, as well as for blunt aortic injury.ConclusionBased on the evidence available, CTA should be the first-line investigation for all patients with suspected vascular trauma and no indication for immediate operative intervention.
Bosman, A; de Jong, M B; Debeij, J; van den Broek, P J; Schipper, I B
doi: 10.1002/bjs.7744pmid: 22139619
BackgroundNo consensus exists as to whether antibiotic prophylaxis in tube thoracostomy as primary treatment for traumatic chest injuries reduces the incidence of surgical-site and pleural cavity infections.MethodsA systematic literature search was performed according to PRISMA guidelines to identify randomized clinical trials on antibiotic prophylaxis in tube thoracostomy for traumatic chest injuries. Data were extracted by two reviewers using piloted forms. Mantel–Haenszel pooled odds ratios (ORs) were calculated with 95 per cent confidence intervals (c.i.).ResultsEleven articles were included, encompassing 1241 chest drains in 1234 patients. Most patients (84·7 per cent) were men, and a penetrating injury mechanism was most common (856, 69·4 per cent). A favourable effect of antibiotic prophylaxis on the incidence of pulmonary infection was found, with an OR for the overall infectious complication rate of 0·24 (95 per cent c.i. 0·12 to 0·49). Patients who received antibiotic prophylaxis had an almost three times lower risk of empyema than those who did not receive antibiotic treatment (OR 0·32, 0·17 to 0·61). A subgroup analysis in patients with penetrating chest injuries showed that antibiotic prophylaxis in these patients reduced the risk of infection after tube thoracostomy (OR 0·28, 0·14 to 0·57), whereas in a relatively small blunt trauma subgroup no effect of antibiotic prophylaxis after blunt thoracic injury was found.ConclusionInfectious complications are less likely to develop when antibiotic prophylaxis is administered to patients with thoracic injuries requiring chest drains after penetrating injury.
doi: 10.1002/bjs.7745pmid: 22396050
In this meta-analysis from the Leiden group, combined with previous seminal publications including the Eastern Association for the Surgery of Trauma (EAST) guidelines1 and Sanabria meta-analysis from 20062, there seem to be unambiguous assertions regarding the efficacy of prophylactic antibiotics against infectious complications. Surprisingly, when discussing this topic with multiple senior trauma surgeons, stated opinions indicate that truly no consensus exists. When questioned, well established and respected academic surgeons' responses range from ‘The data clearly show that prophylactic antibiotics for chest tube placement is standard-of-care’ to ‘There are no good data to support prophylactic antibiotics for chest tubes’. Evidently there is no prevailing agreement on the topic. In the present paper, Bosman and colleagues convince us that their study adds to the supporting literature by compiling 11 studies and 1234 patients with 1241 chest drains, compared with the previous meta-analysis by Sanabria and co-workers2 with only five studies and 351 patients. One of the mandates of the accepted Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines is to consider the relevance of scientific findings on key stakeholders, such as healthcare providers and policy-makers. Given the present data, should antibiotic administration for tube thoracostomy be a mandated benchmark that surgeons/hospitals are expected to achieve? Is this publication the tipping point where prophylactic antibiotics for chest tubes should be mandated rather than recommended—perhaps for all patients with chest trauma, or at least for those with penetrating injuries? Appropriate administration of prophylactic antibiotics was recently shown to be associated with a significant reduction in the rate of surgical-site infection (SSI) and decreased morbidity3 as one of the main process measures of quality examined in the Surgical Care Improvement Project (SCIP) defined by experts from over 30 organizations including the Centers for Disease Control and the Agency for Healthcare Research and Quality in the USA. Should prophylactic antibiotics be standard-of-care for prevention of SSIs in injured patients requiring tube thoracostomy? With the addition of this meta-analysis, one could submit that this mandate should be given serious consideration. Disclosure The author declares no conflict of interest. References 1 Luchette FA , Barrie PS, Oswanski MF, Spain DA, Mullins CD, Palumbo F et al. Practice management guidelines for prophylactic antibiotic use in tube thoracostomy for traumatic hemopneumothorax: the EAST Practice Management Guidelines Work Group. Eastern Association for Trauma . J Trauma 2000 ; 48 : 753 – 757 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Sanabria A , Valdivieso E, Gomez G, Echeverry G. Prophylactic antibiotics in chest trauma: a meta-analysis of high-quality studies . World J Surg 2006 ; 30 : 1843 – 1847 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Ingraham AM , Cohen ME, Bilimoria KY, Dimick JB, Richards KE, Raval MV et al. Association of surgical care improvement project infection-related process measure compliance with risk-adjusted outcomes: implications for quality measurement . J Am Coll Surg 2010 ; 211 : 705 – 714 . Google Scholar Crossref Search ADS PubMed WorldCat Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
Barczyński, M; Konturek, A; Hubalewska-Dydejczyk, A; Gołkowski, F; Nowak, W
doi: 10.1002/bjs.8660pmid: 22287122
BackgroundThe extent of thyroid resection in Graves' disease remains controversial. The aim of this study was to evaluate long-term results of bilateral subtotal thyroidectomy (BST) compared with total thyroidectomy (TT) in patients with Graves' disease and mild active ophthalmopathy.MethodsParticipants were assigned randomly to BST or TT, and followed for 5 years after surgery. The primary endpoints of the study were the prevalence of recurrent hyperthyroidism and changes in Graves' ophthalmopathy. Secondary endpoints were postoperative transient and permanent paresis of the recurrent laryngeal nerve, and postoperative hypocalcaemia and hypoparathyroidism.ResultsTwo hundred patients were included, of whom 191 (BST 95, TT 96) completed the 5-year follow-up. Recurrent hyperthyroidism occurred in nine patients after BST and in none after TT (P = 0·002). Progression of Graves' ophthalmopathy was observed in nine patients after BST compared with seven following TT (P = 0·586). Transient hypoparathyroidism occurred in 13 and 24 patients respectively (P = 0·047). Permanent hypoparathyroidism was diagnosed in no patient after BST and in one after TT (P = 0·318). No differences were noted in transient or permanent recurrent laryngeal nerve injury.ConclusionTT for Graves' disease prevented recurrent hyperthyroidism but did not prevent the progression of ophthalmopathy compared with BST. Registration number: NCT01408368 (http://www.clinicaltrials.gov).
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