Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p<0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p<0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

Comparative study between magnesium sulphate and L-hyoscyamine on duodenal motility during ERCP under general anaesthesia: A prospective randomized study

Objective: Endoscopic retrograde cholangiopancreatography (ERCP) is a relatively complex procedure as compared with other endoscopy which needs longer duration, duodenal relaxation and good sedation. The aim of this study was to evaluate the efficacy and safety of magnesium sulphate as spasmolytic agent during ERCP under general anaesthesia. Design: A prospective randomized study. Setting: Delivery room, operating room and postoperative recovery area. Patients and method: Patients, who were treated for calcular obstructive jaundice by ERCP were randomized into two groups. The patients were randomized into two groups: G I, patients received 500 mg magnesium sulphate in 100 ml saline 15 min before induction and G II, patients received 0.5 mg L-hyoscyamine sulphate before induction of anaesthesia. Measurement: The primary outcome was duodenal relaxation during ERCP under general anaesthesia. Secondary outcomes include changes of heart rate, changes in oxygen saturation, time needed for cannulation, procedure difficulty, duration of the procedure, post-procedure complications, and the need of post-procedure analgesia. Results: Duodenal motility score was found to be 0.85 ± 1.47 in GI and 2.2 ± 3.08 in GII (P = 0.0001). The number of patients who had no duodenal contraction was significantly more in GI. The success rate of biliary cannulation is significantly higher in GI than in GII (58 (100%) vs 54 (93.1%), P = 0.04). The duration of cannulation was significantly shorter in GI. The number of patients who developed pancreatitis, nausea and vomiting was significantly less in GI. The pulse rate was found to be statistically less in GI at different time follow-ups. Conclusion: Magnesium sulphate is a safe spasmolytic agent during general anaesthesia that improves the success rate of ERCP and it allows easy completion of the procedure by decreasing the duodenal motility. It decreases the duration of the procedure, subsequently shortens the period of anaesthesia and improves post procedure recovery. It reduces post ERCP pancreatitis, nausea and vomiting

Pancreatic cystic neoplasms: Predictors of malignant behavior and management

Background/Aim: Pancreatic cystic neoplasms are being increasingly identified with the widespread use of advanced imaging techniques. In the absence of a good radiologic or pathologic test to preoperatively determine the dianosis, clinical characteristics might be helpful. The objectives of this analysis were to define the incidence and predictors of malignancy in pancreatic cysts. Patients and Methods: Patients with true pancreatic cysts who were treated at our institution were included. Patients with documented pseudocysts were excluded. Demographic data, clinical manifestations, radiological, surgical, and pathological records of those patients were reviewed. Results: Eighty-one patients had true pancreatic cyst. The mean age was 47 ± 15.5 years. There were 28.4% serous cystadenoma, 21% mucinous cystadenoma, 6.2% intraductal papillary tumors, 8.6% solid pseudopapillary tumors, 1.2% neuroendocrinal tumor, 3.7% ductal adenocarcinoma, and 30.9% mucinous cystadenocarcinoma. Malignancy was significantly associated with men (P = 0.04), older age (0.0001), cysts larger than 3 cm in diameter (P = 0.001), presence of solid component (P = 0.0001), and cyst wall thickening (P = 0.0001). The majority of patients with malignancy were symptomatic (26/28, 92.9%). The symptoms that correlated with malignancy included abdominal pain (P = 0.04) and weight loss (P = 0.0001). Surgical procedures were based on the location and extension of the lesion. Conclusion: The most common pancreatic cysts were serous and mucinous cysts. These tumors were more common in females. Old age, male gender, large tumor, presence of solid component, wall thickness, and presence of symptoms may predict malignancy in the cyst

Solid pseudopapillary tumour of the pancreas: Incidence, prognosis and outcome of surgery (single center experience)

AbstractBackgroundSolid pseudopapillary tumour (SPT) of the pancreas is a rare neoplasm of low malignant potential. The pathogenesis and guidelines for its treatment remain unclear. This study was designed to evaluate the diagnosis, surgical treatment and prognosis of SPT.Study designA retrospective study during the period between January 1995 to October 2012.Patients and methodCases with SPTs treated at our institution were reviewed. Demographic data, clinical manifestations, radiological, surgical, and pathological records were reviewed for patients with SPT.ResultsTwenty four patients with SPT were identified (22 women and 2 men with a mean age 24.83 ± 8.66 (12–52 years). The tumour was located in the head in (50%) and in the body (8.3%) and in the tail (41.7%). The mean size was 9.2 ± 5.3 (3–25 cm). The main clinical presentation was abdominal pain in (83.3%). All 24 patients had curative resection including pancreaticoduodenectomy (50%), central pancreatectomy (8.3%) and distal pancreatectomy (41.7%). Sex, age, symptoms, tumour size, CT image and tumour markers were not significant clinical factors to predict SPT with malignant behavior. The recurrence rate was (8.3%) after 5 years postoperatively. No hospital mortality, all patients except 2 patients (8.3%) were alive at follow up period. The estimated 1, 3, and 5 year survival rate was 95%, 95%, and 88%.ConclusionSPT are rare neoplasms with malignant potential. Aggressive surgical resection is needed even in presence of local invasion, and also for recurrence as patients had a good long term survival