Factors Influencing the Success of In Vivo Sentinel Lymph Node Procedure in Colon Cancer Patients: Swiss Prospective, Multicenter Study Sentinel Lymph Node Procedure in Colon Cancer

Background: The sentinel lymph node (SLN) procedure has the potential to provide relevant improvement in nodal staging in colon cancer patients. However, there remains room for improvement for SLN identification and sensitivity. Therefore, the objective of the present investigation was to analyze factors influencing the success of the SLN procedure in colon cancer patients. Methods: One hundred seventy-four consecutive colon cancer patients were prospectively enrolled in this multicenter study and underwent in vivo SLN procedure with isosulfan blue 1% followed by open standard oncologic colon resection. Several patient-, tumor-, and procedure-related factors possibly influencing the SLN identification and sensitivity were analyzed. Results: Sentinel lymph node identification rate and accuracy were 89.1 and 83.9%, respectively. Successful identification of SLN was significantly associated with the intraoperative visualization of blue lymphatic vessels (p<0.001) and with female gender (p=0.024). True positive SLN results were significantly associated with higher numbers of SLN (p=0.026) and with pN2 stage (p=0.004). There was a trend toward better sensitivity in patients with lower body mass index (BMI) (p=0.050). Conclusions: The success of the SLN procedure in colon cancer patients depends on both procedure-related factors (intraoperative visualization of blue lymphatic vessels, high number of SLN identified) and patient factors (gender, BMI). While patient factors can not be influenced, intraoperative visualization of blue lymphatics and identification of high numbers of SLN are key for a successful SLN procedur

Malignant solitary fibrous tumor involving the liver

Solitary fibrous tumors are predominantly benign and are most commonly found in the thoracic cavity and pleura; while reports exist in the literature of malignant solitary fibrous tumors and those located in extrathoracic organs, these cases are considered extremely rare. Herein, a case is reported of a malignant solitary fibrous tumor involving the liver that was diagnosed and treated in a 62-year-old woman. The patient presented with complaints of upper abdominal pain and unintentional weight loss. Computed tomography scan of the abdomen revealed a remarkably large mass, measuring 15 cm × 10 cm × 20 cm, which appeared to be unrelated to any particular organ. The intraoperative finding of a wide communication with the left liver suggested hepatic origin, and served as an indicator for tumor resection via left hemihepatectomy. The diagnosis of solitary fibrous tumor and its malignant nature was confirmed by histological and immunohistochemical examination of the resected tissues. Hepatic solitary fibrous tumor is very rare, and surgery remains the mainstay of treatment. Due to limited reports of such tumors in the literature, little can be said about the benefit of adjuvant therapy and prognosis for the rare cases with malignant histological findings

Resident work hour restrictions do not improve patient safety in surgery: a critical appraisal based on 7 years of experience in Switzerland

<p>Abstract</p> <p>In 2005 the Swiss government implemented new work-hour limitations for all residency programs in Switzerland, including a 50-hour weekly limit. The reduction in the working hours of doctors in training implicate an increase in their rest time and suggest an amelioration of doctors' clinical performance and consequently in patients' outcomes and safety - which was not detectable in a preliminary study at a large referral center in Switzerland. It remains elusive why work-hour restrictions did not improve patient safety. We are well advised to thoroughly examine and eliminate the known adverse effects of reduced work-hours to improve our patients' safety.</p

Demographic situation in operative medicine in Switzerland - time to react?

Objective: The decreasing proportion of physicians of Swiss origin and the increasing number of part-time jobs in operative medicine might lead to a shortage of physicians in operative disciplines in Switzerland. The objective of the present study was to analyze the current demographic situation in operative medicine in Switzerland. Methods: During the summer of 2011, a 19-item anonymous electronic questionnaire was mailed to all directors of departments in operative medicine in Switzerland. The questionnaire was designed to gather data about the characteristics of the participating departments, the demographics (including the appointment (consultant, attending or resident), the proportion of female and foreign physicians, the latter’s origin, and the number of part-time jobs with a working time between 20 and 90%), and the proportion of vacant posts. Results: Of 775 questionnaires mailed to all directors of departments in operative medicine in Switzerland, 183 (24%) were returned. Overall, 40% were female, and 42% foreign physicians. The proportion of part-time jobs amounted to 17%. Vacant posts were found in 2%. Conclusions: An expansion of study places at the medical universities and of the incentives for the incumbents in operative medicine is necessary to avert a shortage of physicians in Switzerland

Surgical Safety Checklists in Operative Medicine in Switzerland

Objective: Despite the known positive impact of surgical checklists on morbidity and mortality rates, data on the implementation of checklists in Swiss operating rooms as well as the resulting experiences are missing. The present study evaluated the general use and design of checklists in operative medicine in Switzerland, the difficulties in introduction and the subjective impact on adverse events. Methods: An anonymous national survey of directors of adult departments in operative medicine in Switzerland was conducted during spring 2011. They were identified from the database of the Swiss college of surgeons (fmCh). The survey included questions about the use, type and content of the used checklists, the prevention of mixing up patients and the awareness of wrong site surgery. Results: Overall, 237/799 (29.7%) surveys were returned. At the time of the survey, 172/233 (73.8%) departments used surgical checklists (4 missing values). The median time needed for collecting data per patient was 60 (range 10-600) seconds. In all, 46/161 (28.6%) participants reported a subjective decrease of adverse events after the introduction of a surgical checklist (11 missing values). Out of 217 respondents, 62 (28.6%) knew of one event and 87 (40.1%) of more than one event of wrong site surgery (20 missing values). Conclusions: There is still room for improvement in the use of surgical checklists, which impresses, in regard to the time needed for data collection per patient, and which is not excessively time-consuming. However, acceptance problems of the majority of respondents during the introduction phase of surgical checklists vanished over time. [Arch Clin Exp Surg 2012; 1(3.000): 158-167

Early closure of ileostomy is associated with less postoperative nausea and vomiting

Background/Aims: Temporary loop ileostomy is increasingly used in colorectal surgery but necessitates secondary closure. We evaluated postoperative complications, particularly nausea and vomiting, in patients with early, intermediate, or late elective ileostomy closure. Methods: We included all patients undergoing ileostomy closure from 2001 to 2008. Time from ileostomy construction to closure was classified as early (EC, 18 weeks). Using multivariable logistic regression, we compared the frequency of postoperative complications between the groups. Results: We included 134 patients (87 males; median age 71 years, range 29–91). Carcinoma of the rectum (n = 67, 50%) was the main reason for ileostomy construction. The median time to ileostomy closure was 103 days (range 8–461). Among patients with EC, IC, and LC, postoperative nausea occurred in 50.0, 73.1, and 78.6%, respectively (p = 0.006), and postoperative vomiting in 22.5, 57.7, and 59.5%, respectively (p = 0.001). Adjusting for important covariates, the odds ratio for postoperative nausea was 2.0 (95% CI 0.76–5.1) for IC and 4.1 (95% CI 1.2–14.3) for LC compared to EC (p = 0.069). For postoperative vomiting, adjusted odds ratios were 3.8 (95% CI 1.4–10.4) for IC and 4.6 (95% CI 1.4–15.5) for LC (p = 0.012). Other complications did not differ between the groups. Conclusions: These findings suggest that early ileostomy closure might reduce postoperative nausea and vomiting

Sentinel lymph node procedure leads to upstaging of patients with resectable colon cancer: results of the Swiss prospective, multicenter study sentinel lymph node procedure in colon cancer

The value of the sentinel lymph node (SLN) procedure in colon cancer patients remains a matter of debate. The objective of this prospective, multicenter trial was 3-fold: to determine the identification rate and accuracy of the SLN procedure in patients with resectable colon cancer; to evaluate the learning curve of the SLN procedure; and to assess the extent of upstaging due to the SLN procedure

The influence of the surgeon's and the hospital's caseload on survival and local recurrence after colorectal cancer surgery

BACKGROUND: Past studies have identified surgeon- and institution- related characteristics as prognostic factors in colorectal cancer surgery. The present work assesses the influence of the surgeon's and the hospital's caseload on long-term results of colorectal cancer surgery. METHODS: The data on 2706 patients from 2, randomized, colorectal cancer trials (Swiss Group for Clinical Cancer Research [SAKK] 40/81, SAKK 40/87) investigating adjuvant intraportal and systemic chemotherapy and 1 concurrent registration study (SAKK 40/88) were reviewed. A first analysis included 1809 eligible, nonmetastatic patients from all 3 studies. A subsequent subgroup analysis included 915 eligible patients from both randomized trials. Overall survival (OS), disease-free survival (DFS), and local recurrence (LR) were analyzed in multivariate models taking into account the possible effect of clustering. The main potential covariates were surgeon's annual caseload (>5 operations/year vs 26 operations/year vs < or =26 operations/year), tumor site, T stage, and nodal status. RESULTS: Primary analysis of all 3 studies combined found a high surgeon's caseload to be positively associated with OS (P = .025) and marginally with DFS (P = .058). Separate analysis for each trial, however, showed that a high surgeon's caseload was beneficial for outcome in both randomized trials but not in the registration study. A subgroup analysis of 915 patients with 376 rectal and 539 colonic primaries from both randomized trials, therefore, was performed. Neither age, gender, year of operation, adjuvant chemotherapy (intraportal vs systemic vs operation alone), hospital academic status (university vs non-university), training status of the surgeon (certified surgeon vs surgeon-in-training), nor inclusion in 1 of the 2 randomized trials (SAKK 40/81 vs SAKK 40/87) was a significant predictor of outcome. However, both high surgeon's and high hospital's annual caseloads were independent, beneficial prognostic factors for OS (P = .0003, P = .044) and DFS (P = .0008, P = .020), and marginally significant factors for LR (P = .057, P = .055). CONCLUSIONS: High surgeon's and hospital's annual caseloads are strong, independent prognostic factors for extending overall and disease-free survival and reducing the rate of local recurrence in 2 randomized colorectal cancer trials