Implementation of transanal minimally invasive surgery (TAMIS) for rectal neoplasms: results from a single centre

Background Local excisions are important in a tailored approach to treatment of rectal neoplasms. In cases of low risk T1 local excision facilitates rectal-preserving treatment. Transanal minimally invasive surgery (TAMIS) is the most recent alternative developed for local excision. In this study we evaluate the results after implementing TAMIS as the routine procedure for local excision of rectal neoplasms. Methods All patients who underwent TAMIS from January 2016 to January 2020 at St. Olav’s University Hospital were included, and clinical, pathological and oncological data were prospectively registered. The primary endpoint was local recurrence, and the secondary endpoint was complications. Results There were 76 patients (42 men, mean age was 69 years [range 26–88 years]), The mean tumour level was 82 mm (range 20–140 mm) from the anal verge measured on rigid proctoscopy, and mean tumour size was 32 mm (range 8–73 mm). Three patients experienced complications needing intervention (Clavien–Dindo > 3A). Seventeen patients had rectal adenocarcinoma, 9 of whom underwent R0 completion total mesorectal excision (cTME). Fifty-five patients had an adenoma, 3 of whom developed recurrence (5.4%) within 12 months. All recurrences were treated successfully with a new TAMIS procedure. In addition, TAMIS was used in treatment of 2 patients with a neuroendocrine tumour, 1 patient with a haemangioma and 1 patient with a solitary rectal ulcer. Conclusions TAMIS surgery is associated with a low risk of complications and a low recurrence rate in rectal neoplasms. In cases of adenocarcinoma, R0 cTME surgery is feasible in the sub-group with high risk T1 and T2 tumours

Completion surgery vs. primary TME for early rectal cancer: a national study

Purpose While local excision by transanal endoscopic microsurgery (TEM) or transanal minimally invasive surgery (TAMIS) is an option for low-risk early rectal cancers, inaccuracies in preoperative staging may be revealed only upon histopathological evaluation of the resected specimen, demanding completion surgery (CS) by formal resection. The aim of this study was to evaluate the results of CS in a national cohort. Method This was a retrospective analysis of national registry data, identifying and comparing all Norwegian patients who, without prior radiochemotherapy, underwent local excision by TEM or TAMIS and subsequent CS, or a primary total mesorectal excision (pTME), for early rectal cancer during 2000–2017. Primary endpoints were 5-year overall and disease-free survival, 5-year local and distant recurrence, and the rate of R0 resection at completion surgery. The secondary endpoint was the rate of permanent stoma. Results Forty-nine patients received CS, and 1098 underwent pTME. There was no diference in overall survival (OR 0.73, 95% CI 0.27–2.01), disease-free survival (OR 0.72, 95% CI 0.32–1.63), local recurrence (OR 1.08, 95% CI 0.14–8.27) or distant recurrence (OR 0.67, 95% CI 0.21–2.18). In the CS group, 53% had a permanent stoma vs. 32% in the pTME group (P=0.002); however, the diference was not signifcant when adjusted for age, sex, and tumor level (OR 2.17, 0.95–5.02). Conclusions Oncological results were similar in the two groups. However, there may be an increased risk for a permanent stoma in the CS group

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89·6 per cent) compared with that in countries with a middle (753 of 1242, 60·6 per cent; odds ratio (OR) 0·17, 95 per cent c.i. 0·14 to 0·21, P < 0·001) or low (363 of 860, 42·2 per cent; OR 0·08, 0·07 to 0·10, P < 0·001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high‐HDI countries (risk difference −9·4 (95 per cent c.i. −11·9 to −6·9) per cent; P < 0·001), but the relationship was reversed in low‐HDI countries (+12·1 (+7·0 to +17·3) per cent; P < 0·001). In multivariable models, checklist use was associated with a lower 30‐day perioperative mortality (OR 0·60, 0·50 to 0·73; P < 0·001). The greatest absolute benefit was seen for emergency surgery in low‐ and middle‐HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low‐HDI countries was half that in high‐HDI countries

From Empirics to Empiricists

Although the notion of empiricism looms large in many histories of early modern philosophy, its origins are not well understood. This paper aims to shed light on them. It examines the notions of empirical philosopher, physician, and politician that are employed in a range of seventeenth- and eighteenth-century texts, alongside related notions (e.g. "experimental philosophy") and methodological stances. It concludes that the notion of empiricism used in many histories of early modern thought does not have pre-Kantian origins. It first appeared and became widely used in late eighteenth-century Germany, in the course of the early debates on Kant's Critical philosophy

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially