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

Contin uous sutures in intraabdominal intestinal end -to -end anastomoses

The implementation of conventional and laparoscopic intestinal joining is a problem, remotely solved. Along with many routine methods described, different modifications with automatic staplers are presented, each of certain value and benefits. Achieving an appropriate balance between price, reliability and health benefits is the operator-surgeon responsibility, sometimes in a condition of emergency. We aimed at assessing the safety and effectiveness of the fulfillment of end-to-end continuous anastomoses in the intraabdominal intestinal relations. Author`s own experience of 88 consecutive intra-abdominal anastomoses was presented. They were performed in the period from 01.01.2010 to 30.06.2013, since the technique has been applied. Patients were evaluated in the following groups: Group 1 - after colonic resections: right, intermediate, left hemicolectomies, resection of sigma or rectosigmoid, subtotal colectomy (N1=56, 63,6%). Group 2 - after restoring passages operation, regarding low rectal resection with double-loop protective ileostomy or transversostomy (N2=24, 27,3%). Restoring the transversostomy was performed with partial anastomosis preserving the mesenteric side of the intestine. Group 3 - patients after internal derivation (N3=8, 9,1%). Modified and applied two-layer end-to-end technique suitable for double differences in lumens, with adequate correction approach and saving blood supply of the mesentery. Digital hedging during the implementation of the second floor of the anastomosis allows additional control over the achievement of the other important for success factors: adequate lumen and tight attachment of the bowel ends serous surfaces. A total of 4 (4,54%) of the patients monitored had complications in the form of late postoperative paresis (in three patients until postoperative day 7) and partial insufficiency in one (sigmoid resection). All they were overcome conservatively. There was one exitus (1,14%) after cardiac death on the 6th postoperative day. Three of the patients were operated under a condition of urgency and in all the others a standardized preoperative preparation of the bowel tract was used. Anastomotic time was significantly shorter (25-35 min) due to the following factors: not performing close intestinal loop, small layers widths of the opposite bowel parts, better control of intestinal blood supply. Possible surgical site contamination is minimized. Anastomosis is very simple, fast, and extremely reliable. Early feeding is practiced (after 24 hours), which is the basis for a rapid (fast track) recovery of these patients. Not to ignore the low price of the joining accomplished (1÷3 nontraumatic sutures 3/0). The variability in the performance of intestinal anastomoses allows an opportunity for individualized approach. End-to-end continuous bowel connections have some tactical, technical and economic advantages, and combined with their reliability present a very good option

Transanal Total Mesorectal Excision - a New Approach to the Minimally Invasive Surgical Treatment of Rectal Cancer with Mid and Distal Location

Introduction: Transanal reversed Total Mesorectal Excision is an innovative high-tech method with an exponentially increasing use worldwide since its introduction by Antonio Lacy in 2011. The technique was developed using a single port - platform to improve the quality of the total mesorectal excision of rectal cancer with low- and middle- third localization. The distal mesorectum is processed by a transanal access in the caudo-cranial direction which facilitates its dissection with adequate visual indication of the distal margin. This technology potentially offers a more precise performance of `acute` dissection with a higher percentage of complete removal of the specimen in ablastic borders and a lower percentage of tumor involvement of circumferential resection line. This approach is applied in highly specialized centers but there are still no randomized clinical trials examining the full advantages and drawbacks of this new technology. COLOR III, which launched in late 2015, is the first large-scale study of this kind. Despite the potential benefits and enthusiasm in introducing this method, the method of implementation is relatively complex, it requires serious technical security and a long learning curve. Certain relatively new serious complications associated with this procedure, which are not observed in conventional approaches, have been observed in smaller cohorts. Iatrogenic lesion of the urethra, injury to the structures of lateral pelvic wall with life-threatening bleeding as well as lesions on the lower hypogastric nerves are documented complications occurring less frequently in `conventional laparoscopic` cranio-caudal TME. Introduction of this technique requires serious training programs, preparation of guidelines and monitoring of results. These requirements are the target of the scheduled in May, 2016 TaTME Congress in Amsterdam.Materials and Methods: We used surgical treatment by a reversed (transanal) single port - technique with 3D - visualization of caudo-cranial (down to up) stage of TME in 19 patients with low and middle rectal cancer operated on by the author`s team in the university tertiary center KSSG - St. Gallen, Switzerland, following the criteria of COLOR III multicenter randomized trial with reporting of intra and early postoperative results. Transabdominal laparoscopic single-port approach was used simultaneously in the abdominal stage to mobilize the left colon. All patients were discussed at the preoperative tumor-board with their data from endoscopic, histological and imaging (MRI, PET-CT scan) examinations prior to being included in the study cohort.Results: The average age of the operated patients was 68.7 with the gender distribution being - 59% men and 41% women. All patients have received preoperative radiotherapy. 17 of the patients have been postoperatively histologically confirmed, according to the quality of TME as a whole (complete), performed with intact fascia propria recti and in two patients there was partly damaged fascia. pR0 resection was performed on all of the patients . In all patients underwent protective ileostomy for 6 weeks. There were no major intraoperative complications. During the early postoperative period, the postoperative complications were as follows: Clavien-Dindo I-IIIa - 4 patients; Clavien-Dindo IIIa-IV - 0 patients.Discussion: The evolving tendency towards minimally invasive surgical approaches to rectal cancer continues to face problems such as the necessity of adequate visual exposure of the pelvis, distal ablastic rectal division, lower pelvic anastomosis as well as the appropriate for all of this technical equipment. Laparoscopic transanal total mesorectal excision was developed as an innovative alternative that offers certain advantages over the problems of conventional open and laparoscopic rectal surgery but presented its own specific problems the solution of which requires a coordinated approach at a multinational level

Watch and wait approach in rectal cancer treatment

Introduction: The colorectal carcinoma is the most common gastrointestinal neoplasm worldwide and in Bulgaria. The choice of surgical treatment is often difficult, and organ-preserving surgery is not feasible. In borderline situations, when choosing a surgical approach is difficult, the neoadjuvant chemoradiotherapy may downsize the tumor and provide better results and more surgical options. If the treatment response is partial or complete, the possibility of sphincter-sparing surgery is increased. The aim of the study is to present a clinical case of a patient with rectal carcinoma, submitted to multimodal treatment. Case report: The presented patient is a 65-year old female, with disturbing symptoms and diagnosed rectal adeno- carcinoma. The patient underwent preoperative neoadjuvant treatment. After a full course of treatment, the tumor was resized and was reported an almost complete clinical response to the therapy. After the recommended period had ended, she underwent an anterior resection of the rectum. This case is an example of the potential possibilities of a multidisciplinary team in surgical oncology. Conclusions: There are certain criteria, regarding the “Watch and wait” approach in rectal carcinoma, and it subjected to a set of indications in the case of a complete or near complete response to the treatment. The current case is not the brightest example of applying this approach, but still is a case of performing a sphincter-spearing surgery, which may lead to higher quality of life of the target patient group. The ESMO guidelines for the neoadjuvant treatment of rectal adenocarcinoma are applicable in Bulgaria

Conventional vs. Laparoscopic Appendectomy in Emergency Patients. Is There a Better Approach?

Introduction: Surgical treatment of acute appendicitis is relatively easy with a minimally invasive approach. Laparoscopy produces a very good image; applies less trauma, has better cosmetics and patients recover more quickly. However, its routine use requires prepared laparoscopic sets, trained personnel and specific organization. The main difficulties of both methods are associated with atypical anatomical locations and complicated forms of the disease.Aim: The objective of the study is to compare the reasons influencing the decision to choose a laparoscopic or a conventional approach for appendectomy. Surgeries performed in the span of four years in II-nd Surgery, Hospital Alexandrovska (2012-2016) were evaluated.Materials and Methods: The study covered 67 patients with acute appendicitis. Of those 8 (11.9%) were operated on with a laparoscopic approach . The average age was 27.4 years. There were 23 men (34.3%) and 44 women (65.7%). The average conventional intervention duration was 70 minutes, while in the laparoscopic procedure it was 55 minutes (

Peutz-Jeghers syndrome: a rare condition

Peutz-Jeghers syndrome is a rare inherited condition characterized by hamartomatous gastrointestinal (GI) polyposis and mucocutaneous pigmentation. Most patients depict distinctive clinical signs, with episodes of gastrointestinal bleeding or polyp-induced bowel obstruction. The authors report a clinical case with typical features diagnosed before complication`s development. The patient had high surgical risk as a result of previous adolescent surgery. There were completely eliminated 14 polyps of upper and lower GI measuring up to 6 cm (in cecum) by repeated endoscopic interventions. Thus, prophylaxis of intestinal neoplasms was achieved. With a wide range of additional tests the presence of extra-GI tumours was excluded. An accurate screening mechanism for follow-up in the future was elaborated. Major therapeutic problems of the syndrome are the following complications which require urgent surgery: bleeding, obstruction and intussusceptions. Patients with Peutz-Jeghers syndrome have an increased risk of a number of epithelial malignancies. In conclusion, modern knowledge of the chromosome testing, laboratory, endoscopy and other examinations enables reducing the need of unnecessary laparotomies and postoperative complications. The genetically determined association of the syndrome with numerous neoplasms requires an adequate screening mechanism for prevention of tumour development

Optimizing the Learning Curve in Laparoscopic Colorectal Surgery

Introduction: In the recent decades, the surgical treatment of colorectal neoplasms is further developed with a minimally invasive approach, following the complex approach, modern guidelines and classic oncological principles. Any conventional operation can be performed via laparoscopy and in addition to that it produces a better image of the pelvis. Thus, a high-quality surgery, with a maximal sphincter conservation, minimal blood loss and quicker recovery of the patients can be carried out.Aim: The aim of this study was to analyze factors influencing the period of gaining experience with laparoscopic colorectal resections. We evaluated this surgery performed in the Second Surgery at the „Alexandrovska` Hospital (March, 2013-Februrary, 2016) for a period of three years.Materials and Methods: 317 patients with colonic and rectal neoplasms were operated on. Their average age was 61.4 and the gender distribution was - 172 males (54.3%) and 145 females (45.7%). Laparoscopic approach was planned in 37 (11.7%) of them. The following factors were taken into consideration: location of the tumor, the need to use automatic devices, duration of the surgery, etc. The compared indicators, related to decision making for laparoscopic approach, are the technique used and the obtained result, the duration of the intervention, financial resources and the number of conversions.Results: There were 5 are rectal amputations (13.5%), 14 anterior resection (37.8%) and two intersphincteric resections with coloanal anastomosis (5.4%), 6 (16.2%) right hemicolectomies, 5 left colectomies (13.5%) and three sigma resections (8.1%). The average postoperative stay reported was 6.2 days. The mean operative time was 212 minutes. A steady tendency to reduce it was observed (from 330 to 120 min.). Due to the advanced process, conversion was performed in 5 cases (13.5%).Conclusion: The use of automatic stapling devices and high-energy hemostatic devices predetermines the higher cost of the laparoscopic surgery. It gives the advantages of less postoperative pain and shortened hospitalization. The longer training curve depends on resource availability and personal technical skills. This use of this metehod gives the necessary advantage to patients without oncological safety compromise

Epigenetic alterations in patients with type 2 diabetes mellitus

Epigenetic changes, in particular DNA methylation processes, play a role in the pathogenesis and progression of type 2 diabetes mellitus (T2DM) linking genetic and environmental factors. To clarify this role, we have analyzed in patients with different duration of T2DM: (i) expression levels of methyl-CpG-binding domain protein 2 (MBD2) as marker of DNA methylation, and ii) methylation changes in 22 genes connected to cellular stress and toxicity. We have analyzed MBD2 mRNA expression levels in16 patients and 12 controls and the methylation status of stress and toxicity genes in four DNA pools: (i) controls; (ii) newly-diagnosed T2DM patients; (iii) patients with T2DM duration of 5 years. The MBD2 expression levels were 10.4-times increased on average in T2DM patients compared to controls. Consistent increase in DNA methylation fraction with the increase in T2DM duration was observed in Prdx2 and SCARA3 genes, connected to oxidative stress protection and in BRCA1 and Tp53 tumor-suppressor genes. In conclusion, increased MBD2 expression in patients indicated general dysregulation of DNA methylation in T2DM. The elevated methylation of Prdx2 and SCARA3 genes suggests disturbance in oxidative stress protection in T2DM. The increased methylation of BRCA1 and Tp53 genes unraveled an epigenetic cause for T2DM related increase in cancer risk

Blood cell count indexes as predictors of anastomotic leakage in elective colorectal surgery: A multicenter study on 1432 patients

Background: The aim of this study was to evaluate a series of blood count inflammation indexes in predicting anastomotic leakage (AL) in elective colorectal surgery. Methods: Demographic, pathologic, and clinical data of 1432 consecutive patients submitted to colorectal surgery in eight surgical centers were retrospectively evaluated. The neutrophil to lymphocyte (NLR), derived neutrophil to lymphocyte (dNLR), lymphocyte to monocyte (LMR), and platelet to lymphocyte (PLR) ratios were calculated before surgery and on the 1st and 4th postoperative days, in patients with or without AL. Results: There were 106 patients with AL (65 males, mean age 67.4 years). The NLR, dNLR, and PLR were significantly higher in patients with AL in comparison to those without, on both the 1st and 4th postoperative days, but significance was greater on the 4th postoperative day. An NLR cutoff value of 7.1 on this day showed the best area under the curve (AUC 0.744; 95% CI 0.719-0.768) in predicting AL. Conclusions: Among the blood cell indexes of inflammation evaluated, NLR on the 4th postoperative day showed the best ability to predict AL. NLR is a low cost, easy to perform, and widely available index, which might be potentially used in clinical practice as a predictor of AL in patients undergoing elective colorectal surgery. © 2020 The Author(s)

Blood cell count indexes as predictors of anastomotic leakage in elective colorectal surgery: A multicenter study on 1432 patients

Background: The aim of this study was to evaluate a series of blood count inflammation indexes in predicting anastomotic leakage (AL) in elective colorectal surgery. Methods: Demographic, pathologic, and clinical data of 1432 consecutive patients submitted to colorectal surgery in eight surgical centers were retrospectively evaluated. The neutrophil to lymphocyte (NLR), derived neutrophil to lymphocyte (dNLR), lymphocyte to monocyte (LMR), and platelet to lymphocyte (PLR) ratios were calculated before surgery and on the 1st and 4th postoperative days, in patients with or without AL. Results: There were 106 patients with AL (65 males, mean age 67.4 years). The NLR, dNLR, and PLR were significantly higher in patients with AL in comparison to those without, on both the 1st and 4th postoperative days, but significance was greater on the 4th postoperative day. An NLR cutoff value of 7.1 on this day showed the best area under the curve (AUC 0.744; 95% CI 0.719-0.768) in predicting AL. Conclusions: Among the blood cell indexes of inflammation evaluated, NLR on the 4th postoperative day showed the best ability to predict AL. NLR is a low cost, easy to perform, and widely available index, which might be potentially used in clinical practice as a predictor of AL in patients undergoing elective colorectal surgery