Delphi Method Consensus-Based Identification of Primary Trauma Care Skills Required for General Surgeons in Japan

Purpose General surgeons at regional hospitals should have the primary trauma care skills necessary to treat critically ill trauma patients to withstand transfer. This study was conducted to identify a consensus on primary trauma care skills for general surgeons. Methods An initial list of acute care surgical skills was compiled, and revised by six trauma experts (acute care surgeons); 33 skills were nominated for inclusion in the Delphi consensus survey. Participants (councilors of the Japanese Society for Acute Care Surgery) were presented with the list of 33 trauma care skills and were asked (using web-based software) to rate how strongly they agreed or disagreed (using a 5-point Likert scale) with the necessity of each skill for a general surgeon. The reliability of consensus was predefined as Cronbach’s α ≥ 0.8, and trauma care skills were considered as primarily required when rated 4 (agree) or 5 (strongly agree) by ≥ 80% participants. Results There were 117 trauma care specialists contacted to participate in the Delphi consensus survey panel. In the 1st round, 85 specialists participated (response rate: 72.6%). In the 2nd round, 66 specialists participated (response rate: 77.6%). Consensus was achieved after two rounds, reliability using Cronbach’s α was 0.94, and 34 items were identified as primary trauma care skills needed by general surgeons. Conclusion A consensus-based list of trauma care skills required by general surgeons was developed. This list can facilitate the development of a new trauma training course which has been optimized for general surgeons

CT evaluation of paraaortic lymph node metastasis in patients with biliary cancer.

Background The extent of paraaortic lymph node (PAN) metastasis parellels that of distant metastases in patients with biliary carcinoma. Accurate preoperative assessment of PAN metastasis has a crucial impact on surgical indications. In this retrospective study, we evaluated whether computed tomography (CT) scans were useful for diagnosing PAN metastases and excluding patients with PAN metastases from an indication for surgery. Methods Between March 1999 and November 2003, 57 patients with biliary carcinoma underwent radical lymphadenectomy or surgical biopsy of PANs. Nine of these patients were diagnosed as having PAN metastasis microscopically. All patients had undergone abdominal CT scans before surgery. To diagnose PAN metastases, we used the following diagnostic criteria. (1) Size; when lymph nodes were greater than 12mm, 10mm, 8mm, or 6mm in longo or short-axis diameter, the nodes were considered metastatic. (2) Shape and size; when the axial ratio of a lymph node was greater than 0.5, 0.7, 1.0, and the maximum diameter of the long or short axis was greater than 12mm, 10mm, 8mm, or 6mm, the node was considered metastatic. (3) Internal structure; if the internal structure of a PAN was heterogeneous, the node was considered metastatic. A positive predictive value was calculated for each included criterion when patients numbered ten or more. Results Positive predictive values using the above criteria ranged from 13% to 36%. Only one patient had PANs with heterogeneous internal structures. Conclusions We were unable to determine surgical indications based on the morphological criteria revealed by a CT scan

Evaluation of extra capsular lymph node involvement in patients with extra-hepatic bile duct cancer

Background: Lymph node metastasis is one of the most important prognostic factors for extra-hepatic bile duct carcinoma (ExHBDC). Extra capsular lymph node involvement (ExCLNI) is the extension of cancer cells through the nodal capsule into the perinodal fatty tissue. The prognostic impact of ExCLNI has been shown to be significant mainly in head and neck malignancies. Recently, the prognostic impacts of ExCLNI have evaluated in gastrointestinal malignancies. However no data is available regarding the incidence and prognostic significance of extra-capsular lymph node involvement (ExCLNI) in resectable ExHBDCs. The aim of the present study is first to evaluate the incidence of ExCLNI in surgically-treated ExHBDCs and second, to determine the prognostic impact of ExCLNI in patients with surgically-treated ExHBDCs. Methods: A total of 228 patients (110 cases of hilar cholangiocarcinoma and 118 cases of distal cholangiocarcinoma) with surgically-treated ExHBDCs were included in this retrospective study. ExCLNI was defined as the extension of cancer cells through the nodal capsule into the perinodal fatty tissue. The existence of ExCLNI and its prognostic value were analyzed as a subgroup of lymph node metastasis. Results: ExCLNI was detected in only 22% of patients with lymph node metastasis of surgically-treated ExHBDC. The presence of ExCLNI correlated with distal cholangiocarcinoma (p = 0.002). On univariate analysis for survival, perineural invasion, vascular invasion, histological grade, and lymph node metastasis were statistically significant factors. On multivariate analysis, only lymph node metastasis was identified as a significant independent prognostic factor in patients with resectable ExHBDC. Subgroups of lymph node metastasis including the presence of ExCLNI, location of lymph node metastasis, and the number of lymph node metastasis had no statistically significant impact on survival. Conclusion: ExCLNI was present in only 22% of the LNM (7% of overall patients) in patients with surgical treated ExHBDCs. And ExCLNI would have no impact on the survival of patients with surgically-treated ExHBDCs