The cost of surgical training: analysis of operative time for laparoscopic cholecystectomy

Background: Duration of surgery is a main cost factor of surgical training. The purpose of this analysis of operative times for laparoscopic cholecystectomies (LC) was to quantify the extra time and related costs in regards to the surgeons' experience in the operating room (OR). Methods: All LC performed between January 01, 2005 and December 31, 2008 in 46 hospitals reporting to the database of the Swiss Association for Quality Management in Surgery (AQC) were analyzed (n=10,010). Four levels of seniority were specified: resident (R), junior consultant (JC), senior consultant (SC), and attending surgeon (AS). The differences in operative time according to seniority were investigated in a multivariable log-linear and median regression analysis controlling for possible confounders. The OR costs were calculated by using a full cost rate in a teaching hospital. Results: A total of 9,208 LC were available for analysis; 802 had to be excluded due to missing data (n=212) or secondary major operations (n=590). Twenty-eight percent of the LC were performed by R as teaching operations (n=2,591). Compared with R, the multivariable analysis of operative time showed a median difference of −2.5min (−9.0; 4.8) for JC and −18min (−25; −11) for SC and −28min (−35; −10) for AS, respectively. The OR minute costs were €17.57, resulting in incremental costs of €492 (159; 615) per operation in case of tutorial assistance. Conclusions: The proportion of LC performed as tutorial assistance for R remains low. Surgical training in the OR causes relevant case-related extra time and therefore cost

Predicting complicated appendicitis based on clinical findings: the role of Alvarado and appendicitis inflammatory response scores

PURPOSE: The pre-interventional differentiation between complicated and uncomplicated appendicitis is decisive for treatment. In the context of conservative therapy, the definitive diagnosis of uncomplicated appendicitis is mandatory. This study investigates the ability of clinical scoring systems and imaging to differentiate between the two entities. METHODS: This is a retrospective analysis of two cohorts from two tertiary referral centers in Switzerland and Germany. All consecutive patients underwent appendectomy between January 2008 and April 2013 (in the first cohort) or between January 2017 and June 2019 (the second cohort). Exclusion criteria did not apply as all patients found by the database search and received an appendectomy were included. Diagnostic testing and calculation of a receiver operating curve were performed to identify a cutoff for clinical scores that resulted in a minimum sensitivity of 90% to detect complicated appendicitis. The cutoff was combined with additional diagnostic imaging criteria to see if diagnostic properties could be improved. RESULTS: Nine hundred fifty-six patients were included in the analysis. Two hundred twenty patients (23%) had complicated appendicitis, and 736 patients (77%) had uncomplicated appendicitis or no inflammation. The complicated appendicitis cohort had a mean Alvarado score of 7.03 and a mean AIR of 5.21. This compared to a mean Alvarado of 6.53 and a mean AIR of 4.07 for the uncomplicated appendicitis cohort. The highest Alvarado score with a sensitivity of > 90% to detect complicated appendicitis was >== 5 (sensitivity = 95%, specificity 8.99%). The highest AIR score with a sensitivity of > 90% to detect complicated appendicitis was >== 3 (sensitivity 91.82%, specificity 18.53). The analysis showed that additional CT information did not improve the sensitivity of the proposed cut-offs. CONCLUSION: AIR and Alvarado scores showed limited capability to distinguish between complicated and uncomplicated appendicitis even with additional imaging in this retrospective cohort. As conservative management of appendicitis needs to exclude patients with complicated disease reliably, appendectomy seems until now to remain the safest option to prevent undertreatment of this mostly benign disease

Quality of life with diverticular disease: translation and validation of the German version of the diverticulitis quality of life questionnaire (DV-QOL).

BACKGROUND The DV-QoL is a 17-item questionnaire measuring health-related quality of life in patients affected by symptomatic diverticular disease, covering four domains: physical symptoms, concerns, feelings, and behavioral changes. Given the lack of a diverticulitis-specific questionnaire to be used for German-speaking patients, we prospectively validated the German version of the DV-QoL. METHODS German-speaking patients with CT-confirmed history of recurrent diverticular disease admitted to a Swiss surgical department completed the German version of the DV-QoL, along with short form-36 (SF-36) and the Gastrointestinal Quality of Life Index (GIQLI). Reliability was examined using exploratory and confirmatory factor analysis, a Martin-Loef test, and Cronbach's alpha. For convergent validity testing, correlations were calculated with the GIQLI and SF-36. Discriminant validity tests included age and gender. RESULTS We included 121 patients, of whom 77 were admissions for elective surgery and 44 presented with acute diverticulitis treated conservatively. The DV-QoL's total score showed good correlations with the GIQLI (r = - 0.77) and its subscales (r = - 0.76 to - 0.45), as well as with the SF-36's subscales (r = - 0.30 to - 0.57). No relationships were found with age or gender (p < 0.05). The Cronbach's alpha coefficient was 0.89 over all items and 0.69, 0.90, 0.78, and 0.77 for the four separated domains (physical symptoms, cognitions/concerns, feelings, and behavioral changes, respectively). A nonsignificant Martin-Loef test indicated unidimensionality (p = 1), further supported by the exploratory factor analysis, which showed an item information sharing of 65%. CONCLUSION The German DV-QoL questionnaire can be used as a valid and reliable disease-specific measure for quality of life in patients with recurrent diverticular disease

A rare case of retroperitoneal teratoma with evidence of papillary thyroid carcinoma: a case report

Abstract Background Teratomas are germ cell tumors composed of somatic tissues from up to three germ layers. Primary retroperitoneal teratomas usually develop during childhood and are uncommon in adults and in the retroperitoneal space. While there are only a few cases of retroperitoneal thyroid tissue, we report a unique case of a retroperitoneal papillary thyroid carcinoma. Case presentation A 41-year-old woman presented in our institution due to intermitted unspecific abdominal pain. Magnetic resonance imaging detected a multi-cystic solid retroperitoneal mass ventral to the psoas muscle and the left iliac artery. After surgical removal of the retroperitoneal mass, histology sections of the specimen indicated evidence of papillary thyroid carcinoma cells. A staging computed tomography scan of the body showed no further manifestations. To reduce the risk of recurrence, total thyroidectomy was performed followed by radioiodine therapy with lifelong hormone substitution. Conclusions Primary retroperitoneal teratoma with evidence of papillary thyroid carcinoma is a rare condition. Preoperative diagnosis is difficult due to its non-specific clinical manifestation and lack of specific radiologic findings. Histopathology analysis is necessary for diagnosis. Although surgery is considered the first line treatment, there is still discussion about the extent of resection and the need for total thyroidectomy with adjuvant radioiodine therapy