Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND: The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting. METHODS: Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups. RESULTS: Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005). CONCLUSION: Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery

Migrants’ decision-process shaping work destination choice: the case of long-term care work in the United Kingdom and Norway

Escalating demands for formal long-term care (LTC) result in the reliance on migrant workers in many developed countries. Within Europe, this is currently framed by progressive European immigration policies favouring inter-European mobility. Using the UK and Norway as case studies, this article has two main aims: (1) to document changes in the contribution of European Union (EU) migrants to the LTC sectors in Western Europe, and (2) to gain further understanding of migrants’ decision-processes relating to destination and work choices. The UK and Norway provide examples of two European countries with different immigration histories, welfare regimes, labour market characteristics and cultural values, offering a rich comparison platform. The analysis utilizes national workforce datasets and data obtained from migrants working in the LTC sector in the UK and Norway (n = 248) and other stakeholders (n = 136). The analysis establishes a significant increase in the contribution of EU migrants (particularly from Eastern Europe) to the LTC sector in both the UK and Norway despite their different welfare regimes. The findings also highlight how migrant care workers develop rational decision-processes influenced by subjective perspectives of investments and returns within a context of wider structural migration barriers. The latter includes welfare and social care policies framing the conditions for migrants’ individual actions

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

A critical review and development of a conceptual model of exclusion from social relations for older people

Social exclusion is complex and dynamic, and it leads to the non-realization of social, economic, political or cultural rights or participation within a society. This critical review takes stock of the literature on exclusion of social relations. Social relations are defined as comprising social resources, social connections and social networks. An evidence review group undertook a critical review which integrates, interprets and synthesizes information across studies to develop a conceptual model of exclusion from social relations. The resulting model is a subjective interpretation of the literature and is intended to be the starting point for further evaluations. The conceptual model identifies individual risks for exclusion from social relations (personal attributes, biological and neurological risk, retirement, socio-economic status, exclusion from material resources and migration). It incorporates the evaluation of social relations, and the influence of psychosocial resources and socioemotional processes, sociocultural, social-structural, environmental and policy contextual influences on exclusion from social relations. It includes distal outcomes of exclusion from social relations, that is, individual well-being, health and functioning, social opportunities and social cohesion. The dynamic relationships between elements of the model are also reported. We conclude that the model provides a subjective interpretation of the data and an excellent starting point for further phases of conceptual development and systematic evaluation(s). Future research needs to consider the use of sophisticated analytical tools and an interdisciplinary approach in order to understand the underlying biological and ecopsychosocial associations that contribute to individual and dynamic differences in the experience of exclusion from social relation

Numerical analysis of bariatric configurations after endoscopic surgery

Bariatric surgery is the most effective intervention for severe obesity, which is one of the most serious health problems. Laparoscopic Sleeve Gastrectomy is one of the principal techniques. Nonetheless, major complications are frequent, and weight-loss is not always successful. Non-optimal intervention design and general anesthesia are the principal cause of this situation. A novel approach is required, integrating bioengineering and medical competences, aiming to engineering design the procedure, to improve efficacy and safety. Preliminary outcomes have been reported from activities that are under development in the research field of stomach mechanics and bariatric surgery. The results pointed out the potentiality of computational methods for the investigation of stomach functionality and the planning of bariatric surgery procedures and techniques

P220 DEVELOPMENT OF A NEW PSYCHOLOGICAL TOOL TO IMPROVE PATIENT ABILITIES TO DEAL WITH ESOPHAGECTOMY: PRELIMINARY RESULTS

Aim This study aims to create a tool for evaluation of patient ability to deal with postoperative course after esophagectomy for cancer. Background & Methods Esophagectomy requires patient to be active and compliant to face up to postoperative impairments. Health related quality of life (HRQoL) data in short and medium-term after surgery show that competences used by patients are not appropriate. Lack of patient abilities to manage postoperative course influences patient recovery and reduces HRQoL. Psychological analysis of patient clinical needs was conducted to identify peculiar patient competences involved after esophagectomy. Four competences (future forethought; context evaluation; consequences of own actions forethought; use of available resources), each relevant to four areas (clinical; familiar; working; daily-activities) were identified and converted in open-ended questions to assess patient level of skills: a 16 questions structured interview was composed. From April to June 2019 we performed a feasibility study on 18 consecutive patients between 3rd and 15th postoperative day. They underwent esophagectomy for esophageal or esophagogastric junction cancer in two high volume centers. Patients with metastasis, with language problems due to neurological impairment or age <18 were excluded. M.A.D.I.T.-Methodology of Computerized Textual Data Analysis (University of Padua) was used. Results Each interview was administered orally to all patients and took 15 minutes. 5 questions were asked to be repeated. No complaints or negative comments were received. Non-responding percentage was 0,4% (one question in one interview). Textual corpus was composed of 3210 words, passable of analysis. No differences between postoperative days administration were found. M.A.D.I.T. analysis showed that answers were adequate and pertinent and allowed us to stratify patients in three different levels of competences (low, median, high). No need of additional competences or areas was observed. Conclusion This new psychological tool shows content validity, adequacy and pertinence to the study aim. It is understandable, easy, quick to be answered during any postoperative day and useful to identify patients with low abilities to deal with esophagectomy. Therefore a multicentric study will be conducted to use this tool further in multiple-choice format with a larger number of patients, in order to identify which patients will benefit of psychological intervention for HRQoL improvement