Risk factors for major complications after liver resection: A large liver resection study from Morocco and audit of a non-Eastern/non-Western experience

Background and Study AimsIn developing countries, endemic indications, blood shortages, and the scarcity of liver surgeons and intensive care providers can affect liver resection (LR) outcomes, but these have been rarely addressed in the literature. Therefore, in this study we determined risk factors for major complications after LR in a North African general surgery and teaching department.Patients and MethodsFrom January 2010 to December 2015, 213 consecutive LRs were performed on 203 patients. All patients underwent a postoperative follow-up of >90 days. Postoperative complications were assessed according to the Clavien–Dindo (CD) classification of surgical complications. A score of CD ≥III is considered as major postoperative complications. In this study, we analyzed the variables assumed to affect these complications.ResultsThe overall 90-day complication rate was 35.7% (n = 76), including a CD ≥III of 14% (n = 30) and a mortality rate of 6.1% (n = 14). According to the multivariate analysis, a preoperative performance status (PS) of ≥2 (P = 0.011; odds ratios [OR], 6.8; 95% confidence intervals [CI], 1.55–29.8), an estimated intraoperative blood loss of >500 ml (P = 0.002; OR, 3.71; 95% CI, 1.23–11.20), and bilioenteric anastomosis (P < 0.004; OR, 7.76; 95% CI, 1.5–3.89) were independent risk factors for major complications after LR.ConclusionWe recommend that, in the setting of a non-Eastern/non-Western general surgery and teaching department, patients with a PS of ≥2 should undergo a specific selection and preoperative optimization protocol; intermittent clamping indications should be extended; and special attention should paid to patients undergoing LR associated with biliary reconstruction, such as for perihilar cholangiocarcinoma.     

Communication between an occupational physician and other medical practitioners--an audit

Four hundred and seventy-two consecutive referral episodes relatingto 386 patients attending the Occupational Health Departmentof a general teaching hospital were analyzed to evaluate thefrequency, content and effect on management of communicationsbetween the occupational physician and other doctors. In all,250 episodes (53%) were associated with such a communication.The likelihood of a communication was strongly influenced byreason for referral, particularly in respect of long or shortterm sickness absence; univariate odds ratios (OR)=10.58, 95%Cl=8.13–27.08) and 2.65, 95% Cl=1.55–4.60) respectively;a medical diagnosis of psychiatric illness (OR=3.17, 95% Cl=1.69–5.97));and by number of consultations. Communication was also morelikely when the occupational outcome was ill health retirement,rehabilitation in work or modified work. Ninety-eight per centof specific requests for information or an opinion eliciteda reply. Information received from other doctors influencedthe occupational health physician's management in 52 referralepisodes (20%). Specific action by GPs as a result of communicationwas documented in 54 and by specialists in 37 episodes. Theimportance of communication between occupational health physicianand other doctors in the occupational health process is confirmed.     

Developing and running an EQA scheme in diagnostic histopathology

External quality assessment (EQA) schemes in histopathology form a key part of laboratory quality management, but their principal function is educational. ‘Test’ material is circulated to participants, who evaluate the material following their normal practice and return responses to an organizing laboratory for collation and evaluation. The test material must be representative of the routine workload, but not mundane. Unlike histopathology slide clubs, objective, quantitative, personal feedback for each participant is vital to ensure unambiguously the identification of areas requiring CPD. The objective evaluation of textual responses in EQA is problematic, but various approaches have been used successfully. The participants are individuals, not laboratories, so confidentiality is paramount. Mechanisms to investigate persistent substandard performance must exist, but should be used very rarely; self-improvement is the usual route to protecting standards of patient care.     

Results of a survey of the role of multidisciplinary team coordinators for colorectal cancer in England and Wales

OBJECTIVE: Over the last 6 years, multidisciplinary teams (MDTs) have been established and play a key role in organizing the delivery of cancer care in the UK. There are no published data on the roles of their co-coordinators. To seek the views of colorectal multidisciplinary team co-ordinators (MDTCs) on what they do and how they do it. METHOD: Questionnaires were sent to the colorectal MDTC, or equivalent, in all 180 NHS hospital trusts in England and Wales where colorectal cancer surgery is performed. RESULTS: There was a 70% response rate. Seventy-one per cent of trusts now have a dedicated MDTC, whereas in 2002, only 40% had one. MDTCs generally keep their information on databases, but these differ, and are not coordinated with data entry into the national colorectal cancer database of the Association of Coloproctology of Great Britain and Ireland. In only 26 trusts does the MDTC communicate decisions to primary care, and the patients seem almost completely excluded from this process. CONCLUSION: The recently formed national MDTC Forum should grasp the opportunity of coordinating all of this well-intentioned but pluralistic activity to the benefit of patients, primary care and hospital teams. An effective MDTC with a robust database will be the key in achieving cancer waiting time targets with useful audit, thereby improving patient care.     

Auditing your acute pain service—a UK NHS model

This audit has been conducted in order to provide an evidence base that clarifies the strengths and weaknesses of acute pain management at a UK hospital. Consequently, it sets the strategic direction for service improvement. Awarding up to three stars has identified the quality of each component that constitutes the acute pain service. Six different components were audited and star ratings have been awarded as shown below:

• Pain tool (including patient and staff understanding): no stars.

• Pain team (including education and clinical support): two stars.

• Intermittent opioid analgesia (sub-cut and oral morphine): two stars.

• Epidural patient controlled analgesia (EPCA): two stars.

• Intravenous patient controlled analgesia (IVPCA): two stars.

• Single-dose intrathecal opioid analgesia: three stars.

These star ratings were pulled together in order to award the acute pain service an overall rating. Consequently, the acute pain service was awarded two stars. The findings of this audit identify that this acute pain service provides a safe way to deliver hi-tech pain relief at ward level and can be relied upon to provide good quality pain management. However, too many patients are likely to miss out on the full benefits of the service due to the weaknesses as identified. The quality of the pain relief is impeded across the hospital due to low patient expectation and poor patient education, and also due to a lack of relevant knowledge amongst nursing staff. Developments in the role of the acute pain nurse, staff training and education programs, and a reduction in the variety of pain management pumps are combining to facilitate the opportunities required to address the weaknesses and to build on the strengths of the acute pain service.