Factors influencing surgical decisions in chronic pilonidal sinus disease

Summary  BACKGROUND: Pilonidal sinus disease (PSD) may be present as chronic PSD, which may eventually exacerbate. Factors associated with the progression of chronic PSD to acute abscess-forming PSD were investigated. METHODS: Records of 1962 patients admitted to the surgical departments of three hospitals of the German Armed Forces between 1980 and 1996 with PSD were analyzed. RESULTS: Patients with chronic PSD showed higher sinus numbers (p < 0.001) and longer disease history (p < 0.001), while acute abscess-forming PSD was associated with smoking (p < 0.001). Surgeons were more likely to opt for primary wound closure when fewer sinus were present. Primary wound closure was similarly successful in chronic (67.2%) and acute (66.9%) PSD. Primary wound healing rate was negatively influenced by a high BMI in chronic PSD (p = 0.012). CONCLUSIONS: Early elective surgery in chronic PSD seems justified in patients presenting with a short duration of disease, low sinus number and smoking history.      

A closer look at surgical quality measures across different surgical specialties

Background

Most studies of surgical quality improvement have been performed in large and/or teaching hospitals; the efficacy of safety and quality efforts in smaller hospitals have not been reported.

Methods

Four smaller hospitals joined a collaborative to study process measures through an expanded surgical time-out and some outcomes. The data were collected in real time.

Results

Well-performing hospitals (all 4) improved further but variably. Gynecologic and orthopedic surgeons performed more consistently in most measures than did general surgeons.

Conclusions

These small hospitals readily accepted a time-out-based real-time data collection and with their surgical staff improved in most parameters.     

咖啡酸片在妇科择期手术中的临床应用观察

目的：探讨咖啡酸片在妇科择期手术患者中的临床疗效及安全性。方法将98例择期行妇科手术患者分为观察组（n=59）和对照组（n=39）,对照组予常规手术及治疗,不予咖啡酸片,观察组术前2~3d予咖啡酸片0.2g/次,3次/d,口服,术后继续予咖啡酸片,余治疗同对照组,比较两组患者术中、术后出血量及术后病率、疼痛情况、血常规情况、住院天数。结果观察组术中、术后出血情况、术后病率、疼痛情况、血常规均优于对照组,差异有统计学意义（P＜0.05）。两组均无明显不良反应发生。结论咖啡酸用于妇科择期手术疗效好,安全、可靠,值得临床推广和应用。     

Controversies in the Surgical Management of Sigmoid Diverticulitis

The timing and appropriateness of surgical treatment of sigmoid diverticular disease remain a topic of controversy. We have reviewed the current literature on this topic, focusing on issues related to the indications and types of surgery. Current evidence would suggest that elective surgery for diverticulitis can be avoided in patients with uncomplicated disease, regardless of the number of recurrent episodes. Furthermore, the need for elective surgey should not be influenced by the age of the patient. Operation should be undertaken in patients with severe attacks, as determined by their clinical and radiological evaluation.     

从上海普通外科临床质量控制实践获得的启示

外科质量控制涉及从诊断、术前准备,到手术和术后管理的全过程。严格的质量控制和管理可以持续推动外科的进步。上海普通外科临床质量控制中心成立以来,通过全市外科质量的调研,针对发现的问题,制定了腹股沟疝修补术、糖尿病及代谢手术等手术的质量控制标准,并开展了外科质量督查,取得了一定的成效。总体来说,国内对质量控制的重视程度不够,无论在质量控制的深度、广度和临床一线医生的参与度上,与发达国家有明显的差距。     

ACS national surgical quality improvement program: Targeting quality improvement in Canadian pediatric surgery

Purpose

The pediatric NSQIP program is in the early stages of facilitated surgical quality improvement for children. The objective of this study is to describe the initial experience of the first Canadian Children’s Hospital participant in this program.

Method

Randomly sampled surgical cases from the “included” case list were abstracted into the ACS-NSQIP database. These surgical procedure-specific data incorporate patient risk factors, intraoperative details, and 30 day outcomes to generate annual reports which provide hierarchical ranking of participant hospitals according to their risk-adjusted outcomes.

Results

Our first risk-adjusted report identified local improvement opportunities based on our rates of surgical site infection (SSI) and urinary tract infection (UTI). We developed and implemented an engagement strategy for our stakeholders, performed literature reviews to identify practice variation, and conducted case control studies to understand local risk factors for our SSI/UTI occurrences. We have begun quality improvement activities targeting reduction in rates of SSI and UTI with our general surgery division and ward nurses, respectively.

Conclusions

The NSQIP pediatric program provides high quality outcome data that can be used in support of quality improvement. This process requires multidisciplinary teamwork, systematic stakeholder engagement, clinical research methods and process improvement through engagement and culture change.     

Reliability of robotic system during general surgical procedures in a university hospital

BackgroundData concerning the reliability of robotic systems are scarce, especially for general surgery. The aim of this study was to assess the incidence and consequences of robotic malfunction in a teaching institution.MethodsFrom January 2006 to September 2012, 526 consecutive robotic general surgical procedures were performed. All failures were prospectively recorded in a computerized database and reviewed retrospectively.ResultsRobotic malfunctions occurred in 18 cases (3.4%). These dysfunctions concerned the robotic instruments in 9 cases, the robotic arms in 4 cases, the surgical console in 3 cases, and the optical system in 2 cases. Two malfunctions were considered critical, and 1 led to a laparoscopic conversion (conversion rate due to malfunction, .2%). Overall, there were more dysfunctions at the beginning of the study period (2006 to 2010) than more recently (2011 to 2012) (4.2% vs 2.6%, P = .35).ConclusionsThe robotic system malfunction rate was low. Most malfunctions could be resolved during surgery, allowing the procedures to be completed safely. With increased experience, the system malfunction rate seems to be reduced.     

Surgical site infection rate and associated risk factors in elective general surgery at a public sector medical university in Pakistan

This prospective study aimed to determine the surgical site infection (SSI) rate and associated risk factors was carried in a general surgical ward at Liaquat University Hospital Jamshoro. A total of 460 patients requiring elective general surgery from July 2005 to June 2006 were included in this study. All four surgical wound categories were included. Primary closure was employed in all cases. Patients were followed up to 30th day postoperatively. All cases were evaluated for postoperative fever, redness, swelling of wound margins and collection of pus. Cultures were taken from all the cases with any of the above finding. Mean +/- SD age of the patients was 38.8 +/- 17.4 years with male to female ratio of 1.5:1. The overall rate of surgical site infection was 13.0%. The rate of wound infection was 5.3% in clean operations, 12.4% in clean-contaminated, 36.3% in contaminated and 40% in dirt-infected cases. Age, use of surgical drain, duration of operation and wound class were significant risk factors for increased surgical site infection (P < 0.05). Postoperative hospital stay was double in cases who had surgical site infection. Sex, haemoglobin level and diabetes were not statistically significant risk factors (P > 0.05). In conclusion, surgical site infection causes considerable morbidity and economic burden. The routine reporting of SSI rates stratified by potential risk factors associated with increased risk of infection is highly recommended.     

Visualizing surgical quality data with treemaps

Background

Treemaps are space-constrained visualizations for displaying hierarchical data structures using nested rectangles. The visualization allows large amounts of data to be examined in one display. The objective of this research was to examine the effects of using treemap visualizations to help surgeons assess surgical quality data from the American College of Surgeons created the National Surgical Quality Improvement Program database in a quick and timely manner.

Study design

A controlled human subjects experiment was conducted to assess the ability of individuals to make quick and accurate judgments on surgery data by visualizing a treemap, with data hierarchically displayed by surgeon group, surgeon, and patient. Participants were given 20 task questions to complete involving examining the treemap and comparing surgeons' patients based on outcomes (dead or alive) and length of stay days. The outcomes measured were error (incorrect or correct) and task completion time.

Results

120 participants completed 20 task questions for a total of 2400 responses. The main effects of layout and node size were found to be significant for absolute error, P < 0.0505 and P < 0.0185, respectively. The average judgment time to complete a task was 24 s with an accuracy rate of approximately 68%.

Conclusions

This study served as a proof of concept to determine if treemaps could be beneficial in assessing surgical data retrospectively by allowing surgeons and healthcare administrators to make quick visual judgments. The study found that factors about the layout design affect judgment performance. Future research is needed to examine whether implementing the treemap within a dashboard system will improve on judgment accuracy for surgical quality questions.     

A scoping review of assessment methods of competence of general surgical trainees

BackgroundOnly rigorous evaluation of competence will result in the production of safe surgeons that are able to provide the best care for patients. The development of competency-based assessment should ultimately be evidence driven.ObjectivesExplore the volume of existing evidence pertaining to the different objective assessment methods reported in the literature.Eligibility criteriaStudies describing objective assessment of postgraduate general surgical trainees within the last 20 years.Sources of evidencePubMed, Ovid Medline and Web of Sciences.Charting methodsA data chart proforma was designed and data were extracted into tables. Basic numerical analysis of extracted data and narrative synthesis of charted data.ResultsA total of 343 papers were reviewed. 26 were eligible for inclusion. 92% of articles were published from 2008 onwards. 50% have been published in the last five years. The articles originated from 6 different countries, predominantly the United Kingdom (42%), followed by the United States of America (38%). In addition, a small number were published from Canada (8%), Japan (4%), Germany (4%) and Australia (4%). UK publications were predominantly between 2008 and 2014 while the USA had a later predominance between 2015 and 2018. 42% were based on quantitative methodology, 27% had a qualitative approach while 31% had mixed analysis. There were sixteen assessment methods presented. The most common type of assessment was Objective Structured Assessments (27%), which included Objective Structured Assessment of Technical Skill (OSATS) (23%) and Objective Structured Assessment of Non-Technical Skill (4%). Procedure Based Assessment (PBA) (23%) and Entrustability Scales (23%) were also prevalent.ConclusionsThis scoping review has identified a range of different assessment methods. The assessment methods with a higher volume and level of supporting evidence were OSATS, PBAs and Entrustability Scales. There was a lower volume and level of supporting evidence found within this review for the remaining assessment methods.     

进一步重视外科质量控制

高质量外科系指依据病人病情提供的高性价比医疗服务,改善了病人的生活质量,效果优于或不劣于非手术治疗。高质量外科是通过持续质量改进实现的,具体措施包括专业化团队的建设和人才培养、复杂病人的相对集中、标准化流程和制度的建立与实施、符合现代发展的科室文化建设、并发症与围手术期死亡事件的追责。外科的发展不能走粗放式经营的模式,应该更注重内涵的建设,这样的发展才是可持续的。     

Outcomes research in pediatric surgery. Part 1: overview and resources

Outcomes research in pediatric surgery can be defined as the analysis of pediatric surgical outcomes and their predictors at different levels in the health care delivery system. The objectives of this article are to understand the differences between outcomes research and clinical trials as well as to gain familiarity with public multispecialty and specialty-specific databases. The utility of outcomes research extends to benchmarking the quality of care, refinement of management strategies, patient education, and marketing. Assessment of the integration of a new surgical technique into the health care system is best determined by examining a population-based registry, whereas comparative efficacy of surgical procedures is best assessed by randomized clinical trials. In the first part of this 2-part series, an overview and brief outline of available resources for outcomes research in pediatric surgery are reviewed. In part 2, a template is presented on how to structure and design an outcomes research question.     

A thematic review of the use of electronic logbooks for surgical assessment in sub-Saharan Africa

IntroductionEnsuring that surgical training programmes in low- and middle-income countries (LMICs) provide high quality training, including adequate operative experience, is of crucial importance in meeting the goals set out in the Lancet Global Surgery 2030. Electronic logbooks (eLogbooks) have been adopted to monitor both individual trainee progression and the performance of surgical training programmes.MethodsWe performed a thematic review of the current evidence base surrounding the use of eLogbooks for the assessment of surgeons in training in sub-Saharan Africa, with a view to identifying the learning to date and areas for future research.ResultsWhilst there are multiple papers highlighting the use of surgical eLogbooks in high-income countries, we identified only three papers which discussed their use in sub-Saharan Africa. Four common themes emerged which related to the use of surgical eLogbooks throughout sub-Saharan Africa: ease of analysis, centralised databases, discrepancies in reporting and technology limitations.ConclusionsRobust data to demonstrate trainee progression and the quality of surgical training programmes are of crucial importance in ensuring that surgical training programmes can rapidly scale up to deliver large numbers of well-trained surgical providers to address the unmet patient need in LMICs in the next decade. The limited data on the use of well designed, centralised electronic surgical logbooks indicate that this tool may play an important role in providing key data to underpin these training programmes.     

Data collection and the development of quality assurance for surgical specialities in Asia: A moral obligation?

A ‘quality assurance’ process enables health care providers and receivers to be assured that delivery of care is appropriate, of a high standard and incorporates fiscal considerations. Many components contribute to this process but the initial emphasis should be robust data collection, validation and appropriate analysis. The implementation of such a process is particularly relevant to the surgical specialties in Asia.     

Evaluation of a blended learning surgical skills course for rural surgeons

Background

Rural surgeons have unique learning needs not easily met by traditional continuing medical education courses.

Methods

A multidisciplinary team developed and implemented a skills curriculum focused on leadership and communication, advanced endoscopy, emergency urology, emergency gynecology, facial plastic surgery, ultrasound, and management of fingertip amputations.

Results

Twenty-five of 30 (89%) rural surgeons who completed a follow-up course evaluation reported that the knowledge acquired during the course had improved their practice and/or the quality of patient care, particularly by refining commonly used skills and expanding the care options they could offer to their patients. The surgeons reported incorporating changes in their communication and interaction with colleagues.

Conclusions

This course was successful, from participants' perspectives, in providing hands-on mentored training for a variety of skills that reflect the broad scope of practice of surgeons in rural areas. Attendees felt that their participation resulted in important behavior and practice changes.     

A prospective study of outcomes of emergency and elective surgeries for complicated colonic cancer

BACKGROUND: Although a significantly decreased long-term survival has been observed in patients undergoing surgery for complicated colorectal tumors compared with uncomplicated ones, the role of radical oncologic surgery on emergency colonic cancer is not defined clearly. The aim of this study was to analyze the efficacy of a curative emergency surgery in terms of tumor recurrence and cancer-related survival compared with elective colonic surgery. METHODS: Between January 1996 and December 1998, all patients with colonic cancer deemed to have undergone a curative resection were considered for inclusion in this prospective study. Patients were classified into 2 groups: group 1, after emergency surgery for complicated colonic cancer, and group 2, patients undergoing elective surgery. The main end points were cancer-related survival and the probability of being free from recurrence at 3 years. RESULTS: Of the 266 patients included in the study, 59 patients (22.2%) were in group 1 and 207 patients (77.8%) were in group 2. Postoperative mortality was higher in group 1 (P=.0004). After patients were stratified by the tumor node metastasis system, differences between the groups with respect to overall survival of stage II tumors (P=.0728), the probability of being free from recurrence (P=.0827), and cancer-related survival (P=.1071) of stage III cancers did not reach statistical significance. Differences were observed for the overall survival in stage III tumors (P=.0007), and for the probability of being free from recurrence (P=.0011) and cancer-related survival (P=.0029) in stage II cancers. When patients with elective stage II tumors presenting 1 or more negative prognostic factor were compared with emergency patients affected by a stage II colonic cancer, no differences were observed. CONCLUSION: Curative surgeries for complicated colonic cancer are acceptable in emergency conditions. Cancer-related survival and recurrence in patients with complicated colonic cancers may approach that of elective surgery if a surgical treatment with radical oncologic criteria is performed.