System‐based factors influencing intraoperative decision‐making in rectal cancer by surgeons: an international assessment

Aim Sound surgical judgement is the goal of training and experience; however, system‐based factors may also colour selection of options by a surgeon. We analysed potential organizational characteristics that might influence rectal cancer decision‐making by an experienced surgeon. Method One hundred and seventy‐three international centres treating rectal cancer were invited to participate in a survey assessment of key treatment options for patients undergoing curative rectal‐cancer surgery. The key organizational characteristics were analysed using multivariate methods for association with intra‐operative surgical decision‐making. Results The response rate was 71% (123 centres). Sphincter‐saving surgery was more likely to be performed at university hospitals (OR = 3.63, P = 0.01) and by high‐caseload surgeons (OR = 2.77 P = 0.05). A diverting stoma was performed more frequently in departments with clinical audits (OR = 3.06, P = 0.02), and a diverting stoma with coloanal anastomosis was more likely in European centres (OR = 4.14, P = 0.004). One‐stage surgery was less likely where there was assessment by a multidisciplinary team (OR = 0.24, P = 0.02). Multivariate analysis showed that university hospital, clinical audit, European centre, multidisciplinary team and high caseload significantly impacted on surgical decision‐making. Conclusion Treatment variance of rectal cancer surgeons appears to be significantly influenced by organizational characteristics and complex team‐based decision‐making. System‐based factors may need to be considered as a source of outcome variation that may impact on quality metrics.     

HEURISTICS IN CARDIOTHORACIC SURGERY

Cardiothoracic surgical operations are complex procedures. Involved are an enormous number of steps that need to be carried out consistently, accurately (as the margin for error in cardiothoracic surgery is small) and in a time‐efficient manner – thus the need for repetition in their performance to achieve excellence. Encompassed within the steps is a range of skills – motor and decision‐making. The motor skills span from the gross of median sternotomy and thoracotomy, to the fine of coronary anastomoses. It is the challenge of all of this that I believe entices most prospective cardiothoracic surgeons into training, having already witnessed the difference in the ability of surgeons at surgical heuristics as beautifully described by Michael Patkin. Further, the chase for the ‘perfect operation’ I believe also is what keeps cardiothoracic surgeons enthralled for a career. As a comment, what will be presented is a personal perspective and should be seen as such – to quote Patton ‘if everyone is thinking alike, then somebody isn’t thinking’. Now surgery in general is made of movement systems as already mentioned, but critically layered upon by intellect and information. This affects the decision‐making process throughout an episode of care – preoperatively, intraoperatively and postoperatively. To contemplate surgical heuristics, the two then, the movement systems and the decision‐making process, must be discussed individually and then brought together in the end, for it is the gel that determines patient outcomes and then becomes the science to our craft.     

Three‐dimensional printing for surgical planning in complex congenital heart disease

Surgical management of complex congenital heart disease (CHD) is challenging. Three‐dimensional (3D) printing can improve multidisciplinary team decision‐making, patient and family understanding, and education of medical professionals. We describe 3D printing for surgical management of five patients with complex CHD. The anatomical details of the 3D printed models were instrumental in planning surgical techniques especially in determining between single ventricle, 1.5 ventricle, and biventricular repair.     

Consequences of incomplete repair of acute type A aortic dissection

During emergency repair of acute Stanford type A aortic dissections, surgical compromises in the form of incomplete arch replacement are made due to the unstable condition of the patient and safety issues of the performing team. We report a case of delayed reoperation after previous incomplete surgery for acute type A aortic dissection in a young patient with Marfan's syndrome. He presented again with repetitive chest pain five years after initial surgical treatment. Extensive aneurysmal dilatation of the aorta and remaining dissection led to the decision to replace the ascending aorta and the aortic arch. After a good progress during the first days after surgery, the patient died due to a ruptured thoraco-abdominal aneurysm on the fifth postoperative day. Extensive surgical reconstruction including aortic arch replacement should be considered in patients with Marfan's syndrome who present with aortic dissections type A to avoid unnecessary reoperations and their complications.     

Professionalism in 21st Century Professional Practice: Autonomy and Accountability in Orthopaedic Surgery

Orthopaedic surgical practice is becoming increasingly complex. The rapid change in pace associated with new information and technologies, the physician-supplier relationship, the growing costs and growing gap between costs and reimbursements for orthopaedic surgical procedures, and the influences of advertising on the patient, challenge all involved in the delivery of orthopaedic care. This paper assesses the concepts of professionalism, autonomy, and accountability in the 21st century practice of orthopaedic surgery. These concepts are considered within the context of the complex value chain surrounding orthopaedic surgery and the changing forces influencing clinical decision making by the surgeon. A leading impetus for challenge to the autonomy of the orthopaedic surgeon has been cost. Mistrust and lack of understanding have characterized the physician-hospital relationship. Resource dependency has characterized the physician-supplier relationship. Accountability for the surgeon has increased. We suggest implant surgery involves shared decision making and “coproduction” between the orthopaedic surgeon and other stakeholders. The challenge for the profession is to redefine professionalism, accountability, and autonomy in the face of these changes and challenges.     

Zerebrale Protektion während offen-chirurgischer Rekonstruktionen des Aortenbogens

The surgical treatment of thoracic aorta aneurysms and dissections which include the aortic arch, are still a great challenge in vascular surgery. The primary aims of surgery are protection of the brain and the spinal column from ischemic and embolic complications, avoidance of coagulation disorders and hemorrhaging as well as the prevention of myocardial damage during extracorporeal circulation. Various techniques have been included in the clinical routine in order to protect the central nervous system from ischemic damage during aortic arch reconstruction. These include deep hypothermia with circulation arrest, retrograde cerebral perfusion via the superior vena cava as well as selective antegrade cerebral perfusion. Despite all advantages of these protective methods ischemic cerebral complications are still relatively common. Knowledge on the advantages and disadvantages of the three techniques as well as the pathophysiological consequences of deep hypothermia should be included in decision making on the indications for circulation arrest and the duration.     

The importance of surgical therapy with expansion of TAVR to low‐risk patients

Despite the landmark release of recent transcatheter aortic valve replacement data, the gold standard of surgical therapy is here to stay. Surgery remains vital in patient populations with low coronary height raising risk of coronary occlusion, aneurysmal ascending aorta, isolated aortic regurgitation, noncalcific disease, bicuspid valves, and multivessel coronary disease, or other structural abnormality requiring cardiac surgery. Consideration of these issues highlights the ongoing importance of multidisciplinary consideration of individual patient cases, careful review of imaging, and preservation of a robust surgical program to complement transcatheter development. As the landscape of valvular heart disease management continues to evolve, the surgeon's role is changing, but by no means diminished and their engagement in heart team decision making remains paramount.     

Management of aortic valve disease during pregnancy: A review

Cardiovascular disease represents a significant portion of pregnancy‐related complications and is associated with high rates of morbidity and mortality in this cohort. Cardiac valvulopathy, and aortic valve pathologies, in particular, pose a significant challenge to women who are pregnant and to the health care professionals who look after them. Depending on the type and severity of aortic valve pathology, pregnancy may exacerbate or accelerate the progression of valvulopathy sequelae because of the hemodynamic changes that occur from conception, throughout gestation, up to Labor and postpartum. Management of such patients ranges from basic conservative measures such as bed‐rest, extending to high‐risk emergency open heart surgery. This nonstructured review aims to highlight the current evidence available relating to the management of aortic valve disease in pregnancy, with a key focus on cases which requires intervention beyond that of medical therapy. In conclusion, the management of aortic valvulopathy in pregnancy is a challenging field with only a small amount of clinical experience and retrospective study supporting evidence‐based decisions in this field. A greater understanding of the most recent advances is recommended to support decision making in this specialist field of clinical medicine.     

Choosing the surgical mortality threshold for high risk patients with stage Ia non-small cell lung cancer: insights from decision analysis

The recent British Thoracic Society guidelines recommend that surgical mortality should not be greater than 8% for pneumonectomy and 4% for lobectomy. These cut offs are advanced as guidelines to inform decision making as to whether or not patients with operable lung cancer should be offered surgery. They have been developed from a notion of what acceptable surgical mortality should be. The planning of care for patients with lung cancer involves making choices between different treatments with different outcomes. While it is accepted that the probability of these outcomes is likely to differ among patients, individual patient preferences for them are also likely to vary. Fixed cut offs for surgical mortality mean ignoring this variation. Decision analysis can be used to assist in the complex task of integrating clinical characteristics and varying patient preferences. By considering high risk patients with potentially curable stage Ia non-small cell lung cancer, it is shown that decision analysis has the potential to illuminate decision making and guideline development within the field of cancer care.     

Komplexe Becken- und Sarkomchirurgie mit Gefäßersatz

Due to optimization of surgical techniques in surgical oncology and vascular surgery, the most modern approaches of anesthesia and intensive care medicine and effective multimodal therapeutic strategies, locally advanced malignant tumors are resected more frequently with a potentially curative intent. In the case of extensive tumors with infiltration of vital vascular structures or of structures which are crucial for extremity preservation, the necessary surgical procedure for complete tumor removal poses a major challenge for the surgeon and incorporates a high risk of perioperative morbidity for the patient. The decision to attempt tumor resection should therefore always be based on a concept considering all aspects of the malignant disease. The treating team should be highly experienced in this complex field of surgery, not only with respect to the surgical approach but also regarding the management of postoperative complications. In this article relevant aspects of decision making, surgical technique and postoperative outcome for malignant tumors involving vascular structures of the retroperitoneum and pelvis are presented.     

Chirurgische Therapie der Aortenisthmusstenose

The aortic isthmus represents the region of the smallest aortic diameter and is located at the beginning of the descending aorta between the left subclavian artery and the origin of the first intercostal artery. Aortic coarctation (CoA) is defined as a pathologic narrowing of the aortic isthmus and accounts for 5–8?% of all congenital heart defects. A CoA can exist as an isolated entity or in combination with other cardiac anomalies. Due to the close relationship and interaction between the ductal orifice and development of coarctation, the term juxtaductal CoA prevails. Neonates with CoA and ductal-dependent lower body perfusion need urgent surgical repair. Spontaneous ductal closure can be prevented by infusion of prostaglandin E1 and if ineffective, emergency surgery is necessary. In contrast, in older children who suffer from arterial hypertension of the upper body, CoA can be corrected by intervention or surgery, as necessary. In most centers coarctation resection with direct end-to-end anastomosis has gained acceptance as the surgical repair of choice. In cases of associated aortic arch hypoplasia, which is common in 50?% of neonatal CoA cases, an extended resection and repair with simultaneous aortic arch enlargement by direct descending aorta to aortic arch anastomosis is recommended. Pronounced proximal arch hypoplasia should be corrected by an anterior approach facilitated by a cardiopulmonary bypass (CPB). Alternative operative techniques need individual implementation after careful decision making.     

Thorakale Aortenaneurysmen

Open surgical repair of thoracic aortic aneurysms can nowadays be performed with low morbidity and mortality rates in specialized cardiovascular centers. In recent years, thoracic endovascular aortic repair (TEVAR) and hybrid aortic procedures have also been established as treatment options for a variety of thoracic aortic lesions, including thoracic aneurysm. However, decision making in choosing between the distinct treatment options in patients with thoracic aortic aneurysms cannot be based on the results of randomized trials. Therefore, the level of evidence is poor and factors, such as the etiology of the aneurysms, comorbidity, anticipated life expectancy, aortic diameter, and morphology (including suitability of landing zones), are of relevance and have to be considered for an individual therapy. This article reviews recent publications on open surgical, endovascular, and hybrid thoracic aortic aneurysms repair.     

Machine learning with PROs in breast cancer surgery; caution: Collecting PROs at baseline is crucial

As high breast cancer survival rates are achieved nowadays, irrespective of type of surgery performed, prediction of long‐term physical, sexual, and psychosocial outcomes is very important in treatment decision‐making. Patient‐reported outcomes (PROs) can help facilitate this shared decision‐making. Given the significance of more personalized medicine and the growing trend on the application of machine learning techniques, we are striving to develop an algorithm using machine learning techniques to predict PROs in breast cancer patients treated with breast surgery. This short communication describes the bottlenecks in our attempt to predict PROs.     

Optimizing perioperative management of geriatric patients with head and neck cancer

Given emerging demographic trends, many more elderly patients are being diagnosed with head and neck cancers. The surgical care paradigm for this cohort of patients must take into account specific challenges inherent to geriatric perioperative management. This article attempts to summarize the existing body of literature relevant to the geriatric head and neck cancer population, and to extrapolate relevant data from geriatric perioperative medicine in order to better understand and guide management decisions. The involvement of geriatricians and of patients' primary care providers may be invaluable in assisting in complex perioperative decision‐making and in participating in longitudinal management. Preoperative risk stratification and assessment of medical, social, and functional variables are critical for appropriate decision‐making in this challenging patient population. © 2013 Wiley Periodicals, Inc. Head Neck 36 : 743–749, 2014     

Damage control surgery and the abdomen

There is a complex interplay between primary injury, particularly major abdominal injury in the multi-system trauma patient, and secondary injury, which relate to patient physiology, decision making and surgical technique. Analysis of outcomes is further confounded by the variety of surgical techniques used. The challenge is to match the correct operation, for a critically injured patient, with the patient’s physiology. Excellence in general surgery does not equate with excellence in trauma surgery, and a clear understanding of damage control is essential.     

Abdominal aortic aneurysm repair

Options for abdominal aortic aneurysm (AAA) repair include both open and endovascular approaches. Patient selection for each of these requires careful consideration relating to patient health, fitness and anatomy. This article aims to provide an overview of the essential aspects of both open surgical repair (OSR) and endovascular AAA repair (EVAR), focussing upon decision making, the procedures, follow-up and long-term outcomes. Consideration is also given to more complex AAA repairs, including fenestrated/branched stent grafts and open juxta-renal aneurysm repairs. AAA epidemiology, screening, and work up for repair are covered in the previous article.     

Ulcerative colitis indications and timing for surgery

Surgery continues to have a major role in the management of ulcerative colitis because it may save the patient's life, eliminate the long-term risk of cancer, and most important, abolish the disease. Treatment of ulcerative colitis still remains the challenge despite growing knowledge about the disease, advances in medical treatment and surgical techniques. Indications and optimal timing for surgery are the mainstays of good outcome and are as important as the quality of medical therapy and surgery. Ulcerative colitis is a complex disease where medical and surgical treatment frequently overlap and clinical decision making should be in hands of well trained and experienced team consisting of surgeon, gastroenterologist, radiologist and pathologist. Recently developed drugs, with high potential in the treatment of severe attacks of ulcerative colitis brought some changes in therapy and indications for surgical treatment. Although as many as half of patients with inflammatory bowel disease require at least one surgical procedure to address complications derived from their disease, the decision in favor of a surgical approach and its timing is rarely an easy one.     

Prediction of postoperative complications in elective surgery

Experience in prediction of surgical outcomes is summarized. Preliminary results of elective treatment of various surgical diseases are reviewed. Over the last 14 years some theoretical problems of prediction (surgical risk) were solved by the authors and decision making in critical situations is illustrated. Surgical outcomes in 500 patients operated on from 1972 to 2002 (30 years) were analyzed depending on a number of factors--age, severity of combined diseases and surgery traumaticity. It is noted that qualitative assessment of surgical risk is not enough for decision on the method of surgical treatment. It is necessary to create adequate and simple classification of criteria of postoperative prognosis in elective surgery able to realize quantitative assessment of surgical risk.     

The impact of intraoperative ultrasonography on the surgical treatment of patients with colorectal liver metastases

Introduction  

Intraoperative ultrasonography (IOUS) has been the standard in surgical decision making in oncologic liver surgery. Preoperative imaging techniques have improved substantially in resent years; therefore, the importance of IOUS might change. The current results of IOUS were compared with preoperative high-resolution helical CT scanning and the impact of IOUS on surgical decision making was evaluated.