Amit Vats

Is minimally invasive surgery beneficial in the management of esophageal cancer? A meta-analysis

IntroductionOpen esophagectomy for cancer is a major oncological procedure, associated with significant morbidity and mortality. Recently, thoracoscopic procedures have offered a potentially advantageous alternative because of less operative trauma compared with thoracotomy. The aim of this study was to utilize meta-analysis to compare outcomes of open esophagectomy with those of minimally invasive esophagectomy (MIE) and hybrid minimally invasive esophagectomy (HMIE).MethodsLiterature search was performed using Medline, Embase, Cochrane Library, and Google Scholar databases for comparative studies assessing different techniques of esophagectomy. A random-effects model was used for meta-analysis, and heterogeneity was assessed. Primary outcomes of interest were 30-day mortality and anastomotic leak. Secondary outcomes included operative outcomes, other postoperative outcomes, and oncological outcomes in terms of lymph nodes retrieved.ResultsA total of 12 studies were included in the analysis. Studies included a total of 672 patients for MIE and HMIE, and 612 for open esophagectomy. There was no significant difference in 30-day mortality; however, MIE had lower blood loss, shorter hospital stay, and reduced total morbidity and respiratory complications. For all other outcomes, there was no significant difference between the two groups.ConclusionMinimally invasive esophagectomy is a safe alternative to the open technique. Patients undergoing MIE may benefit from shorter hospital stay, and lower respiratory complications and total morbidity compared with open esophagectomy. Multicenter, prospective large randomized controlled trials are required to confirm these findings in order to base practice on sound clinical evidence.

Information transfer and communication in surgery: a systematic review.

Objectives:We conducted a systematic review of published literature to gain a better understanding of interprofessional information transfer and communication (ITC) in hospital setting in the field of surgical and anesthetic care. Background:Communication breakdowns are a common cause of surgical errors and adverse events. Data Sources:Medline, Embase, PsycINFO, Cochrane Database of Systematic Reviews, and hand search of articles bibliography. Study Selection:Of the 4027 citations identified through the initial electronic search and screened for possible inclusion, 110 articles were retained following title and abstract reviews. Of these, 38 were accepted for this review. Data Extraction:Data were extracted from the studies about objectives, clinical domain, methodology including study design, sample population, tools for assessing communication, results, and limitations. Results:Information transfer failures are common in surgical care and are distributed across the continuum of care. They not only lead to errors in care provision but also lead to patient harm. Most of the articles have focused on ITC process in different phases especially in operating room. None of the studies have looked at whole of the surgical care process. No standard tool has been developed to capture the ITC process in different teams and to evaluate the effect of various communication interventions. Uses of standardized communication through checklist, proformas, and technology innovations have improved the ITC process, with an effect on clinical and patient outcomes. Conclusions:ITC deficits adversely affect patient care. There is a need for standard measures to evaluate this process. Effective and standardized communication among healthcare professionals during the perioperative process facilitates surgical safety.

Postoperative handover: problems, pitfalls, and prevention of error.

Objective:To identify the information transfer and communication problems in postoperative handover and to develop and validate a novel protocol for standardizing this communication. Background:Effective clinical handover ensures continuity of patient care. Patient handovers within surgical units are largely informal. A thorough understanding of the problem is vital to develop standardized protocols. Methods:A qualitative semistructured interview study was conducted with 18 healthcare professionals to uncover the problems with postoperative handover and to identify solutions, including components of a postoperative handover protocol. Interviews were recorded, transcribed verbatim, and submitted to emergent theme analysis. Multiple blind coders were used to ensure triangulation and reliability of the coding process. A Delphi method was used to elicit consensus from a group of 50 surgical professionals so as to validate the handover protocol. Results:Many of the information transfer and communication failures at the postoperative phase are deemed to be due to an incomplete handover. All the interviewed healthcare professionals agreed that postoperative handover should be structured in the form of a standardized protocol so as to prevent omissions of any critical information. Based on this, 28 items were submitted to the Delphi process. Of these, 21 items had a mean importance score greater than 4.0 and were included in the final postoperative handover proforma under the following headings: patient-specific information, surgical information, and anesthetic information. Conclusion:The present study identified that the postoperative handover is informal, unstructured and inconsistent with often incomplete information transfer. Based on end-user input, a handover protocol was successfully developed and validated. Use of this may facilitate standardization of this critical activity and thereby improve the quality of patient care.

Evaluation of postoperative handover using a tool to assess information transfer and teamwork.

Objective:To assess the feasibility, validity, and reliability of a postoperative Handover Assessment Tool (PoHAT) and to evaluate the current practices of the postoperative handover at 2 large European hospitals. Background:Postoperative handover is one of the most critical phases in the care of a patient undergoing surgery. However, handovers are largely informal and variable. A thorough understanding of the problem is necessary before safety solutions can be considered. Methods:Postoperative Handover Assessment Tool (PoHAT) was developed through task analysis, semistructured interviews, literature review, and learned society guidelines. Subsequent validation was done by the Delphi technique. Feasibility and reliability were then evaluated by direct observation of handovers at 2 large European hospitals. Outcomes measures included information omissions, task errors, teamwork evaluation, duration of handover, and number of distractions. Results:The tool was feasible to use and inter-rater reliability was excellent (r = 0.96, P < 0.001). Evaluation of handover at the 2 study sites revealed a median of 8 information omissions per handover at both the centers (IQR 7–10). There were a median of 3 task errors per handover (IQR 2–4). Thirty-five percent of handovers had distractions, which included competing demands for nurse attention, bleeps, and case-irrelevant communication. Conclusion:This study has established the feasibility, validity, and reliability of a tool for evaluating postoperative handover. In addition to serving as an objective measure of postoperative handover, the tool can also be used to evaluate the efficacy of any intervention developed to improve this process. The study has also shown that postoperative handover is characterized by incomplete transfer of information and failures in the performance of key tasks.

An evaluation of information transfer through the continuum of surgical care: a feasibility study.

Objective:To evaluate information transfer and communication (ITC) across the surgical care pathway with the use of Information Transfer and Communication Assessment Tool for Surgery (ITCAS). Background:Communication failures are the leading cause of surgical errors and adverse events. It is vital to assess the ITC across the entire surgical continuum of care to understand the process, to study teams, and to prioritize the phases for intervention. Methods:Twenty patients undergoing major gastrointestinal procedures were followed through their entire surgical care, and ITC process was assessed using ITCAS. ITCAS consisted of 4 checklists for 4 phases of the surgical care. Results:ITC failures are distributed across the entire surgical continuum of care. Preprocedural teamwork and postoperative handover phases have the maximum number of ITC failures (61.7% and 52.4%, respectively). Moreover, it was found that information degrades as it crosses from one phase to another. Of patients, 75% had clinical incidents or adverse events because of ITC failures. Conclusions:The study demonstrated that ITC failures are ubiquitous across surgical care pathway and there is an imminent need to modify current ITC practices. Standardization of ITC through use of checklists, protocols, or information technology is essential to reduce these communication failures.

Current status of robotic assisted pelvic surgery and future developments.

AIMS The aim of this review is to assess the role of robotics in pelvic surgery in terms of outcomes. We have also highlighted the issues related to training and future development of robotic systems. MATERIALS AND METHODS We searched MEDLINE, EMBASE and the Cochrane Databases from 1980 to 2009 for systematic reviews of randomised controlled trials, prospective observational studies, retrospective studies and case reports assessing robotic surgery. RESULTS During the last decade, there has been a tremendous rise in the use of robotic surgical systems for all forms of precision operations including pelvic surgery. The short-term results of robotic pelvic surgery in the fields of urology, colorectal surgery and gynaecology have been shown to be comparable to the laparoscopic and open surgery. Robotic surgery offers an opportunity where many of these obstacles encountered during open and laparoscopic surgery can be overcome. CONCLUSIONS Robotic surgery is a continually advancing technology, which has opened new horizons for performing pelvic surgery with precision and accuracy. Although its use is rapidly expanding in all surgical disciplines, particularly in pelvic surgery, further comparative studies are needed to provide robust guidance about the most appropriate application of this technology within the surgical armamentarium.

A systematic quantitative assessment of risks associated with poor communication in surgical care.

HYPOTHESIS Health care failure mode and effect analysis identifies critical processes prone to information transfer and communication failures and suggests interventions to improve these failures. DESIGN Failure mode and effect analysis. SETTING Academic research. PARTICIPANTS A multidisciplinary team consisting of surgeons, anesthetists, nurses, and a psychologist involved in various phases of surgical care was assembled. MAIN OUTCOME MEASURES A flowchart of the whole process was developed. Potential failure modes were identified and evaluated using a hazard matrix score. Recommendations were determined for certain critical failure modes using a decision tree. RESULTS The process of surgical care was divided into the following 4 main phases: preoperative assessment and optimization, preprocedural teamwork, postoperative handover, and daily ward care. Most failure modes were identified in the preoperative assessment and optimization phase. Forty-one of 132 failures were classified as critical, 26 of which were sufficiently covered by current protocols. Recommendations were made for the remaining 15 failure modes. CONCLUSIONS Modified health care failure mode and effect analysis proved to be a practical approach and has been well received by clinicians. Systematic analysis by a multidisciplinary team is a useful method for detecting failure modes.

Reducing Error and Improving Efficiency during Vascular Interventional Radiology: Implementation of a Preprocedural Team Rehearsal

PURPOSE To determine the type and frequency of errors during vascular interventional radiology (VIR) and design and implement an intervention to reduce error and improve efficiency in this setting. MATERIALS AND METHODS Ethical guidance was sought from the Research Services Department at Imperial College London. Informed consent was not obtained. Field notes were recorded during 55 VIR procedures by a single observer. Two blinded assessors identified failures from field notes and categorized them into one or more errors by using a 22-part classification system. The potential to cause harm, disruption to procedural flow, and preventability of each failure was determined. A preprocedural team rehearsal (PPTR) was then designed and implemented to target frequent preventable potential failures. Thirty-three procedures were observed subsequently to determine the efficacy of the PPTR. Nonparametric statistical analysis was used to determine the effect of intervention on potential failure rates, potential to cause harm and procedural flow disruption scores (Mann-Whitney U test), and number of preventable failures (Fisher exact test). RESULTS Before intervention, 1197 potential failures were recorded, of which 54.6% were preventable. A total of 2040 errors were deemed to have occurred to produce these failures. Planning error (19.7%), staff absence (16.2%), equipment unavailability (12.2%), communication error (11.2%), and lack of safety consciousness (6.1%) were the most frequent errors, accounting for 65.4% of the total. After intervention, 352 potential failures were recorded. Classification resulted in 477 errors. Preventable failures decreased from 54.6% to 27.3% (P < .001) with implementation of PPTR. Potential failure rates per hour decreased from 18.8 to 9.2 (P < .001), with no increase in potential to cause harm or procedural flow disruption per failure. CONCLUSION Failures during VIR procedures are largely because of ineffective planning, communication error, and equipment difficulties, rather than a result of technical or patient-related issues. Many of these potential failures are preventable. A PPTR is an effective means of targeting frequent preventable failures, reducing procedural delays and improving patient safety.

Urethral diverticular carcinoma: an overview of current trends in diagnosis and management

AimsTo review the management of female urethral diverticular tumours, and rationalize treatment protocols.MethodsA literature search through Medline, Psychoinfo, EMBASE and the Cochrane library from 1951 was performed for all reports and series of urethral diverticular tumours.ResultsA total of one male patient and 75 female patients were reported, with data on demographics, presentation, diagnosis, treatment modalities, recurrence rates and mortality. There is considerable variation in the method of reporting outcomes, and heterogeneity in treatment methods.ConclusionThere appears to be no current consensus in the management of these rare tumours. There is an urgent need to establish an international registry of rare tumours to help formulate guidelines on management of such tumours. We propose a management algorithm based on the evidence gathered from review of the published literature.

Surgery: a risky business.

The advancement of surgical technology has made surgery an increasingly suitable management option for an increasing number of medical conditions. Yet there is also a growing concern about the number of patients coming to harm as a result of surgery. Studies show that this harm can be prevented by better teamwork and communication in operating theatres. This article discusses the extent of adverse events in surgery and how effective teamwork and communication can improve patient safety. It also highlights the role checklists and briefing in improving teamwork and reducing human error in surgery.