Discrete-choice experiment to analyse preferences for centralizing specialist cancer surgery services

Journal
BJS
Volume 105, Issue 5

Article Title
Discrete-choice experiment to analyse preferences for centralizing specialist cancer surgery services

First published online
2018-03-07

Authors
L. Vallejo‐Torres, M. Melnychuk, C. Vindrola‐Padros, M. Aitchison, C. S. Clarke, N. J. Fulop, J. Hines, C. Levermore, S. B. Maddineni, C. Perry, K. Pritchard‐Jones, A. I. G. Ramsay, D. C. Shackley, S. Morris

DOI
10.1002/bjs.10761

Abstract

Background

Centralizing specialist cancer surgery services aims to reduce variations in quality of care and improve patient outcomes, but increases travel demands on patients and families. This study aimed to evaluate preferences of patients, health professionals and members of the public for the characteristics associated with centralization.

Methods

A discrete-choice experiment was conducted, using paper and electronic surveys. Participants comprised: former and current patients (at any stage of treatment) with prostate, bladder, kidney or oesophagogastric cancer who previously participated in the National Cancer Patient Experience Survey; health professionals with experience of cancer care (11 types including surgeons, nurses and oncologists); and members of the public. Choice scenarios were based on the following attributes: travel time to hospital, risk of serious complications, risk of death, annual number of operations at the centre, access to a specialist multidisciplinary team (MDT) and specialist surgeon cover after surgery.

Results

Responses were obtained from 444 individuals (206 patients, 111 health professionals and 127 members of the public). The response rate was 52·8 per cent for the patient sample; it was unknown for the other groups as the survey was distributed via multiple overlapping methods. Preferences were particularly influenced by risk of complications, risk of death and access to a specialist MDT. Participants were willing to travel, on average, 75 min longer in order to reduce their risk of complications by 1 per cent, and over 5 h longer to reduce risk of death by 1 per cent. Findings were similar across groups.

Conclusion

Respondents' preferences in this selected sample were consistent with centralization.

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Pancreas‐sparing, ampulla‐preserving duodenectomy for major duodenal (D1–D2) perforations.

Background

Ideal surgical treatment for acute duodenal injuries should offer a definitive treatment, with low morbidity and mortality. It should be simple and easily reproducible by acute care surgeons in an emergency. Duodenal injury, due to major perforated or bleeding peptic ulcers or iatrogenic/traumatic perforation, represents a surgical challenge, with high morbidity and mortality. The aim was to review definitive surgery with pancreas‐sparing, ampulla‐preserving duodenectomy for these patients.

Method

Pancreas‐sparing, ampulla‐preserving D1–D2 duodenectomy was used for patients presenting with major duodenal injuries over a 5‐year interval. The ampulla was identified and preserved using a transcystic/transpapillary tube. The outcomes were recorded.

Results

Ten patients were treated with this technique; seven had perforated or bleeding peptic ulcers, two had iatrogenic perforations and one blunt abdominal trauma. Their mean age was 78 (range 65–84) years. Four patients were haemodynamically unstable. The location of the duodenal injury was always D1 and/or D2, above or in close proximity to the ampulla of Vater. The surgical approach was open in nine patients and laparoscopic in one. The mean duration of surgery was 264 (range 170–377) min. All patients were transferred to the ICU after surgery (mean ICU stay 4·4 (range 1–11) days), and the overall mean hospital stay was 17·8 (range 10–32) days. Six patients developed major postoperative complications: cardiorespiratory failure in five and gastrointestinal complications in four. Surgical reoperation was needed in one patient for postoperative necrotizing and bleeding pancreatitis. Two patients died from their complications.

Conclusion

Pancreas‐sparing, ampulla‐preserving D1–D2 duodenectomy for emergency treatment of major duodenal perforations is feasible and associated with satisfactory outcomes.

BJS 2018; 105: 1487-1492.

Published: 19th July 2018

Authors: S. Di Saverio, E. Segalini, A. Birindelli, S. Todero, M. Podda, A. Rizzuto et al.

Prospective trial to evaluate the prognostic value of different nutritional assessment scores in pancreatic surgery (NURIMAS Pancreas).

Published: 30th March 2017

Authors: P. Probst, S. Haller, T. Bruckner, A. Ulrich, O. Strobel, T. Hackert et al.

Background

Preoperative nutritional status has an impact on patients' clinical outcome. For pancreatic surgery, however, it is unclear which nutritional assessment scores adequately assess malnutrition associated with postoperative outcome.

Method

Patients scheduled for elective pancreatic surgery at the University of Heidelberg were screened for eligibility. Twelve nutritional assessment scores were calculated before operation, and patients were categorized as either at risk or not at risk for malnutrition by each score. The postoperative course was monitored prospectively by assessors blinded to the nutritional status. The primary endpoint was major complications evaluated for each score in a multivariable analysis corrected for known risk factors in pancreatic surgery.

Results

Overall, 279 patients were analysed. A major complication occurred in 61 patients (21·9 per cent). The proportion of malnourished patients differed greatly among the scores, from 1·1 per cent (Nutritional Risk Index) to 79·6 per cent (Nutritional Risk Classification). In the multivariable analysis, only raised amylase level in drainage fluid on postoperative day 1 (odds ratio (OR) 4·91, 95 per cent c.i. 1·10 to 21·84; P = 0·037) and age (OR 1·05, 1·02 to 1·09; P = 0·005) were significantly associated with major complications; none of the scores was associated with, or predicted, postoperative complications.

Conclusion

None of the nutritional assessment scores defined malnutrition relevant to complications after pancreatic surgery and these scores may thus be abandoned.

Human papillomavirus infection and anal dysplasia in renal transplant recipients

Author: H. S. Patel, A. R. Silver, T. Levine, G. Williams, J. M. Northover
Published: Aug 20, 2010
Pages: 1716-1721
DOI: 10.1002/bjs.7218

Abstract

Background:

Immunosuppression is a known risk factor for anal human papillomavirus (HPV) disease, including anal squamous cell carcinoma. Additional risk factors for HPV‐related disease have not been studied in the renal transplant population. The demographics of anal HPV and associated risk factors were investigated in this population.

Methods:

Anal cytology and polymerase chain reaction were used to assess anal HPV disease in a cohort of transplant recipients at the Royal London Hospital. Risk factors associated with increased immunosuppression and HPV exposure were collated to determine any association with anal disease.

Results:

Anal dysplasia was associated with anal oncogenic HPV infection (P < 0·001), duration of immunosuppression (P = 0·050), previous genital warts (P = 0·018) and receptive anal intercourse (P = 0·013).

Conclusion:

Management of blunt injuries to the spleen

Author: P. Renzulli, T. Gross, B. Schnüriger, A. M. Schoepfer, D. Inderbitzin, A. K. Exadaktylos, H. Hoppe, D. Candinas
Published: Aug 26, 2010
Pages: 1696-1703
DOI: 10.1002/bjs.7203

Abstract

Background:

Non‐operative management (NOM) of blunt splenic injuries is nowadays considered the standard treatment. The present study identified selection criteria for primary operative management (OM) and planned NOM.

Methods:

All adult patients with blunt splenic injuries treated at Berne University Hospital, Switzerland, between 2000 and 2008 were reviewed.

Results:

There were 206 patients (146 men) with a mean(s.d.) age of 38·2(19·1) years and an Injury Severity Score of 30·9(11·6). The American Association for the Surgery of Trauma classification of the splenic injury was grade 1 in 43 patients (20·9 per cent), grade 2 in 52 (25·2 per cent), grade 3 in 60 (29·1 per cent), grade 4 in 42 (20·4 per cent) and grade 5 in nine (4·4 per cent). Forty‐seven patients (22·8 per cent) required immediate surgery. Transfusion of at least 5 units of red cells (odds ratio (OR) 13·72, 95 per cent confidence interval 5·08 to 37·01), Glasgow Coma Scale score below 11 (OR 9·88, 1·77 to 55·16) and age 55 years or more (OR 3·29, 1·07 to 10·08) were associated with primary OM. The rate of primary OM decreased from 33·3 to 11·9 per cent after the introduction of transcatheter arterial embolization in 2005. Overall, 159 patients (77·2 per cent) qualified for NOM, which was successful in 143 (89·9 per cent). The splenic salvage rate was 69·4 per cent. In multivariable analysis age at least 40 years was the only factor independently related to failure of NOM (OR 13·58, 2·76 to 66·71).

Conclusion:

NOM of blunt splenic injuries has a low failure rate. Advanced age is independently associated with an increased failure rate. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

New anatomical classification of the axilla with implications for sentinel node biopsy

Author: K. B. Clough, R. Nasr, C. Nos, M. Vieira, C. Inguenault, B. Poulet
Published: Aug 26, 2010
Pages: 1659-1665
DOI: 10.1002/bjs.7217

Abstract

Background:

The exact anatomical location of the sentinel lymph node (SLN) in the axilla has not ascertained clinically, but could be useful both for teaching purposes and to reduce the morbidity of SLN biopsy. The aim of the study was to determine the position of the SLN in the axilla and to demonstrate that this location is not random.

Methods:

A consecutive series of 242 patients with stage I breast cancer (T1/T2 N0) or ductal carcinoma in situ who underwent SLN localization by peritumoral injection were included in a prospective study to map the location of the SLN in the axilla. A new anatomical classification of the lower part of the axilla based on the intersection of two anatomical landmarks, the lateral thoracic vein (LTV) and the second intercostobrachial nerve (ICBN), is described. These two constant elements form the basis of four axillary zones (A, B, C and D).

Results:

In 98·2 per cent of patients the axillary SLN was located medially, alongside the LTV, either below the second ICBN (zone A, 86·8 per cent) or above it (zone B, 11·5 per cent). In only four patients (1·8 per cent) was the SLN located laterally in the axilla.

Conclusion:

Regardless of the site of the tumour in the breast, 98·2 per cent of SLNs were found in the medial part of the axilla, alongside the LTV. This information should help to avoid unnecessary lateral dissections. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Randomized clinical trial comparing surgery, endovenous laser ablation and ultrasound‐guided foam sclerotherapy for the treatment of great saphenous varicose veins

Background
Endovenous ablation techniques and ultrasound‐guided foam sclerotherapy (UGFS) have largely replaced open surgery for treatment of great saphenous varicose veins. This was a randomized trial to compare the effect of surgery, endovenous laser ablation (EVLA) (with phlebectomies) and UGFS on quality of life and the occlusion rate of the great saphenous vein (GSV) 12 months after surgery.

Methods
Patients with symptomatic, uncomplicated varicose veins (CEAP class C2–C4) were examined at baseline, 1 month and 1 year. Before discharge and at 1 week, patients reported a pain score on a visual analogue scale. Preoperative and 1‐year assessments included duplex ultrasound imaging and the Aberdeen Varicose Vein Severity Score (AVVSS).

Results
The study included 214 patients: 65 had surgery, 73 had EVLA and 76 had UGFS. At 1 year, the GSV was occluded or absent in 59 (97 per cent) of 61 patients after surgery, 71 (97 per cent) of 73 after EVLA and 37 (51 per cent) of 72 after UGFS (P < 0·001). The AVVSS improved significantly in comparison with preoperative values in all groups, with no significant differences between them. Perioperative pain was significantly reduced and sick leave shorter after UGFS (mean 1 day) than after EVLA (8 days) and surgery (12 days).

Conclusion
In comparison with open surgery and EVLA, UGFS resulted in equivalent improvement in quality of life but significantly higher residual GSV reflux at 12‐month follow‐up.

Author: M. Venermo, J. Saarinen, E. Eskelinen, S. Vähäaho, E. Saarinen, M. Railo, I. Uurto, J. Salenius, A. Albäck,
Published: Aug 26, 2016
Pages: 1438-1444
DOI: 10.1002/bjs.10260