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.