British Journal of Surgery最新文献

Background: The anaesthesia regimen may affect the risk of postoperative respiratory complications. However, the optimal anaesthetic choice for oesophagectomy remains unclear. This retrospective study compared the effect of desflurane, sevoflurane, and propofol anaesthesia on short-term outcomes after oesophagectomy.

Methods: Data of patients who underwent oesophagectomy for cancer during April 2012-March 2022 were extracted from a nationwide Japanese inpatient database. Propensity score matching weight analysis was conducted to compare respiratory complications, ventilatory failure, and in-hospital mortality between desflurane, sevoflurane, and propofol anaesthesia, adjusting for potential confounders. Sensitivity analyses were performed using multivariable logistic regression and instrumental variable analyses.

Results: Among 21 080 included patients (desflurane group 7823, sevoflurane group 8932, and propofol group 4325 patients), respiratory complications and ventilatory failure occurred in 3399 (16.1%) and 960 (4.6%) patients respectively. Upon matching weight analysis, sevoflurane and propofol anaesthesia were significantly associated with higher incidences of respiratory complications (OR 1.13, 95% c.i. 1.03 to 1.24 and OR 1.43, 95% c.i. 1.28 to 1.58 respectively) and ventilatory failure (OR 1.21, 95% c.i. 1.02 to 1.43 and OR 1.29, 95% c.i. 1.06 to 1.56 respectively) compared with desflurane anaesthesia. In-hospital mortality after desflurane anaesthesia was the lowest of the three anaesthesia (1.6% and 1.8% versus 1.2%; OR 1.30, 95% c.i. 0.98 to 1.73 and OR 1.49, 95% c.i. 1.08 to 2.06 respectively). Multivariable logistic regression and instrumental variable analyses demonstrated similar results.

Conclusions: Sevoflurane and propofol anaesthesia for oesophagectomy were associated with worse respiratory outcomes compared with desflurane anaesthesia.

Background: Poor quality ward rounds contribute to a large proportion of patient complications, delayed discharge, and increased hospital cost. This systematic review investigated all interventions aiming to improve patient and process-based outcomes in ward rounds.

Methods: This systematic review was prospectively registered in PROSPERO, the international prospective register of systematic reviews (CRD42023394325). MEDLINE, Embase, Emcare, and PsycInfo were searched for studies with interventions aiming to improve ward round processes or patient outcomes in hospital settings. Studies were excluded if there was no baseline comparator or they were not in the ward round setting. Interventions were coded as checklist interventions (that is electronic or paper-based pro formas, templates, and checklists), structure interventions (that is defined rules or protocol to guide or standardize conduct), or other interventions. Outcomes were assessed via meta-analyses using the I2 statistic, Cochran's Q P value, and random-effects models. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool for RCTs and the Newcastle-Ottawa scale for non-randomized studies.

Results: This review included 84 studies, from 18 countries, in 23 specialties, involving 43 570 patients. Checklist interventions significantly reduced ICU length of stay, improved overall documentation, and did not increase ward round duration. Structure interventions did not increase the time spent per patient or impact 30-day readmission rates or patient length of stay.

Conclusion: This is the first systematic review with meta-analyses synthesizing the evidence of all ward round interventions targeted at improving patient and process outcomes. Results from this review should be used to inform guidelines for the 'ideal ward round'.

Background: To reduce the clinical and economic burden of complications after gastrectomy for gastric cancer, specific complications should be targeted to effectively allocate healthcare resources for quality improvement and preventive measures. The aim of this study was to assess the impact of complications on clinical outcomes.

Methods: This was a retrospective multicentre study of patients who underwent (sub)total gastrectomy for gastric or junctional adenocarcinoma at 43 centres in 16 countries between 2017 and 2021. Outcomes were escalation of care, reoperation, prolonged hospital stay (greater than the 75th percentile), readmission, and 30-day mortality. Adjusted relative risks and population attributable fractions were estimated for specific complication-outcome pairs. The population attributable fraction represents the percentage reduction in the frequency of an adverse outcome if a complication could be completely prevented in the population.

Results: In total, 7829 patients were included. Postoperative complications occurred in 1884 patients (24.1%). The most frequent complications were pulmonary complications (436 patients (5.6%)), anastomotic leakage (363 patients (4.6%)), and abdominal collection (301 patients (3.8%)). Anastomotic leakage, cardiac complications, and pulmonary complications had the greatest impact on 30-day mortality (population attributable fraction 26.6% (95% c.i. 14.5% to 38.6%), 18.7% (95% c.i. 9.4% to 28.0%), and 15.6% (95% c.i. 12.0% to 30.0%) respectively). Anastomotic leakage and pulmonary complications had the greatest impact on escalation of care (population attributable fraction 26.3% (95% c.i. 20.6% to 32.0%) and 18.4% (95% c.i. 11.7% to 25.2%) respectively), whereas anastomotic leakage and intra-abdominal bleeding had the greatest impact on reoperation (population attributable fraction 31.6% (95% c.i. 26.4% to 36.9%) and 8.5% (95% c.i. 5.5% to 11.5%) respectively). Most of the studied complications contributed to a prolonged hospital stay, whereas the contribution of complications to readmission did not exceed 15.9%. Subgroup analysis showed regional variation in the impact of complications.

Conclusion: Anastomotic leakage had the largest overall negative impact on clinical outcomes after gastrectomy for gastric adenocarcinoma. Reducing the incidence of anastomotic leakage and pulmonary complications would have the most impact on the burden of complications.

Introduction: Most reports on the outcome of Watch-and-Wait (W&W) in rectal cancer come from expert centres. This study reports on a broad implementation in the Netherlands.

Material and methods: The process of W&W implementation is described and the outcome of patients in a W&W registry between 2004 and 2022 analysed (regrowth, metastases, survival, and organ preservation). Three equally sized chronological cohorts were compared to capture any differences during implementation over time.

Results: W&W was gradually implemented in 18 high-volume hospitals coordinated by a single expert centre. One thousand and eighty patients with a clinical good response after (chemo)radiotherapy were included, with a median follow-up of 42 months (95% c.i. 40 to 44). At first response evaluation, 45% had a clinical complete response (cCR) and 55% near-complete reponse (nCR). In patients with nCR, 75% eventually achieved cCR, 14% underwent local excision, 2% received additional contact X-ray brachytherapy, and 10% underwent total mesorectal excision (TME) for persistent residual disease. Three-year actuarial local regrowth incidence was 23%. Three-year organ preservation rate was 76%. The 3-year distant metastases rate and overall survival were 10% and 97%. There were no significant differences in 3-year local regrowth or distant metastases between the three consecutive cohorts. In the two more recent cohorts more patients underwent TME for residual disease (13% versus 3%), likely due to a more liberal inclusion of patients with nCR.

Conclusion: The results of W&W in rectal cancer patients in high-volume hospitals mirror those of expert centres.