Archives of Surgery最新文献

HYPOTHESIS The cost of robotic thyroidectomy (RT) is significantly higher than that of standard open thyroidectomy (ST). DESIGN A retrospective cost analysis of ST was compared with a projected cost analysis of RT using institution-specific data. SETTING Endocrine surgery division at an academic center. PARTICIPANTS Standard open thyroidectomy data from 2 high-volume endocrine surgeons vs published variables from high-volume RT surgeons. MAIN OUTCOME MEASURES A cost analysis was performed for ST (Current Procedural Technology code 60240). The cost of RT was estimated as operative time plus anesthesia fees plus consumables plus the robotic system (da Vinci Surgical System; Intuitive Surgical, Inc). Institution-specific data were collected for ST, and only those costs that varied between ST and RT were included in the analysis. The mean operative time for ST was based on data from 2 high-volume endocrine surgeons at our institution. The RT operative data were extracted from published series of high-volume RT surgeons. RESULTS The relative costs calculated were $2668 for ST vs $5795 for RT. This represents a 217% increased cost of RT compared with ST. The mean operative times were 113 minutes for ST vs 137 minutes for RT. CONCLUSIONS Technologic advances are paramount in providing the best medical care for patients. This progress must be tempered by a rational, open discussion about the costs of these advancements. Only then can the proposed benefits of a new technology be weighed accurately against the overall societal cost. Surgeons need to be aware of the cost of their technologic choices and the burdens that those place on limited resources.

Objectives: To describe the surgical oncology experience at a major regional hospital in Malawi and to identify barriers to improved outcomes.

Design: Retrospective review of operating logbooks from a single tertiary referral center.

Setting: Major tertiary referral center (Kamuzu Central Hospital) in Lilongwe, Malawi, in sub-Saharan Africa.

Patients: Patients were identified with a suspected diagnosis of cancer from January 1, 2004, through March 7, 2007.

Main outcome measures: Cancer cases were classified according to patient demographic characteristics, disease location, and therapeutic intent. The Malawi data were compared with US data from the Surveillance Epidemiology and End Results database.

Results: A malignant diagnosis was suspected in 255 of the 1440 patients undergoing a major resection (17.8%) (mean patient age, 53 years). The most common cancers in males were prostate, esophageal, and gastric. In females, the most common cancers were breast, colon, and esophageal. Many of the procedures were performed with palliative intent.

Conclusions: Cancer surgery comprises a significant proportion of the surgical caseload in low-income countries. Patients often present with late-stage, inoperable cancer. The participation of the surgical community is critical for addressing barriers to effective cancer care.

OBJECTIVE To evaluate the accuracy of liver biopsy findings in preoperative assessment of chemotherapy-associated liver injuries (CALIs). DESIGN Prospective study. SETTING Tertiary care referral hospital. PATIENTS From July 1, 2007, to January 31, 2011, all patients with colorectal metastases receiving preoperative oxaliplatin- and/or irinotecan-based chemotherapy (≥4 cycles) were considered for the present study. Patients underwent parenchymal biopsy before liver resection. Blinded CALI evaluation was performed on biopsy and resection specimens. INTERVENTION Liver resection. MAIN OUTCOME MEASURES Sensitivity, specificity, and accuracy of liver biopsy in CALI evaluation. RESULTS We included 100 patients. At specimen analysis, grade 2 or 3 steatosis was diagnosed in 30 patients; grade 2 or 3 sinusoidal dilatation, in 28; grade 2 hepatocellular ballooning, in 3; grade 2 or 3 lobular inflammation, in 25; and steatohepatitis in 19. Obesity was associated with grade 3 steatosis (20.8% vs 5.3%; odds ratio [OR], 4.74 [P = .03]) and steatohepatitis (33.3% vs 14.5%; OR, 2.96 [P = .04]). Oxaliplatin administration was associated with higher sinusoidal dilatation grade (P = .049). Mortality (2 cases) was increased among patients with steatohepatitis (10.5% vs 0; OR, 13.67 [P = .04]). Biopsy findings correctly predicted steatosis (sensitivity, 88.9%; accuracy, 93.0%) but had low sensitivity and accuracy for sinusoidal dilatation (21.4% and 63.0%, respectively), hepatocellular ballooning (16.0% and 69.0%, respectively), lobular inflammation (20.0% and 78.0%, respectively), and steatohepatitis (21.1% and 79.0%, respectively). Biopsy accuracy did not improve regarding specific chemotherapy regimens or prolonged treatments. CONCLUSIONS Liver biopsy cannot be considered a reliable tool in assessing CALIs except for steatosis. The procedure should not be recommended during preoperative workup.

Objectives: To determine the safety, clinical yield, and cost of computed tomography angiography (CTA) use in the workup of potential renal transplant recipients.

Design: Single-site, retrospective review of medical, surgical, and radiologic records.

Setting: Large university tertiary care center.

Patients: Potential recipients of transplants from living donors.

Interventions: Computed tomography with and without 100 mL of iodixanol intravenous contrast enhancement as part of the preoperative workup.

Main outcome measures: Mean pre- and post-CTA estimated glomerular filtration rate and number of patients requiring emergent dialysis after CTA, number of patients who had their treatment changed by CTA findings, patient predictors of significant CTAs, and cost per significant CTA.

Results: From July 20, 2006, through December 10, 2010, a total of 179 transplant candidates underwent CTA. Forty-two patients were predialysis at the time of CTA. Mean (SD) serum creatinine levels in this group were unchanged after CTA (5.06 [2.13] mg/dL vs 5.00 [2.28] mg/dL [to convert to micromoles per liter, multiply by 88.4], P = .49), and no patients required subsequent emergent dialysis. Forty-one patients (22.9%) had their treatment changed by CTA findings. Multivariate logistic regression analysis revealed 3 patient history and physical criteria that predicted significant CTA findings: chronic infection (odds ratio, 10.91; 95% CI, 2.72-43.69; P < .001), patient weight less than 69 kg (3.11; 1.49-6.51; P < .001), and ventral torso surgical scarring (4.13; 1.57-10.84; P < .001). Diagnostic cost per significant CTA study was $2660, with an estimated reduced cost of $1480 per significant study with screening using 1 of the 3 predictors.

Conclusion: Diagnostic CTA is a safe and cost-effective procedure for both operative planning and screening for potentially prohibitive abdominal disease.