Background and Aims:The lack of consensus on how to define and grade adverse postoperative events has greatly hampered the evaluation of surgical procedures. A new classification of complications, initiated in 1992, was updated 5 years ago. It is based on the type of therapy needed to correct the co

The Clavien-Dindo classification of surgical complications: five-year experience.

https://aasldpubs.onlinelibrary.wiley.com/doi/epdf/10.1053/jhep.2001.22172

A model to predict survival in patients with end‐stage liver disease

https://globalhealth.duke.edu/sites/default/files/event-attachments/2.18_meara.pdf

Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development

Background The technical skill of surgical trainees is not well assessed. This study aimed (1) to compare the reliability of three scoring systems, (2) to compare live and bench formats and (3) to assess construct validity of a test of operative skill.

Methods Parallel examinations of operative skill, one using live animals and one using simulations, were developed. Performance was graded using operation-specific checklists, detailed global rating forms and pass/fail judgements. Twenty surgical residents each took both formats.

Results Disattenuated correlations between live and bench scores were high (0.69–0.72). Mean inter-rater reliability across stations ranged from 0.64 to 0.72. Internal consistency was moderate to high (α: 0.61–0.74) for the live format using the checklist and for live and bench formats using global ratings. Global ratings discriminated between resident levels for both formats (bench: F(2,17) = 4.45, P < 0.05; live: F(2,17) = 3.5, P < 0.05), checklists did not.

Conclusion This preliminary study suggests that the Objective Structured Assessment of Technical Skill can reliably and validly assess surgical skills. Global ratings are a better method of assessment than task-specific checklists. Bench model simulation gives equivalent results to use of live animals for this test format.

Objective structured assessment of technical skill (OSATS) for surgical residents.

Consensus statement on the pathology of IgG4-related disease

Le traitement chirurgical de l'hydatidose hepatique est greve d'un taux de recidive locale d'environ 10%. On voit rarement une recidive locale apres resection complete d'un kyste intact et celle-ci est habituellement la consequence soit d'eparpillement de parasites vivants ou parce qu'on a laisse en place un residu de paroi kystique contenant de l'epithelium germinal, des vesicules filles ou des protoscolices. La recidive est frequemment asymptomatique; le diagnostic depend donc d'un suivi implique des patients traites par une serologie et soit une echographie, soit une tomodensitometrie. Le traitement d'une recidive locale doit comprendre l'administration d'albendazole, suivi soit de la radiologie interventionelle ou d'une intervention chirurgicale, comme indiquee. Comme c'est le cas avec le traitement de la maladie primitive, la preservation de la fonction hepatique et la minimisation du risque pour le patient sont les principes qui doivent guider la therapie de la recidive locale.

Recurrence of hydatid disease : World progress in surgery : Hydatid disease-continuing serious public health problem

Hepatic metastasis from colorectal cancer (CRC) is best managed with a multimodal approach; however, the optimal timing of liver resection in relation to administration of perioperative chemotherapy remains unclear. Our strategy has been to offer up-front liver resection for patients with resectable hepatic metastases, followed by post–liver resection chemotherapy. We report the outcomes of patients based on this surgical approach. A retrospective review of all patients undergoing liver resection for CRC metastases over a 5-year period (2002–2007) was performed. Associations between clinicopathologic factors and survival were evaluated by the Cox proportional hazard method. A total of 320 patients underwent 336 liver resections. Median follow-up was 40 (range 8–80) months. The majority (n = 195, 60.9 %) had metachronous disease, and most patients (n = 286, 85 %) had a major hepatectomy (>3 segments). Thirty-six patients (11 %) received preoperative chemotherapy, predominantly for downstaging unresectable disease. Ninety-day mortality was 2.1 %, and perioperative morbidity occurred in 68 patients (20.2 %). Actual disease-free survival at 3 and 5 years was 46.2 % and 42 %, respectively. Actual overall survival (OS) at 3 and 5 years was 63.7 % and 55 %, respectively. Multivariate analysis identified four factors that were independently associated with differences in OS (hazard ratio; 95 % confidence interval): size of metastasis >6 cm (2.2; 1.3–3.5), positive lymph node status of the primary CRC (N1 (2.0; 1.0–3.8), N2 (2.4; 1.2–4.9)), synchronous disease (2.1; 1.3–3.5), and treatment with chemotherapy after liver resection (0.42; 0.23–0.75). Up-front surgery for patients with resectable CRC liver metastases, followed by chemotherapy, can lead to favorable OS.

/pdf/up-front-hepatic-resection-for-metastatic-colorectal-cancer-4hiwjc6yfr.pdf

Up-front Hepatic Resection for Metastatic Colorectal Cancer Results in Favorable Long-term Survival

Twenty-nine patients with hepatocellular carcinoma (HCC) underwent orthotopic liver transplantation (OLTx) at the University of Toronto. Four patients did not have cirrhosis. Of the 25 patients with cirrhosis, 19 had known or suspected HCC before OLTx. Eleven patients tested positive for the hepatitis B surface antigen (HBsAg). No patients received adjuvant chemotherapy. None of the patients have developed recurrent HCC in a follow-up of 9 to 87 months (mean: 33 months). The actuarial post-transplant survival of all patients at 3 months, 1 year and 3 years was 75%, 61%, and 46%, respectively. The survival of HBsAg-negative patients was 69% at 3 years, whereas HBsAg-negative patients had a 3-year survival of 18% (p = 0.045). These results suggest that OLTx for carefully selected patients with otherwise unresectable HCC is associated with a low risk of recurrence. HBsAg-positive patients with HCC have a high mortality, suggesting that they make poor candidates for OLTx.

Liver transplantation for hepatocellular carcinoma.

Background The issue of residents operating and disclosure to patients about this have not been explored from staff surgeons' perspectives. Methods A preliminary survey was sent to all active surgeons at the University of Toronto. A qualitative interview study followed. Thirty-nine face-to-face interviews were conducted with surgeons. Interviews were transcribed and subjected to thematic analysis by 3 reviewers. Results Four encompassing themes emerged: (1) surgeons are comfortable allowing residents to operate independently with graded responsibility, (2) surgeons do not voluntarily inform patients about the involvement of residents in their operation, (3) residents are seen as important assets in a teaching hospital and are beneficial to patient care, and (4) surgeons recognize the trust their patients place in them. Conclusions Surgeons recognize their patient care and teaching responsibilities and the trust that is placed in them. Patients might benefit from a discussion with their surgeon about the role of residents in their surgery.

What surgeons tell their patients about the intraoperative role of residents: a qualitative study.

BACKGROUND: Recent reports in the scientific and lay press have suggested that bile duct injuries during laparoscopic cholecystectomy are common in Ontario. The reports were based on administrative data collected by hospital medical records departments and the Canadian Institute for Health Information (CIHI). The current study involved a direct inspection of hospital records to determine if the CIHI data accurately captured the rate of clinically significant bile duct complications. METHODS: For the period 1991 to 1995, records of bile duct injuries after laparoscopic cholecystectomy were independently evaluated to clarify the clinical significance of the complications. Of 21 Ontario hospitals for which data on complications had been reported in the media, 18 provided detailed information on all patients reported to have suffered bile duct complications classified by the hospital as "major". In addition, each institution provided information on a random sample of one-sixth of the patients who had suffered complications classified as "minor". The reviewer then examined each relevant hospital chart to assess the grade and significance of the reported complications. RESULTS: All 24 bile duct injuries classified by the hospitals as "major" were confirmed as major (clinically relevant) injuries. Of the 80 bile duct complications classified by the hospitals as "minor", 76 (95%) were irrelevant to patient outcome. The discrepancy between data collected and reported frequency of injury lies in the use of nonspecific coding methods. INTERPRETATION: The rate of significant bile duct injuries cannot be inferred from nonspecific codes taken from the International Classification of Diseases, ninth revision, and presented in hospital discharge records. Therefore, such data must be interpreted with extreme caution.

/pdf/common-bile-duct-injury-during-laparoscopic-cholecystectomy-m29eys03vd.pdf

Bryce R. Taylor

Papers

Recurrence of hydatid disease : World progress in surgery : Hydatid disease-continuing serious public health problem

Up-front Hepatic Resection for Metastatic Colorectal Cancer Results in Favorable Long-term Survival

Liver transplantation for hepatocellular carcinoma.

What surgeons tell their patients about the intraoperative role of residents: a qualitative study.

Common bile duct injury during laparoscopic cholecystectomy in Ontario: Does ICD-9 coding indicate true incidence?