Low-volume Unit Research Articles

Pelvic Exenteration Surgery Outcomes Following Establishment of a Complex Pelvic Surgery Multidisciplinary Tertiary Unit

Background: Pelvic exenteration surgery (PES) is a complex operation associated with significant morbidity. PES requires sub-specialised multidisciplinary input along with expertise in complex pelvic surgery and anatomy. The majority of published data on PES comes from high volume units, however there is emerging evidence of comparable short and long-term outcomes in lower volume units where dedicated multidisciplinary teams are established. This study reports outcomes of PES in a lower volume centre with a collaborative multidisciplinary surgical approach. Methods: A retrospective review of patients who underwent PES for benign or malignant pathology at Liverpool and Macquarie University Hospitals between September 2015 and June 2022. Descriptive statistics were performed and KaplanMeier survival analysis for patients treated for malignancy with curative intent. Results: A total of 67 patients undergoing pelvic exenteration were included (53.8% female; with mean age 59 years). Indications for PES were colorectal cancer (56.7%), gynaecological cancer (22.4%), other malignancy (9.0%) and complex benign pathology (11.9%). Posterior or total pelvic exenteration was performed in 88.1%. Median hospital stay was 16 days. Clavien-Dindo grade III or IV complications occurred in 34.3%. There were two post-operative deaths (3.0%; one palliative intent). For patients treated with curative intent (n=51), R0 resection margin was achieved in 92.2%, and R1 margin in 7.8%. Estimated five-year disease-free survival was 57.1%, and five-year overall survival was 65.5%. Conclusion: Short and long-term outcomes of PES in a low volume unit with appropriate multidisciplinary expertise are comparable to published data on pelvic exenteration from higher volume units.

Complications of Scheker semiconstrained distal radioulnar joint arthroplasty in a low-volume unit

Semiconstrained arthroplasty of the distal radioulnar joint (DRUJ) (Scheker prosthesis, Aptis Medical, Glenview, KY, USA) is a treatment option in case of irreparable destruction of the DRUJ. In our unit, a Scheker endoprosthesis was implanted in 5 wrists in 4 patients. 3/5 wrists (60%) in 3/4 patients (75%) underwent revision surgery. Reasons for revision surgery were implant loosening, periprosthetic fracture of the radius and suspicion of periprosthetic infection. Asymptomatic loosening of the screw of the radial head cover was detected in one wrist. Scheker arthroplasty is technically demanding. The prosthesis is prone to failure over the long term. Before implantation, all patients should be informed of the high risk of revision surgery.

Reappraisal learning curve of laparoscopic Roux-en Y gastric bypass: retrospective results of one hundred and eight cases from a low-volume unit

BackgroundThis study aimed to reevaluate the learning curve of laparoscopic Roux-en Y gastric bypass (LRYGB) in the modern era while considering a single surgeon’s experience.MethodsFrom the beginning of our LRYGB practice, all patients who met the regional criteria and underwent primary LRYGB were retrospectively enrolled. Patients with a body mass index (BMI) > 50 kg/m2 were excluded. Those who underwent surgery in 2016–17, 2018 and 2019 by a single surgeon with 10 + years of laparoscopic experience were assigned to groups A, B and C, respectively. The patient demographics and 30-day outcome data, including the operation time, length of stay (LOS), emergency room visits, readmission, and reoperation, were compared among the groups.ResultsOne hundred and eight patients met the inclusion criteria; 36, 38, and 34 patients were assigned to groups A, B and C, respectively. There were no differences in age, sex distribution or common comorbidities among the groups; however, B had a lower BMI (35.1 kg/m2 vs. 37.0 kg/m2) and a higher rate of hypertension (44.7% vs. 22.2%) than group A. The operation time was markedly reduced (96.1 min and 114.9 min, p < 0.001), and the LOS was shortened (2.2 days and 2.9 days, p < 0.001) in group B compared to group A and remained stationary in group C, with no further reduction in 30-day complications.ConclusionThe learning process of LRYGB can be shortened to approximately 30 cases if conducted selectively by experienced laparoscopic surgeons. Further follow-up is required to verify the long-term safety and applicability in other patient subgroups.

Transanal Minimally Invasive Surgery (TAMIS) in Qatar: initial experience

BackgroundTransanal Minimally Invasive Surgery (TAMIS) has revolutionized local excision of mid and high rectal lesions; benign or malignant. It is a technique that is developed as a hybrid between Transanal Endoscopic Microsurgery (TEM) and laparoscopic surgery for resection of rectal lesions.MethodsWe retrospectively reviewed prospectively collected data on patients who underwent TAMIS for benign and early malignant rectal lesions between Jan 2015 and Sept 2019, at Hamad General Hospital, Doha, Qatar.We assessed the following outcomes: feasibility, fragmentation of specimen, operative time, length of stay (LOS) post-operative complications, and margin negativity.ResultsSeventeen consecutive patients underwent TAMIS for benign and malignant rectal lesions. The average length of stay (LOS) is 1.5 days (1–6 days). Seven patients had different types of benign adenomas, five patients had proven adenocarcinoma, three patients had well-differentiated neuroendocrine tumors, one patient with hyperplastic polyp, and one patient had inflammatory polyp. No fragmentation occurred or detected by histopathologic examination, except in a patient who had inflammatory polyp, where the lesion removed in two fragments.ConclusionTAMIS procedure is feasible and safe even in a relatively low-volume colorectal unit. Using this tool, many patients can avoid unnecessary radical surgery. Therefore, we believe that TAMIS should form part of every specialized colorectal service repertoire. To our knowledge, this is the largest series in the gulf region.

Sa1102 Lesion Selection for Colorectal Endoscopic Submucosal Dissection Novice--- Learning Curve From Low Volume Unit

Sa1102 Lesion Selection for Colorectal Endoscopic Submucosal Dissection Novice--- Learning Curve From Low Volume Unit

Safety of video-assisted thoracic surgery lobectomy for non-small-cell lung cancer in a low-volume unit.

Several studies have demonstrated that for complex surgical procedures, surgeons who treat more patients have better outcomes than their lower-volume counterparts. The aim of this paper is to review the experience with video-assisted thoracic surgery (VATS) lobectomies in our small thoracic unit (group A), to understand whether our short-term results were different to the outcomes obtained by the same surgeon previously working in a high-volume unit (group B). 37 patients underwent VATS lobectomy. Hospital stay was on average 4.5 days (group A) versus 4.1 days (group B). Operative time and the number of 'frozen sections' were higher in group A. Hospital mortality was 0. VATS lobectomies are a safe approach in a low-volume unit formed by a single surgeon with a previous high-volume experience.

Results of Porous-Coated Anatomic and Duracon Total Knee Arthroplasty

The Duracon total knee replacement and its forerunner the Porous-Coated Anatomic (PCA) knee system have been associated with good results. This study reviews a series of 181 knee replacements performed with these systems by seven general orthopedic surgeons with follow-up to a mean of 6.7 years. The mean Knee Society knee and function scores were 72 and 68. The mean Western Ontario and MacMaster Universities Osteoarthritis Index score was 76, and the mean 12-Item Short-Form Health Survey result was 55. A mean flexion of 104 degrees was recorded, and 93.8% of patients rated their satisfaction as good to excellent. Fifty-five percent of patients had minor radiographic lucencies-these were of questionable clinical significance. Seven patients required revision. These knee systems used in a relatively low-volume general unit provide consistent results comparable with those from larger arthroplasty units.

High quality colonoscopy in a low volume unit; is it achievable?

Background and study aims Colonoscopy is a technically demanding procedure with potential for harm if performance is poor. Bolak Eldakror Hospital is a secondary-care governmental hospital in Giza, Egypt with an average colonoscopy volume of 28 procedures per year. Our aim was to determine whether a high standard of practice could be achieved in our unit by instituting a rigorous quality assurance programme in spite of a low colonoscopy volume (<50 colonoscopies per year). We assessed the quality of our colonoscopic service with the goal of improving performance. Patients and methods The crude completion rate was 50% in 2003. The main reasons for failure of completion were operator inexperience, poor patient tolerance and inadequate bowel preparation. Changes were instituted to improve performance. We assessed the quality of our colonoscopic service prospectively over a period of 6 years. Colonoscopy completion rates and patient discomfort were considered to be the key measures for improvement. A total of 168 patients undergoing colonoscopies from the year 2004 to 2009 were evaluated. Results The colonoscopy completion rates improved consistently. The crude completion rate improved from 52% in 2004 to 94% in 2009. The adjusted completion rate improved from 60% in 2004 to 100% in 2009. There were no procedure-related complications. The percentage of patients who experienced moderate or severe pain during colonoscopy was 50% in 2004, increased to 72% in 2007 and improved to 27% in 2009. Conclusion A high standard of colonoscopy can be achieved in endoscopy units with a low colonoscopy volume by the rigorous application of quality assurance measures.

Can a “novice” do aneurysm surgery? Surgical outcomes in a low-volume, non-subspecialised neurosurgical unit

The objective of this paper is to review the results of a junior general neurosurgeon performing aneurysm surgery and compare these to the remainder of his low-volume unit. Prospectively collected data was analysed for 114 aneurysms clipped in 99 patients between July 2001 and May 2005. Overall there was a 0.9% mortality rate and 10.8% complication rate. The favourable outcome rate for the unit was 100% for unruptured aneurysms, 90.4% for grades 1–3 patients and 30% for poor grade patients (grades 4 and 5). The novice neurosurgeon had no mortality and a favourable outcome rate of 94.7% for grades 1–3 patients and 50% for poor grade patients. Acceptable results can be obtained with cerebral aneurysm surgery in a low-volume centre by Australian-trained, non-subspecialty neurosurgeons.

Surgery for Colorectal Cancer in a Low-Volume Unit: Assessment of Key Issues in the Achievement of Acceptable Clinical Results

The maintenance of modern therapeutic principles requires a proper case load to achieve acceptable surgical results. This may obligate administrative reorganization to overcome these problems and to provide an adequate level of cancer surgery. To assess the surgical results of patients coming for surgery for colorectal cancer in a low-volume non-academic unit during the past 15 yr. 458 consecutive patients referred for surgery between 1988 and 2001 in Kanta-Häme Central Hospital in Finland were analyzed regarding their disease, mode of surgery, and the immediate and long-term result. The data were collected from patient journals and from the National Centre of Statistics and analyzed in two successive periods. The number of patients with a localized disease (Dukes A + Dukes B) decreased during the followup from 49% to 45%. A curative procedure was achieved in 68% in the first half and in 73% in the second half of the observation period. The immediate mortality was 5% and 2% in the two periods, respectively. The corrected 5-year survival according to the Dukes Classification was 92% (A), 69% (B), 41% (C ), and 6% (D). In curative surgery for rectal cancer, the incidences of local recurrence decreased from 21% to 9% (NS) and the use of permanent colostomy from 59 to 42% (NS). Acceptable immediate and long-term results in curative surgery for colorectal cancer can be achieved in a low-volume surgical unit. Nevertheless, owing to the low volume, the improvement of the results obligates team-based institutional specialization and careful consideration about the extensiveness of the primary procedure in case of cancer obstruction.

Drift-pump and drift-net—two devices for the collection of bottom-near drifting biota

A low-volume submersible drift-pump unit is described for the collection of demersally drifting biota, particularly for shallow aquatic situations. This unit collects less motile biota quantitatively (so far zooplankton, larvae of macrofauna, and meiofauna are successfully collected). It can easily be modified for the sampling of a variety of other aquatic organisms, in particular nano- and picoplankton (algal, bacterial, fungal and viral plankton) at high temporal and spatial resolution. A new drift-net unit allows qualitative comparisons of demersally drifting invertebrates. Both light-weighted stationary systems can be modified for sampling at varying distances from the bottom and are suggested for fine-scale appliances at moderate depths from shore, pier, boat, or deployed by divers.

MOVING BED CHROMATOGRAPHY

Moving bed chromatography, and simulated moving bed chromatography has been known for over 50 years, but has recently become important in the isolation of pure substances where the components are very similar, as in the case of enantiomers and in the isolation of substances which would be difficult or impossible by other means. The first example of moving bed chromatography was in the separation of pure acetylene from methane oxidation products, reported in 1956. Subsequently, in 1958, the separation of pure benzene from coal gas was described using gas liquid chromatography and a moving bed system. The movement of solely the chromatographic packing proved difficult to control and an alternative method using circular columns with moving ports to simulate the moving bed proved to be partially successful. Eventually, the circular columns were replaced by a group of static packed columns connected in series by a rotary valve that simulated a moving bed. This device proved very successful and was developed further, the disc valve eventually being replaced by low dead volume unit valves under computer control. Today, effective simulated moving bed chromatographic systems are becoming available, but it is still left to the operator to determine the optimum operating conditions, and that can often be difficult and tedious.

Chronic post-treatment symptoms in patients with breast cancer operated in different surgical units

AimsThis study was designed to find out whether women operated in high volume surgical units have less chronic symptoms than women operated in smaller volume units.MethodsA questionnaire was sent to 265 consecutive women treated at the Department of Oncology, Helsinki University Central Hospital, from January to June 1996. Of the patients, 129 were operated in hospitals experienced in breast cancer surgery (high volume units=HVU) and 92 patients in district hospitals with less experience in breast surgery (low volume units=LVU).ResultsChronic symptoms were less common in HVU than in LVU: chronic pain (56 vs 43%,P<0.05) or strange sensations (45 vs 26%,P<0.01) in the ipsilateral arm or phantom sensations in the removed breast (66 vs 26%,P<0.001). The risk factors included in the multivariate model for chronic pain in the breast area were: intensity of acute post-operative pain, radiotherapy and depression and for the chronic arm pain: low volume unit and depression.ConclusionsMore careful surgical technique seems to reduce the risk of chronic pain following treatment of breast cancer. Chronic pain is associated with more intense post-operative pain and depression.