Development of a System to Support Surgical Safety-I and Safety-II. Implementation of Resilient Surgical Healthcare for Bleeding Incidents in Thoracic Surgery

Background: Since bleedings in surgery are infrequent and inexperienced, we always try to proceed with surgery assuming a crisis situation, adhere to routine procedures and its standardization. We focus on the bleeding accidents and reveal how to implement a resilient healthcare theory. By clarifying the Safety-I and Safety-II, we developed a system to support surgical safety based on the surgeon’s individual, team, and organization. Material and Methods: We searched 25 cases of bleeding incidents in thoracic surgery, which were obtained from the database of the Project to Collect Medical Near-Miss/Adverse Event Information of the Japan Council of Quality Health Care in April 2018. Retrospectively, we analyzed 13 hemorrhage cases in our department between July 2002 and March 2020. We studied their surgical factors such as procedures, sites and causes of bleeding, response, treatment, and outcomes. Results: The causes of bleeding included damage of the adhesion detachment, insertions of automatic sutures and forceps, detachment of ultrasonic scalpel, vascular taping, removal of resected lung, lymph node dissection, exfoliation of the infiltrated adventitia of vessels, pull-out of vessel, gauze attachment with staple cut-line of vessel, thoracoscopic collision, infectious vascular rupture, detachment of vascular ligature, and suction tube hit. We summarized the variation in the usual controllable and unexpected uncontrollable bleeding and learned how to respond and treat them. We built up the balanced combination of Safety-I and Safety-II in the daily routine work in normal surgery, the patient’s individual factors, the massive bleeding, and its life-threatening crisis. Conclusions: We can learn how to prevent and respond to bleeding accidents by developing a system to support surgical safety (Safety-I and Safety-II). We can flexibly respond to unexpected bleeding disturbances under constraints by adjusting the surgeon’s individuals, team, and organization.

Efficiency and safety of laparoscopic left hemihepatectomy: A study of intrathecal vs extrathecal Glissonean pedicle techniques

BACKGROUND Selective hemihepatic vascular occlusion is utilized in both right and left hemihepatectomies to preserve blood supply to the intact lobe,maintain hemo-dynamic stability,and mitigate surgical risks.While this technique encompasses both intrathecal and extrathecal Glissonean pedicle transection methods,there is a lack of systematic comparative reports on these two approaches.AIM To retrospectively analyze the clinical data of patients with hepatocellular carcinoma(HCC)undergoing laparoscopic anatomical hepatectomy in our hospital to explore the feasibility,safety,and short-and long-term efficacy of extrathecal and intrathecal Glissonean pedicle transection methods in laparo-scopic left hemihepatectomy.METHODS A retrospective study was performed to analyze the clinical data of 49 HCC patients who underwent laparoscopic left hemihepatectomy from January 2019 to December 2022 in our hospital.These patients were divided into extrathecal Glissonean pedicle transection(EGP)group(n=24)and intrathecal Glissonean pedicle transection(IGP)group(n=25)according to the different approaches used for selective hemihepatic vascular occlusion.The perioperative indicators,liver function indexes,complications,and follow-up findings were compared between these two groups.RESULTS The surgeries were smooth in both groups,and no perioperative death was noted.The hepatic pedicle transection time and the operation time were(16.1±2.3)minutes and(129.6±19.0)minutes,respectively,in the EGP group,which were significantly shorter than those in the IGP group[(25.5±2.4)minutes and(184.8±26.0)minutes,respectively],both P<0.01.There were no significant differences in intraoperative blood loss,time to anal exhaust,hospital stay,drain indwelling time,and postoperative liver function between the two groups(all P>0.05).The incidence of postoperative complications showed no significant difference[16.67%(4/24)vs 16.0%(4/25),P>0.05].All the 49 HCC patients were followed up after surgery(range:11.2-53.3 months;median:36.4 months).The overall survival rate and disease-free survival rate were not significantly different(both P>0.05).CONCLUSION Both extrathecal and intrathecal Glissonean pedicle approaches are effective and safe hepatic inflow occlusion techniques in laparoscopic left hemihepatectomy for HCC.However,the extrathecal approach simplifies the hepatic pedicle transection,shortens the operation time,and increases the surgical efficiency,making it a more feasible technique.

Thinking in three's: Changing surgical patient safety practices in the complex modern operating room

The three surgical patient safety events, wrong site surgery, retained surgical items (RSI) and surgical fires are rare occurrences and thus their effects on the complex modern operating room (OR) are difficult to study. The likelihood of occurrence and the magnitude of risk for each of these surgical safety events are undefined. Many providers may never have a personal experience with one of these events and training and education on these topics are sparse. These circumstances lead to faulty thinking that a provider won't ever have an event or if one does occur the provider will intuitively know what to do. Surgeons are not preoccupied with failure and tend to usually consider good outcomes, which leads them to ignore or diminish the importance of implementing and following simple safety practices. These circumstances contribute to the persistent low level occurrence of these three events and to the difficulty in generating sufficient interest to resource solutions. Individual facilities rarely have the time or talent to understand these events and develop lasting solutions. More often than not, even the most well meaning internal review results in a new line to a policy and some rigorous enforcement mandate. This approach routinely fails and is another reason why these problems are so persistent. Vigilance actions alone havebeen unsuccessful so hospitals now have to take a systematic approach to implementing safer processes and providing the resources for surgeons and other stake-holders to optimize the OR environment. This article discusses standardized processes of care for mitigation of injury or outright prevention of wrong site surgery, RSI and surgical fires in an action-oriented framework illustrating the strategic elements important in each event and focusing on the responsibilities for each of the three major OR agents-anesthesiologists, surgeons and nurses. A Surgical Patient Safety Checklist is discussed that incorporates the necessary elements to bring these team members together and influence the emergence of a safer OR.

Oncological features and prognosis of colorectal cancer in human immunodeficiency virus-positive patients: A retrospective study

BACKGROUND Due to the prolonged life expectancy and increased risk of colorectal cancer(CRC)among patients with human immunodeficiency virus(HIV)infection,the prognosis and pathological features of CRC in HIV-positive patients require examination.AIM To compare the differences in oncological features,surgical safety,and prognosis between patients with and without HIV infection who have CRC at the same tumor stage and site.METHODS In this retrospective study,we collected data from HIV-positive and-negative patients who underwent radical resection for CRC.Using random stratified sampling,24 HIV-positive and 363 HIV-negative patients with colorectal adenocarcinoma after radical resection were selected.Using propensity score matching,we selected 72 patients,matched 1:2(HIV-positive:negative=24:48).Differences in basic characteristics,HIV acquisition,perioperative serological indicators,surgical safety,oncological features,and long-term prognosis were compared between the two groups.RESULTS Fewer patients with HIV infection underwent chemotherapy compared to patients without.HIV-positive patients had fewer preoperative and postoperative leukocytes,fewer preoperative lymphocytes,lower carcinoembryonic antigen levels,more intraoperative blood loss,more metastatic lymph nodes,higher node stage,higher tumor node metastasis stage,shorter overall survival,and shorter progression-free survival compared to patients who were HIV-negative.CONCLUSION Compared with CRC patients who are HIV-negative,patients with HIV infection have more metastatic lymph nodes and worse long-term survival after surgery.Standard treatment options for HIV-positive patients with CRC should be explored.

Establishment and implementation of safety check project for invasive procedures outside the operating room

Objective:This study aimed to describe the implementation of the surgical safety check policy and the surgical safety checklist for invasive procedures outside the operating room(OR)and evaluate its effectiveness.Methods:In 2017,to improve the safety of patients who underwent invasive procedures outside of the OR,the hospital quality and safety committee established the surgery safety check committee responsible for developing a new working plan,revise the surgery safety check policy,surgery safety check Keywords:Invasive procedures outside the operating room Safety management Surgical safety checklist Patient safety form,and provide training to the related staff,evaluated their competency,and implemented the updated surgical safety check policy and checklist.The study compared the data of pre-implementation(Apr to Sep 2017)and two post-implementation phases(Apr to Sep 2018,Apr to Sep 2019).It also evaluated the number of completed surgery safety checklist,correct signature,and correct timing of signature.Results:The results showed an increase in the completion rate of the safety checklist after the program implementation from 41.7%(521/1,249)to 90.4%(3,572/3,950),the correct rates of signature from 41.9%(218/521)to 99.0%(4,423/4,465),and the correct timing rates of signature from 34.4%(179/521)to 98.5%(4,401/4,465),with statistical significance(P<0.01).Conclusion:Implementing the updated surgery safety check significantly is a necessary and effective measure to ensure patient safety for those who underwent invasive procedures outside the OR.Implementing surgical safety checks roused up the clinical staff's compliance in performing safety checks,and enhanced team collaboration and communication.