Ethics of surgical complications

Ethical Considerations in Pediatric Surgery

Pediatric surgeons need to learn to give as much importance to the ethical approach as they have been giving to the systemic methodology in their clinical approach all along. The law of the land and the governmental rules also need to be kept in mind before deciding the final solution. They need to always put medical problems in the background of ethical context, reach a few solutions keeping in mind the available resources, and apply the best solution in the interest of their pediatric patients.

Persistent Pain Following Proplast-Teflon Implants of the Temporomandibular Joint: A Case Report and 35-Year Management Perspective

Over three decades ago, hundreds of predominantly young women with temporomandibular joint pain and other symptoms were implanted with a prosthetic device composed of Proplast-Teflon that subsequently caused considerable harm, with patients developing chronic pain, dysfunction, and disability. This perspective review presents such a patient who suffered for decades with severe pain despite extensive pharmacotherapy, injection therapy, multiple surgeries, and behavioral health interventions. The details of the origin and subsequent events regarding the use of Proplast-Teflon interpositional implants in the temporomandibular joint are described with resources from several different perspectives. The lessons learned demonstrate failures at the federal, professional, and individual level.

Ethics Consultation in Surgical Specialties

Multiple studies have been performed to identify the most common ethical dilemmas encountered by ethics consultation services. However, limited data exists comparing the content of ethics consultations requested by specific hospital specialties. It remains unclear whether the scope of ethical dilemmas prompting an ethics consultation differ between specialties and if there are types of ethics consultations that are more or less frequently called based on the specialty initiating the ethics consult. This study retrospectively assessed the incidence and content of ethics consultations called by surgical vs. non-surgical specialties between January 1, 2013 to December 31, 2018 using our RedCap Database and information collected through the EMR via our Clinical and Translational Science Center. 548 total ethics consultations were analyzed (surgical n = 135, non-surgical n = 413). Our results demonstrate that more surgical consults originated from the ICU, as opposed to lower acuity units (45.9% vs. 14.3%, p ≤ 0.001), and surgical patients were more likely to have a DNR in place (37.5% vs. 22.2%, p = 0.002). Surgical specialties were more likely to call about issues relating to withholding/withdrawing life-sustaining treatment (p ≤ 0.001), while non-surgical specialties were more likely to call about issues related to discharge planning (p = 0.001). There appear to be morally relevant differences between consults classified as the “same” that are not entirely captured by the usual ethics consultations classification system. In conclusion, this study highlights the unique ethical issues experienced by surgical vs. non-surgical specialties. Ultimately, our data can help ethics consultation services determine how best to educate various hospital specialties to approach ethical issues commonly experienced within their field.

Comprehensive Complication Index or Clavien-Dindo Classification: Which is Better for Evaluating the Severity of Postoperative Complications Following Pancreatectomy?

BACKGROUND

Complications are important indicators of immediate postoperative outcomes. The Clavien-Dindo classification (CDC) is a widely used index for the classification of surgical complications. More recently, the comprehensive complication index (CCI) has also been introduced for classifying postoperative complications. The aim of this study was to compare the relationship of CCI and CDC with clinical or economic parameters.

METHODS

The study prospectively enrolled patients from April 2015 to October 2016. Two hundred and twenty-two patients underwent pancreatectomy during the enrolled period. Complications were ranked according to CDC and CCI indices. After analyzing the correlation between CCI and CDC, the correlations of length of stay (LOS) and cost with CCI and CDC were compared. Finally, differences between the correlation coefficients of CDC and CCI parameters were calculated.

RESULTS

Complications occurred in 211 patients (95.0%). The correlation between CDC and CCI was r = 0.938. (p < 0.001) Compared to the CDC, CCI showed significantly stronger correlations with LOS and cost of complications (LOS: CCI vs. CDC, r = 0.725 vs. r = 0.630, p < 0.001; cost: CCI vs. CDC, r = 0.774 vs. r = 0.723, p < 0.001).

CONCLUSION

CCI is a more accurate classification index, compared to CDC, for evaluating the risk of postoperative complications.

Eyelid reconstruction using the "Hughes" tarsoconjunctival advancement flap: Long-term outcomes in 122 consecutive cases over a 13-year period

This article evaluates the complications and long term functional and cosmetic outcomes of tarsoconjunctival advancement flaps for repairing a range of lower eyelid defects in a large cohort of consecutive cases. A retrospective series of 122 consecutive cases of eyelid reconstruction using tarsoconjunctival-advancement flaps was conducted at Waikato Hospital, or Hamilton Eye Clinic, New Zealand. All cases of lid reconstruction using tarsoconjunctival-advancement flaps between January 1, 2001 until April 3, 2014 were included for analysis. All patients provided written consent for surgery and the study complied with New Zealand Health and Disability Ethics Committee guidelines and the Declaration of Helsinki. Data were collected on patient demographics, lesion histology, defect size, adjuvant surgical procedures required for reconstruction, surgical and postoperative complications, cosmesis and patient satisfaction. Patients requiring lower eyelid reconstruction were predominantly male (56%) and basal cell carcinoma was the most common pathology (>80%). Male gender was associated with larger tarsoconjunctival-advancement-flap width (P-value = 0.0432), larger maximum flap width (20 vs 15 mm), and required on average more adjuvant procedures for reconstruction (1.80 vs 1.48, P-value = 0.02). Mean duration to flap division was 37 days and decreased over the duration of the study. Complicated cases were associated with shorter duration to flap division. Mean follow-up was 7 months, complications were observed in 14% with revision required in 4%. Tarsoconjunctival flap reconstruction of the lower lid is suitable for a range of defect sizes and produces excellent functional and cosmetic outcomes. Complications are relatively infrequent and may be associated in some cases with decreased duration to flap division.

Prevention of chronic post-surgical pain: the importance of early identification of risk factors

Chronic post-surgical pain (CPSP) is currently an inevitable surgical complication. Despite the advances in surgical techniques and the development of new modalities for pain management, CPSP can affect 15-60% of all surgical patients. The development of chronic pain represents a burden to both the patient and to the community. In order to have a meaningful impact on this debilitating condition it is essential to identify those at risk. Early identification of patients at risk will help to reduce the percentage of patients who go on to develop CPSP. Unfortunately, evidence about any effective actions to reduce this condition is limited. This review will focus on providing context to the challenging problem of CPSP. The possible role of both the surgeon and anesthesiologist in reducing the incidence of this problem will be explored.

The Ethics of Breast Surgery

Breast surgery has evolved as a subspecialty of general surgery and requires a working knowledge of benign and malignant diseases, surgical techniques, shared decision-making with patients, collaboration with a multi-disciplinary team, and a basic foundation in surgical ethics. Ethics is defined as the practice of analyzing, evaluating, and promoting best conduct based upon available standards. As new information is obtained or as cultural values change, best conduct may be re-defined. In 2014, the Ethics Committee of the ASBrS acknowledged numerous ethical issues, specific to the practice of breast surgery. This independent review of ethical concerns was created by the Ethics Committee to provide a resource for ASBrS members as well as other surgeons who perform breast surgery. In this review, the professional, clinical, research and technology considerations that breast surgeons face are reviewed with guidelines for ethical physician behavior.

Prospective review of a single center's general pediatric neurosurgical intraoperative and postoperative complication rates

OBJECT

The authors conducted a study to compare the complication rate (CR) of pediatric neurosurgical procedures in a general neurosurgery department to the CRs that are reported in the literature and to establish a baseline of CR for further targeted improvement of quality neurosurgical care.

METHODS

The authors analyzed the prospectively collected data from a complication registration of 1000 consecutive pediatric neurosurgical procedures in 581 patients from the beginning of the registration in January 2004 through August 2008. A pediatric neurosurgeon was involved in 50.5% of the procedures. All adverse events (AEs) from induction of anesthesia until 30 days postoperatively were recorded.

RESULTS

Overall, 229 complications were counted in 202 procedures. The overall CR was 20.2%, with a 2.7% intraoperative CR and a 17.5% postoperative CR. Tumor surgery was associated with the highest CR (32.7%), followed by CSF disorders (21.8%). The mortality rate was 0.3%. An unplanned return to the operating room in relation to an AE happened in 10.5% of all procedures and in 52% of procedures associated with AEs, the majority of which were related to CSF disorders.

CONCLUSIONS

The CR in pediatric neurosurgical procedures was significant, and more than half of the patients with an AE required a repeat surgical procedure. Analysis of CRs should be a prerequisite for the prevention of complications and for the development of targeted interventions to reduce the CR (for example, infection rates).

Ethical debate: the ethics of not performing extended lymphadenectomy in patients with gastrointestinal cancer

The ethical debate about performing-or not-extended lymphadenectomy in patients with a gastrointestinal malignancy is approached in this work. It offers a thorough overview of the ethical principles. Problem-solving tools are provided to assist in framing the issues and resolving the conflicts.