Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for peritoneal malignancy: preliminary results of a multi-disciplinary teamwork model in Asia

BACKGROUND

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is an emerging surgical procedure for peritoneal carcinomatosis (PC). CRS/HIPEC is a complicated treatment that requires multi-disciplinary teamwork (MDT), which may be lacking when establishing a CRS/HIPEC programme. Herein, we report our preliminary treatment outcomes with the early implementation of an MDT model for CRS/HIPEC.

METHODS

From April 2015 to December 2016, 45 patients with a diagnosis of PC who received CRS/HIPEC were reviewed retrospectively in a single institution in Taiwan.

RESULTS

Among the 45 patients, CRS was mainly performed by laparotomy (n = 42), and only three patients with limited PC underwent laparoscopic CRS. The first 13 patients received treatment before the MDT had been established (group 1), and the other 32 patients were treated after the MDT had been established (group 2). The highest peri-HIPEC body temperature in group 2 was significantly lower than that in group 1 (36.8 °C vs. 37.5 °C, p < 0.001). Overall, eight patients experienced major complications. The trend of a lower major complication rate was observed after the MDT model had been implemented (30.7% in group 1 vs. 12.4% in group 2, p = 0.202). Pre-CRS/HIPEC abdominal pain significantly increased the risk of post-operative major complications (p = 0.017).

CONCLUSIONS

Our experience suggests that the early implementation of an MDT model when establishing a CRS/HIPEC programme at a single institution may result in a higher complete cytoreduction rate and lower major complication rate, and also shorten the learning curve of this complicated procedure.

Medical Education and Curriculum Reform: Putting Reform Proposals in Context

The purpose of this paper is to elaborate criteria by which the principles of curriculum reform can be judged. To this end, the paper presents an overview of standard critiques of medical education and examines the ways medical curriculum reforms have responded to these critiques. The paper then sets out our assessment of these curriculum reforms along three parameters: pedagogy, educational context, and knowledge status. Following on from this evaluation of recent curriculum reforms, the paper puts forward four criteria with which to gauge the adequacy medical curriculum reform. These criteria enable us to question the extent to which new curricula incorporate methods and approaches for ensuring that its substance: overcomes the traditional opposition between clinical and resource dimensions of care; emphasizes that the clinical work needs to be systematized in so far as that it feasible; promotes multi-disciplinary team work, and balances clinical autonomy with accountability to non-clinical stakeholders.

Working towards clinical effectiveness-a multi-disciplinary approach to robotic surgery

The importance of a multi-disciplinary team (MDT) approach to conventional surgical techniques has strong empirical support. The MDT approach to robotic-assisted surgery (RAS) has not been clearly defined, which encourages prospectively poor MDT performance. Poor performance of the MDT approach, allied to the constant evolution of technology-assisted surgery, can generate unacceptable operative and patient outcomes. This review offers a nursing perspective to the complex paradigm of thoracic RAS, demonstrating key indicators to perioperative MDT engagement. This will be achieved by offering a rationale for RAS in pulmonary resection, identifying additional surgeries where utility is demonstrated. Evaluation of the available evidence will synthesize clinical quality indicators, while key strategies in effective MDT development can be summarised. Conclusively, bespoke and experiential knowledge will be shared, based upon the investigatory findings discussed throughout this article. Allied to a recommended developmental framework, this perspective should allow for transfer of knowledge, creation and replication of useful interventions. Lung cancer is an ever-increasing global concern, currently being the co-modal cancer with an estimated 2.09 million cases worldwide. Populations are ageing and with annual global costs of at least $1.16 trillion, effective treatments are required. RAS shows promise in treating large and complex lesions when compared to a video-assisted thoracoscopic surgery (VATS) approach. A critical indicator being enhanced vision and dexterity in comparison to a VATS approach. Economically, RAS has proven to be an expensive technique, however, when initial purchase costs are excluded, intra-operatively, there are ways to narrow the expense gap and make RAS cheaper. When assessing per hospital stay, exclusive of initial purchase cost, RAS is found to be cheaper than open thoracotomy. This article demonstrates that RAS for pulmonary resection has utility for complex lesions where a VATS approach would be unsuitable. Crucially, as with all complex surgery, the MDT must be performed effectively for optimum patient outcomes.