Evolution of transanal total mesorectal excision according to the IDEAL framework.

Tremendous innovations have taken place in surgical procedures, but contrary to drug development, this process has been unregulated in the past. IDEAL promotes a structured framework for the safe implementation and assessment of a new surgical technique or intervention, by describing five stages for evaluating and reporting of innovations: Idea, Development, Exploration, Assessment and Long term. Transanal total mesorectal excision (TaTME) is a relatively new technique in rectal cancer surgery that has attracted huge interest and increasing adoption worldwide. This review article aims to provide an overview of the evolution of TaTME, according to the IDEAL framework, which guides us in the difficult yet exciting process of surgical innovation.

Targeting vulnerable households in urban Burkina Faso: effectiveness of geographical criteria but not of proxy-means testing.

The 2007/2008 food prices hike has increased the interest in social safety nets programmes to fight food insecurity. Targeting the most in need is central to achieve effectiveness of such interventions. In 2009 in Ouagadougou, Burkina Faso, a food voucher (FV) programme targeted the 25 000 most vulnerable households (8.3% of the population). Targeting used a two-stage process: first geographical selection of poorest districts (∼90 000 households); then, in those districts, identification of the most vulnerable households according to a proxy-means test (PMT). Targeted households were entitled to receive FV for 1 year. A first survey was conducted at the beginning of the FV distribution on a representative sample of 2273 households drawn from the poorest districts. One year later a second survey, conducted on a subsample of same households (n = 901), identified those who actually received FV (beneficiary). The performance of the whole process was assessed against household food expenditure, used as the reference measure for vulnerability with a cut-off point of 1513 FCFA (corresponding to the 8.3th percentile of the distribution of expenditure). The 'normalized share of transfers going to vulnerable households' (NSTVH), i.e. proportion of FVs allocated to households below the cut-point, was the main criteria of judgement. Almost twice as many FV were allocated to vulnerable households as compared with a theoretical random distribution all over Ouagadougou (NSTVH = 1.85). When considering the sole targeted districts the NSTVH was only 0.84 (i.e. no more effective than a random distribution), meaning that the geographical stage was effective to select vulnerable districts while the PMT did not perform well to identify the most vulnerable households in those districts. Results could have been improved if only targeted households had received FV (NSTVH = 2.61 and 1.18 for the whole Ouagadougou and targeted districts, respectively). Improved targeting procedures or alternate targeting instruments are needed.

Is a preoperative assessment of the early recurrence of pancreatic cancer possible after complete surgical resection?

BACKGROUND/AIMS: The prognosis of pancreatic adenocarcinoma (PAC) is poor. The serum carbohydrate antigen 19-9 (CA 19-9) level has been identified as a prognostic indicator of recurrence and reduced overall survival. The aim of this study was to identify preoperative prognostic factors and to create a prognostic model able to assess the early recurrence risk for patients with resectable PAC. METHODS: A series of 177 patients with PAC treated surgically at the St. Andrea Hospital of Rome between January 2003 and December 2011 were reviewed retrospectively. Univariate and multivariate analyses were utilized to identify preoperative prognostic indicators. RESULTS: A preoperative CA 19-9 level >228 U/mL, tumor size >3.1 cm, and the presence of pathological preoperative lymph nodes statistically correlated with early recurrence. Together, these three factors predicted the possibility of an early recurrence with 90.4% accuracy. The combination of these three preoperative conditions was identified as an independent parameter for early recurrence based on multivariate analysis (p=0.0314; hazard ratio, 3.9811; 95% confidence interval, 1.1745 to 15.3245). CONCLUSIONS: PAC patient candidates for surgical resection should undergo an assessment of early recurrence risk to avoid unnecessary and ineffective resection and to identify patients for whom palliative or alternative treatment may be the treatment of choice.