Predictive Factors for Delayed Gastric Emptying After Pancreatoduodenectomy: A Swedish National Registry-Based Study.

BACKGROUND: Delayed gastric emptying (DGE) is a common complication after pancreatoduodenectomy (PD). DGE causes prolonged hospital stay and a decrease in quality of life. This study analyzes predictive factors for development of DGE after PD, also in the absence of surgical complications. METHOD: Data from the Swedish National Pancreatic Cancer Registry for patients undergoing standard and pylorus preserving open PD from January 2010 until June 30, 2018, were collected. Data were analyzed in two groups, no DGE and DGE. A subgroup of patients with DGE but without surgical complications was compared to patients without DGE or any other surgical complication. RESULTS: In total, 2503 patients were included, of which 470 (19%) had DGE. In the DGE group, 238 had other coexisting surgical complications and 232 had not. Postoperative pancreatic fistula (OR = 4.22, p < 0.001), surgical infection (OR = 1.44, p = 0.013), heart disease (OR = 1.32, p = 0.023) and medical complications (OR = 1.35, p = 0.025) increased the risk for DGE. A standard PD compared with pylorus preserving resection (OR = 1.69, p = 0.001) and a reconstruction with a pancreaticojejunostomy compared with a pancreaticogastrostomy (OR = 1.83, p < 0.001) increased the risk. For patients without surgical complications, a standard PD and reconstruction with pancreaticojejunostomy still increased the risk for DGE. CONCLUSION: DGE is more common after standard PD compared to pylorus preserving PD and after reconstruction with PJ compared to PG in this national cohort, both in the presence of other surgical complications as well as in the absence of other complications.

The agreement among urological experts on the diagnostic management of patients with common urological problems.

OBJECTIVE: To assess the level of agreement among randomly selected international urologists on the diagnostic management of patients with prostate cancer, bladder cancer, urinary stones or lower urinary tract symptoms (LUTS) arising from benign prostatic hyperplasia (BPH). METHODS: A computer program was used to provide an unbiased format of 53 simulated patients, comprising 13 with prostate cancer, 10 with bladder cancer, 10 with stones in the upper urinary tract and 20 with LUTS from BPH. For each case, the history was provided to the user while information from 60 diagnostic tests could be chosen interactively. Thirty-three university-based urologists participated in the study. The probability that a certain test was used by them in a certain patient [P(test)] and the related costs (Swedish 1995 prices) were recorded. The probability that two urologists would agree (relative measure of agreement, RMA) on whether or not to use one particular test in a certain case was RMA(test) = P(test)2 + [1-P(test)]2 and the mean of this RMA(test) for a certain patient [RMA(case)] was used as a measure of the inter-individual agreement among the urologists on the diagnostic management. The significance levels of the generalized kappa statistic, KG, were also calculated. The correlation between the RMA(case) and the diagnostic groups was analysed. RESULTS: The KG was statistically significant for all cases; the RMA(case) was significantly correlated with the diagnostic groups (rs = 0.86). The agreement in the diagnostic management was the strongest for stones, then for bladder cancer and prostate cancer, and the weakest for BPH. The mean cost for the diagnostic evaluation for one case varied from $455 to $1771 (mean 898) and varied in the diagnostic groups, i.e. $1718 for prostate cancer, $947 for bladder cancer, $400 for stones and $594 for BPH. CONCLUSION: The diagnostic management of urological patients varies greatly among urological experts from the industrial world. As a consequence, the related diagnostic costs might vary by about 400% if prices were similar everywhere. The agreement on the diagnostic management of cases is strongly correlated to the diagnosis. LUTS from BPH seems to be managed with the poorest agreement.

The urological management of men with lower urinary tract symptoms, recorded using an interactive computer program.

OBJECTIVE: To analyse the level of agreement among urologists from the industrialized world in the management of men with lower urinary tract symptoms (LUTS). METHODS: Thirty-three urological departments participated in the study. A computer program was used to provide an unbiased format of 18 simulated cases of men with LUTS which individual urologists then evaluated diagnostically and made therapeutic decisions about their management. The management of the patients was assessed for the probability that a diagnostic test was used, that a therapy was offered to a particular patient, the first-choice therapies selected, the mean cost and range for the diagnostic process per patient and the number of first-choice therapies offered by one urologist for all the patients. Various discriminators for these therapeutic decisions were evaluated, analysing the correlations between the information provided by the diagnostic tests and the probability of a particular therapy. RESULTS: For the 18 patients, the urologists, as a first choice, treated a mean (SD, range) of 8.3 (3.4, 3-16) patients with TURP, 3.9 (3.6, 0-11) with alpha-blockers, 2.3 (1.7, 0-6) with watchful waiting and 1.7 (2.4, 0-9) with finasteride. The other therapy options were only offered as a first choice by a few of the urologists in a few of the cases. The mean (SD, range) cost per patient of the diagnostic process was US$ 594 (209, 326-1350). CONCLUSION: There was considerable disagreement among the urologists about the management of men with LUTS, which included both the choice of diagnostic tests and the criteria for offering therapy to patients. If such disagreement prevails generally, it may be detrimental for the outcome of patients seeking medical attention for LUTS, and the cost of the medical care of these patients will be unnecessarily high.

The use of a simple home flow test as a quality indicator for male patients treated for lower urinary tract symptoms suggestive of bladder outlet obstruction.

OBJECTIVE: To evaluate the performance of a simple home flow test (HFT) in the examination and follow-up of patients suffering from lower urinary tract symptoms suggestive of bladder outlet obstruction. METHODS: One hundred seventy-two patients who were treated with either transurethral resection of the prostate or transurethral microwave therapy were included. Symptom evaluation, HFT and uroflowmetry were done before and 3 months following treatment. The patients' opinions about the need for further therapy and the effect of therapy were categorised at the follow-up. RESULTS: The HFT correlated strongly with the maximum flow rate (Qmax) both before and after therapy and it was better correlated to the symptoms of the patients and to the subjective effect of therapy compared to the Qmax. CONCLUSION: HFT is a cost-saving diagnostic technique for the classification of urinary flow and should be useful as a quality indicator in large-scale health care management programs.

Pre treatment decision making in prostatism--a stochastic analysis based on the most used diagnostic tests.

In order to estimate the probabilities that a patient would belong to subgroups created by the diagnostic tests most used by European urologists four hundred and twenty-one consecutively referred prostatism patients were studied. It was demonstrated that all the qualities described by these tests were distributed in such a way that the presumed accuracy of the tests might result in a 20 per cent variance in the number of treated patients. A simple self administered home flow test, which was significantly correlated to the maximum flow rate, was shown to be stronger correlated to the symptoms of the patients compared to any other quality. A stochastic table for prostatism was constructed, which may be used for estimations of the influence different decision making may have on the outcome of treatments in this kind of patients.

Prostatism symptoms in a randomly selected population: introduction of a patient administered population based symptom evaluation score.

A questionnaire concerning micturition symptoms and bother was answered by 2559 (66%) randomly selected males. Voiding problems increased with age from about 4 to 40%. The symptoms were weakly but significantly correlated to each other (rs < 0.55). The ability of a particular symptom question to predict whether a subject actually would seek a doctor was generally low. A score system with a maximum score of 33 points was constructed. If prostatism was defined as a certain score or higher, a change in the definition in the score interval 4-10 would change the number of subjects with this syndrome with approximately 10%/score point. As a consequence of the results, the use of a symptom score as a criterion for the decision to treat patients suffering from prostatism is challenged. A patient administered symptom evaluation from is strongly recommended to obtain a more objective symptom registration.