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The use of common surgical procedures varies widely across geographical regions. Differences in illness burden, diagnostic practices, and patient attitudes about medical intervention explain regional variation in surgery rates to only a small degree. Instead, current evidence suggests that surgical variation primarily reflects differences in physician beliefs about the indications for surgery and the extent to which patient preferences are incorporated into treatment decisions. These two components of clinical decision making help explain the “surgical signatures” of specific procedures, as well as why some consistently vary more than others. Variation in clinical decision making is in turn influenced by broader environmental factors, including technology diffusion, specialist supply and local training paradigms, financial incentives, and regulatory factors, which vary across countries. Better scientific evidence about the comparative effectiveness of surgical and non-surgical interventions may help mitigate regional variation, but broader dissemination of shared decision making tools will be essential in reducing variation with preference-sensitive conditions.

Unintended harm to patients in operating theatres is common. Correlations have been demonstrated between teamwork skills and error rates in theatres. This was a single-institution uncontrolled before-after study of the effects of ''non-technical'' skills training on attitudes, teamwork, technical performance and clinical outcome in laparoscopic cholecystectomy (LC) and carotid endarterectomy (CEA) operations. The setting was the theatre suite of a UK teaching hospital. Attitudes were measured using the Safety Attitudes Questionnaire (SAQ). Teamwork was scored using the Oxford Non-Technical Skills (NOTECHS) method. Operative technical errors (OTEs), non-operative procedural errors (NOPEs), complications, operating time and length of hospital stay (LOS) were recorded. A 9 h classroom non-technical skills course based on aviation ''Crew Resource Management'' (CRM) was offered to all staff, followed by 3 months of twice-weekly coaching from CRM experts. Forty-eight procedures (26 LC and 22 CEA) were studied before intervention, and 55 (32 and 23) afterwards. Nontechnical skills and attitudes improved after training (NOTECHS increase 37.0 to 38.7, t = 22.35, p = 0.021, SAQ teamwork climate increase 64.1 to 69.2, t = 22.95, p = 0.007). OTEs declined from 1.73 to 0.98 (u = 1071, p = 0.009), and NOPEs from 8.48 to 5.16 per operation (t = 4.383, p,0.001). These effects were stronger in the LC group than in CEA procedures. The operating time was unchanged, and a non-significant reduction in LOS was observed. Non-technical skills training improved technical performance in theatre, but the effects varied between teams. Considerable cultural resistance to adoption was encountered, particularly among medical staff. Debriefing and challenging authority seemed more difficult to introduce than other parts of the training. Further studies are needed to define the optimal training package, explain variable responses and confirm clinical benefit.We studied personnel performing laparoscopic cholecystectomy (LC) and carotid endarterectomy (CEA) procedures in the theatre suites of a major UK teaching hospital. These procedures were selected to minimise difficulties in evaluating performance caused by variations in the operative procedure. All CEA operations were performed in one theatre while the LC procedures were mostly done in three others, one of which was designated a day-case theatre. All CEA operations were elective or semielective procedures performed or directly supervised by consultant vascular surgeons. About 20% of LC were performed by experienced trainees without supervision, and a similar percentage were ''hot'' procedures. There were no major differences in availability and quality of equipment between the LC theatres except that intraoperative cholangiography was difficult to perform in the day-case theatre. The consultant surgical and anaesthetic staff and senior theatre nurses were largely constant throughout the study, but junior staff turnover was relatively high, typical of UK practice. The day-case theat...

The results of 1281 potentially curative resections for advanced gastric cancer performed at the National Cancer Center Hospital between 1972 and 1986 were studied using a novel approach which circumvents the stage migration phenomenon. The incidence of metastasis and the 5-year survival rate of patients with positive nodes were calculated independently for each lymph node 'station', without any reference to overall pathological nodal stage. The therapeutic value of extended lymph node dissection was estimated by multiplication of incidence of metastasis and percentage 5-year survival rate of patients with metastasis for each station. The incidence of metastasis ranged from 2.4 per cent to 66 per cent and the 5-year survival rate of affected patients from 0 to 58.7 per cent in perigastric stations, depending on the site of the primary tumour. The incidence of metastasis was between 3.0 per cent and 44.4 per cent in the second tier of nodes (n2), and the 5-year survival rate ranged from 0 per cent to 47.5 per cent. The majority of second-tier stations showed evidence of benefit from node dissection.