World J Surg DOI 10.1007/s00268-014-2493-3
Video-Assisted Surgery Implementation in the Public Health System of a Developing Country Jose´ Gustavo Olijnyk • Leandro Totti Cavazzola • Jose´ Eduardo de Aguilar-Nascimento • Miguel Prestes Na´cul • Elias Couto e Almeida Filho
Ó Socie´te´ Internationale de Chirurgie 2014
Abstract Background Over the last two decades, video-assisted surgery has become the preferential access route for many procedures. Despite cholecystectomy being the laparoscopic procedure most frequently performed in Brazilian public hospitals from 2008 to 2012, the lack of populationbased studies led us to conduct a survey on the prevalence of video-assisted surgery in the treatment of patients using ´ nico de Sau´de (SUS) (Unified Health Systhe Sistema U tem), which is the universal, free, and public healthcare system of Brazil. Methods By analyzing the DATASUS (national public health registry database), the prevalence of laparoscopic cholecystectomy and open cholecystectomy (OC) was calculated in the period from January to December in 2008, 2010 and 2012, taking into consideration their geographic distribution throughout Brazil. Results At the end of the study period, an increase in the number of laparoscopic cholecystectomies was observed, with a variation of 125.7 %. However, OC was more prevalent despite an increase in the use of video-assisted
J. G. Olijnyk (&) L. T. Cavazzola M. P. Na´cul Surgery Department, Postgraduation in Surgical Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil e-mail: [email protected] J. E. de Aguilar-Nascimento Surgery Department, Universidade Federal do Mato Grosso, Cuiaba´, MT, Brazil E. C. e Almeida Filho Experimental Surgery Department, Centro de Ensino e Treinamento Experimental em Cieˆncias da Sau´de (Cetrex), Brası´lia, DF, Brazil
surgery over the 5-year study period, increasing from 12 to 25 % in 2012. Conclusions In spite of a trend toward increased use of video-assisted surgery for treating SUS patients during the period under study, the data from 2012 are still far from being ideal. For this population, OC via laparotomy is still the most prevalent option in all regions. This information must encourage the Brazilian surgical societies to push for an improvement in the supply of the treatment provided by the public health system.
Introduction Since the introduction of video-assisted surgery in Brazil in the 1990s, procedures using this access route have been performed all across the country. Reference hospitals, located mostly in Brazilian state capitals, have been incorporating both regular procedures, such as laparoscopic cholecystectomy (LC), and more complex operations, such as prostatectomies [1] and colectomies [2, 3], into the daily life of surgery centers for 20 years. Despite the establishment of video-assisted surgery techniques as routine in these hospitals, studies are needed about the actual use of video-assisted surgery in the ´ nico de Sau´de (SUS) country, especially in the Sistema U (Unified Health System, public healthcare) [4]. Among the most frequently performed video-assisted procedures in the SUS, LC is undoubtedly the most prevalent [5] (Table 1). This comes as no surprise given that it has been performed since the beginning of laparoscopic surgery and is currently considered the gold standard for the treatment of symptomatic cholelithiasis and cholecystitis, in view of the prevalence of gallstones in the Brazilian population (9.3 % [6] or 10.3 % [7]), and given its pronounced presence in
123
World J Surg Table 1 The most frequently performed video-assisted procedures in the SUS from 2008 to 2012 [5]
Procedure
n
Cholecystectomy
162,008
Biopsy and drainage
14,825
Appendectomy
7,652
Thoracic sympathectomy
5,752
Inguinal hernioplasty
3,982
Thoracoscopy
3,642
Salpingectomy
2,762
Umbilical hernioplasty
2,274
Choledochotomy
2,007
Salpingoplasty
1,476
medical residency and postgraduate training programs [8, 9]. The goal of this study was to survey the use of videoassisted surgery in the public health system using LC as an indicator, since it is the most performed laparoscopic procedure and the most representative of the implementation of video-assisted surgery in the Brazilian public healthcare system. The authors hypothesize that although it is routinely used in public referral hospitals and in the treatment of the population covered by private health plans [10, 11], the prevalence of LC compared with open cholecystectomy (OC) still leaves much to be desired when we consider the ideal treatment of the population that relies on the SUS.
Materials and methods Our goal was to conduct a cross-sectional study of the prevalence of the performance of OC and LC from January to December in 2008, 2010, and 2012 by accessing the DATASUS [5] (national public health system registry database). Facilities that are part of the public health system issue a Hospitalization Authorization (AIH), which links the procedure performed for treatment of a patient with the payment that will be made later by the government. The steps below were taken to use the database, updated on May 6, 2013: The Health Information (TABNET) chapter was accessed to obtain the number of procedures performed since 2008. The Healthcare subchapter and its section ‘‘Hospital Procedures per Admission Location’’ were selected. The geographic coverage was established for Brazil per Region and State (Fig. 1). A yearly analysis was carried out by choosing sequential periods from January to December.
123
Fig. 1 Geographic regions of Brazil
To generate an information table for each period, the Line, Column, and Content were set for Region, Not Active, and paid AIH, respectively. In the field Procedure, Cholecystectomy (code 0407030026) and LC (code 0407030034) were chosen. For Procedure Group, Surgical Procedures (code 04) was selected. The Procedure Subgroup was set for Surgery of Digestive Tract, Annexed Organs and Abdominal Wall (code 0407). The remaining fields did not influence the quantitative data and All Categories was chosen. As notified by the DATASUS system, data from 2012 (until December) and 2013 (until March) could be subject to correction until the time of data collection by the authors of this study. To detail the quantitative data obtained for the population of the Brazilian regions, the last demographic census conducted in 2010 by the Brazilian Geography and Statistics Institute (IBGE) was used [12], which coincided with the median of the studied period.
Results Among the health facilities that have an agreement with the SUS, the survey on the prevalence of open and LC in Brazil from January to December 2008, 2010, and 2012 led to the results presented in Table 2. The open procedure was found to prevail; the rate of LC performed was 25 % in 2012, when the entire country was analyzed. In that same year, some regions were noted to be above the national rate, namely, the South and Southeast, with 28 and 37 %, respectively. The other regions had lower rates than the
World J Surg Table 2 Cholecystectomies performed in Brazil per region [5]
Regions
OC North
OC open cholecystectomy, LC laparoscopic cholecystectomy, Tx laparoscopic cholecystectomy rate
2008
2010 LC
Tx
OC
2012 LC
Tx
OC
LC
Tx
LC % Increase
9,821
346
3
10,806
522
4
12,372
735
6
112.4
Northeast
36,383
2,159
5
39,283
3,843
8
38,166
4,873
11
125.7
Southeast
50,675
9,305
15
49,441
19,598
28
44,294
26,224
37
181.8
South
22,049
6,671
23
22,393
8,636
27
25,396
9,791
28
46.8
Central-West
11,262
706
5
12,277
1,144
8
12,741
1,894
13
168.3
130,190
19,227
12
134,200
33,743
20
132,969
43,517
25
125.7
Total
100 LC OC 90 80 70 60 50 40 30 20 10 0
Fig. 2 Cholecystectomies per 10,000 inhabitants in regions of Brazil in 2010 [5, 12]
national rate. Also, in 2012, of 43,517 identified LCs, 51.3 % were performed in hospitals that are in the 27 capitals of the Brazilian states. With respect to the progress in the use of laparoscopy, all regions had an increase in absolute numbers of laparoscopic procedures, most notably in Southeast region (Table 2). The open procedure also had an increase in the variation of absolute numbers, except for the Southeast, which showed a negative absolute variation from 2008 to 2012. The percent increase of LC was 125.7 % in Brazil during the period studied. In analyzing the regions, the Southeast was observed to have the greatest positive variation. However, although the Central-West still had fewer laparoscopic procedures performed than the national mean in 2012, that region had the second largest increase, followed by the Northeast and North. The only region that did not show this trend in the period was the South, with an increase below 100 % (Table 2). However, when the number of procedures was analyzed per 100,000 inhabitants, according to IBGE data from the last census the South region was found to have the greatest density of laparoscopic procedures for its population (32 LC/100,000
inhabitants) in 2010, followed by the Southeast (25 LC/ 100,000 inhabitants), the Central-West (9 LC/100,000 inhabitants), the Northeast (8 LC/100,000 inhabitants), and the North (4 LC/100,000 inhabitants) (Fig. 2). In general, Brazil had 18 LC/100,000 inhabitants. For comparison purposes, the rate of OC this year in Brazil was 71 per 100,000 inhabitants, with the Central-West region having the greatest density. When the total number of cholecystectomies performed in 2010 was analyzed (using the two access routes), we observed that the incidence of the procedure was greater in the South region (144 cases/100,000 inhabitants), followed by the Central-West (97 cases/100,000 inhabitants), the Southeast (87 cases/100,000 inhabitants), the Northeast (82 cases/100,000 inhabitants), and the North (73 cases/ 100,000 inhabitants). The prevalence of cholecystectomies all across Brazil in that year was 89 cases/100,000 inhabitants.
Discussion The Ministry of Health database, DATASUS, created in 1991, allows us to conduct epidemiological studies of the prevalence of diseases and treatments in Brazil, and of healthcare in both public and private hospitals that have an agreement with the SUS. The variable Regime in the database indicates the type of agreement the Hospital Unit has with the SUS: Public Regime comprise of federal, state, and municipal hospitals and Private Regime are hired, philanthropic, and union hospitals. The Hospital and Ambulatory Information Communication System (CIHA) used by DATASUS is a health information system employed by the Ministry of Health and the National Supplementary Health Agency (ANS) to keep track of and monitor admissions to all hospitals in the country, both public and private, whether they take part in the SUS or not. Therefore, DATASUS encompasses data from public hospitals and from the care network of health insurance companies, allowing epidemiological studies of the Brazilian population to monitor clinical practices [5].
123
World J Surg
However, in the survey that was carried out, one of the key fields in the study was Paid AIH (Paid Hospitalization Authorizations), a system that is used by the SUS, not by health insurance companies. Such information shows that the surveyed sample is representative of the public health system, which in 2012 accounted for 74.9 % Brazilians who had no supplementary health plan [13]. The data resulting from this study showed that the Brazilian public healthcare sector still performs laparoscopic procedures for the treatment of cholelithiasis at a very low rate. It also should be noted that despite the South being the region with the largest number of LCs performed per 100,000 inhabitants in 2010, the percent variation from 2008 to 2012 was smaller. All other regions had a greater than 100 % increase, especially the Central-West and Southeast regions. A possible reason for this phenomenon may be that, despite the implementation of video-assisted surgery in the South (where one of the states that pioneered it in Brazil in 1990 is located [14]), the services that provide cholelithiasis treatment by means of video-assisted surgery are mainly in the SUS reference hospitals. In addition, the rate of open procedures remained consistently high in the period, without any trend toward a decline. We identified possible limitations of our cross-sectional study, which may have underestimated the use of the laparoscopic access route at the SUS. When a hospitalization authorization is issued by a service provider, there may be problems with the notification of a cholecystectomy procedure, which may be entered without the description ‘‘laparoscopic.’’ Furthermore, by doing a search in DATASUS on the average amount paid for admission to a hospital that has an agreement with the SUS in the period under study, we found that the costs for laparoscopic and open procedures were similar (R$ 755.02 and R$ 756.61, respectively). This detail may explain the lack of interest in specifying the type of procedure. A possible answer to ‘‘how can we increase the rate of LC?’’ could be the judicious use of hospital admissions compared with outpatient treatment [15, 16]. A shorter hospital stay for elective LC compared with OC has an effect on hospitalization costs and on the optimization of bed management in public hospitals [17]. Despite initially increasing the rate of video-assisted surgeries by going this route, LCs will reach a plateau at which its growth will be restrained by reaching the limit of currently available services, including previously trained staff, operating rooms, and recovery beds. We believe that public health managers need to adopt a ‘‘primary attention’’ policy for video-assisted surgery, involving the technical training of both the surgeon and the staff, implementing safety protocols, and making basic technology available in hospitals that do not have it yet. Surgeons who want to provide differentiated treatment to
123
their patients, often have to acquire supplies and equipment, in addition to attending courses, at their own expense to allow video-assisted surgeries to be performed. They also have to train the staff that will assist them, from surgical instrument handlers to technicians at material sterilization centers. This practice started with the implementation of LC in Brazil in 1990, initially in the treatment of private patients, which still prevails in Brazil. When confronted with the fact that 51.3 % of LCs were performed in hospitals located in Brazilian state capitals, the deficiencies of public hospitals in rural areas are quantitatively identified. As the services for treatment of the population in public hospitals in the capitals have reached their limit, another way to increase the rate of laparoscopic cholecystectomies in Brazil would be to provide hospitals in the countryside that can perform this procedure. A task force of surgeons could travel to these remote hospitals to perform elective surgeries [18]. Another way would be to train surgeons in more remote locations to utilize laparoscopy effectively and safely. This was done to bring LC to the rural regions of Mongolia, where the limitations on physical resources, restricted opportunity of suitable training, and harsh environment often resemble the reality on the ground in Brazil [19]. It should be noted that, given the high prevalence of OC in Brazil, an increase in the use of video-assisted surgery may result in a second national learning curve, similar to the one observed in the early 1990s that led to conversions to the open procedure [20] and bile duct lesions. However, as noted by Savassi-Rocha et al. [21], until 1997 the incidence of these iatrogenic events tended to be equal to those of the open procedure in Brazilian facilities. Brazilian surgical societies must seek to supply patients with the best treatment resources, both those covered by supplementary health plans and by the public system. As our study sought to identify current shortcomings in the services provided to the Brazilian population, further studies must be conducted to evaluate whether current public health strategies have been effective. Likewise, quantitative data may be useful to compare the use of video-assisted surgery in other countries with economic characteristics that are similar to those of Brazil. Conflicts of interest
None.
References 1. Mariano MB, Tefilli MV, Fonseca GN et al (2009) Laparoscopic radical prostatectomy: 10 years experience. Int Braz J Urol 35:565–571 2. Queiroz FL, Coˆrtes MG, Neto PR et al (2010) Colorectal laparoscopic surgeries performed in the State of Minas Gerais: Brazil from 1996 to 2009. Rev Bras Coloproctol 30:61–67
World J Surg 3. Pinto JO, Fallatah B, Espalieu P et al (2010) Elective laparoscopic left colectomy for diverticular disease: a monocentric study on 205 consecutive patients. Arq Bras Cir Dig 23:234–239 4. Biscione FM, Couto RC, Pedrosa TM et al (2007) Comparison of the risk of surgical site infection after laparoscopic cholecystectomy and open cholecystectomy. Infect Control Hosp Epidemiol 28:1103–1106 5. Ministe´rio da Sau´de do Brasil (2013) DATASUS-Procedimentos hospitalares do SUS por local de internac¸a˜o. http://tabnet.datasus. gov.br/cgi/deftohtm.exe?sih/cnv/qiuf.def Accessed 16 June 2013 6. Coelho JC, Bonilha R, Pitaki SA et al (1999) Prevalence of gallstones in a Brazilian population. Int Surg 84:25–28 7. Mantovani M, Leal RF, Fontelles MJ (2001) Incidence of cholelithiasis: a necropsy study performed in Campinas university hospital, SP. Rev Col Bras Cir 28:259–263 8. Pinotti HW, Domene CE, Volpe P et al (1999) Training of surgeons in laparoscopic surgery of the digestive system. Experience in 1,818 interventions without accidents and mortality. Rev Assoc Med Bras 45:337–341 9. Na´cul MP (2004) Modern aspects about education in endoscopic surgery in Brazil: a critique analysis. Rev Bras Videocir 2:1–4 10. Instituto de Estudos de Sau´de Suplementar-IESS (2010) Study of the impact of the incorporation of technologies and costs of results for the patient—traditional cholecystectomy versus videolaparoscopic cholecystectomy. http://www.iess.org.br/html/ relatoriocolecistectomia.pdf Accessed 6 Dec 2013 11. Ministe´rio da Sau´de do Brasil (2008) Atualizac¸a˜o do rol de procedimentos e eventos em sau´de. In: Dia´rio Oficial da Unia˜o de 10/01/2008, DF, Brası´lia, p. 348 12. Instituto Brasileiro de Geografia e Estatı´stica-IBGE (2013) Censo Demogra´fico 1960, 1970, 1980, 1991, 2000, e 2010. http://www.
13.
14.
15.
16.
17.
18.
19.
20.
21.
censo2010.ibge.gov.br/sinopse/index.php?dados=8 Accessed 28 June 2013 Agencia Nacional de Sau´de Suplementar-ANS (2012) FOCO Sau´de Suplementar. http://www.ans.gov.br/images/stories/Mate riais_para_pesquisa/Perfil_setor/Foco/20130124_foco_dezem bro_web_2012.pdf Accessed 1 Jul 2013 Guilhermano LG, Schwartsmann LB, Serres JC (2010) A evoluc¸a˜o histo´rica da colecistectomia laparosco´pica. In: Pa´ginas da Histo´ria da Medicina. Porto Alegre: Edipucrs, p. 138 Callan JF, Tanaka K, Foley E (2001) Outpatient laparoscopic cholecystectomy: patient outcomes after implementation of a clinical pathway. Ann Surg 233:704–715 Ahmad NZ, Byrnes G, Naqvi AS (2008) A meta-analysis of ambulatory versus inpatient laparoscopic cholecystectomy. Surg Endosc 22:1928–1934 Kaman L, Verma GR, Sanyal S (2005) Relevance of day care laparoscopic cholecystectomy in a developing nation. Trop Gastroenterol 26:95–97 Ryan SM, Milsom P, Yang J et al (2009) Travelling surgeons: a clinical audit of laparoscopic cholecystectomy procedures in Northland, New Zealand. N Z Med J 122:34–40 Straub CM, Prince RR, Matthews D et al (2011) Expanding laparoscopic cholecystectomy to rural Mongolia. World J Surg 35:751–759. doi:10.1007/s00268-011-0965-2 Lima EC, Queiroz FL, Ladeira FN et al (2007) Factors implied with conversion to open cholecystectomy. Rev Col Bras Cir 34:321–325 Savassi-Rocha PR, Almeida SR, Sanches MD et al (2003) Iatrogenic bile duct injuries. Surg Endosc 17:1356–1361
123
Video-Assisted Surgery Implementation in the Public Health System of a Developing Country Jose´ Gustavo Olijnyk • Leandro Totti Cavazzola • Jose´ Eduardo de Aguilar-Nascimento • Miguel Prestes Na´cul • Elias Couto e Almeida Filho
Ó Socie´te´ Internationale de Chirurgie 2014
Abstract Background Over the last two decades, video-assisted surgery has become the preferential access route for many procedures. Despite cholecystectomy being the laparoscopic procedure most frequently performed in Brazilian public hospitals from 2008 to 2012, the lack of populationbased studies led us to conduct a survey on the prevalence of video-assisted surgery in the treatment of patients using ´ nico de Sau´de (SUS) (Unified Health Systhe Sistema U tem), which is the universal, free, and public healthcare system of Brazil. Methods By analyzing the DATASUS (national public health registry database), the prevalence of laparoscopic cholecystectomy and open cholecystectomy (OC) was calculated in the period from January to December in 2008, 2010 and 2012, taking into consideration their geographic distribution throughout Brazil. Results At the end of the study period, an increase in the number of laparoscopic cholecystectomies was observed, with a variation of 125.7 %. However, OC was more prevalent despite an increase in the use of video-assisted
J. G. Olijnyk (&) L. T. Cavazzola M. P. Na´cul Surgery Department, Postgraduation in Surgical Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil e-mail: [email protected] J. E. de Aguilar-Nascimento Surgery Department, Universidade Federal do Mato Grosso, Cuiaba´, MT, Brazil E. C. e Almeida Filho Experimental Surgery Department, Centro de Ensino e Treinamento Experimental em Cieˆncias da Sau´de (Cetrex), Brası´lia, DF, Brazil
surgery over the 5-year study period, increasing from 12 to 25 % in 2012. Conclusions In spite of a trend toward increased use of video-assisted surgery for treating SUS patients during the period under study, the data from 2012 are still far from being ideal. For this population, OC via laparotomy is still the most prevalent option in all regions. This information must encourage the Brazilian surgical societies to push for an improvement in the supply of the treatment provided by the public health system.
Introduction Since the introduction of video-assisted surgery in Brazil in the 1990s, procedures using this access route have been performed all across the country. Reference hospitals, located mostly in Brazilian state capitals, have been incorporating both regular procedures, such as laparoscopic cholecystectomy (LC), and more complex operations, such as prostatectomies [1] and colectomies [2, 3], into the daily life of surgery centers for 20 years. Despite the establishment of video-assisted surgery techniques as routine in these hospitals, studies are needed about the actual use of video-assisted surgery in the ´ nico de Sau´de (SUS) country, especially in the Sistema U (Unified Health System, public healthcare) [4]. Among the most frequently performed video-assisted procedures in the SUS, LC is undoubtedly the most prevalent [5] (Table 1). This comes as no surprise given that it has been performed since the beginning of laparoscopic surgery and is currently considered the gold standard for the treatment of symptomatic cholelithiasis and cholecystitis, in view of the prevalence of gallstones in the Brazilian population (9.3 % [6] or 10.3 % [7]), and given its pronounced presence in
123
World J Surg Table 1 The most frequently performed video-assisted procedures in the SUS from 2008 to 2012 [5]
Procedure
n
Cholecystectomy
162,008
Biopsy and drainage
14,825
Appendectomy
7,652
Thoracic sympathectomy
5,752
Inguinal hernioplasty
3,982
Thoracoscopy
3,642
Salpingectomy
2,762
Umbilical hernioplasty
2,274
Choledochotomy
2,007
Salpingoplasty
1,476
medical residency and postgraduate training programs [8, 9]. The goal of this study was to survey the use of videoassisted surgery in the public health system using LC as an indicator, since it is the most performed laparoscopic procedure and the most representative of the implementation of video-assisted surgery in the Brazilian public healthcare system. The authors hypothesize that although it is routinely used in public referral hospitals and in the treatment of the population covered by private health plans [10, 11], the prevalence of LC compared with open cholecystectomy (OC) still leaves much to be desired when we consider the ideal treatment of the population that relies on the SUS.
Materials and methods Our goal was to conduct a cross-sectional study of the prevalence of the performance of OC and LC from January to December in 2008, 2010, and 2012 by accessing the DATASUS [5] (national public health system registry database). Facilities that are part of the public health system issue a Hospitalization Authorization (AIH), which links the procedure performed for treatment of a patient with the payment that will be made later by the government. The steps below were taken to use the database, updated on May 6, 2013: The Health Information (TABNET) chapter was accessed to obtain the number of procedures performed since 2008. The Healthcare subchapter and its section ‘‘Hospital Procedures per Admission Location’’ were selected. The geographic coverage was established for Brazil per Region and State (Fig. 1). A yearly analysis was carried out by choosing sequential periods from January to December.
123
Fig. 1 Geographic regions of Brazil
To generate an information table for each period, the Line, Column, and Content were set for Region, Not Active, and paid AIH, respectively. In the field Procedure, Cholecystectomy (code 0407030026) and LC (code 0407030034) were chosen. For Procedure Group, Surgical Procedures (code 04) was selected. The Procedure Subgroup was set for Surgery of Digestive Tract, Annexed Organs and Abdominal Wall (code 0407). The remaining fields did not influence the quantitative data and All Categories was chosen. As notified by the DATASUS system, data from 2012 (until December) and 2013 (until March) could be subject to correction until the time of data collection by the authors of this study. To detail the quantitative data obtained for the population of the Brazilian regions, the last demographic census conducted in 2010 by the Brazilian Geography and Statistics Institute (IBGE) was used [12], which coincided with the median of the studied period.
Results Among the health facilities that have an agreement with the SUS, the survey on the prevalence of open and LC in Brazil from January to December 2008, 2010, and 2012 led to the results presented in Table 2. The open procedure was found to prevail; the rate of LC performed was 25 % in 2012, when the entire country was analyzed. In that same year, some regions were noted to be above the national rate, namely, the South and Southeast, with 28 and 37 %, respectively. The other regions had lower rates than the
World J Surg Table 2 Cholecystectomies performed in Brazil per region [5]
Regions
OC North
OC open cholecystectomy, LC laparoscopic cholecystectomy, Tx laparoscopic cholecystectomy rate
2008
2010 LC
Tx
OC
2012 LC
Tx
OC
LC
Tx
LC % Increase
9,821
346
3
10,806
522
4
12,372
735
6
112.4
Northeast
36,383
2,159
5
39,283
3,843
8
38,166
4,873
11
125.7
Southeast
50,675
9,305
15
49,441
19,598
28
44,294
26,224
37
181.8
South
22,049
6,671
23
22,393
8,636
27
25,396
9,791
28
46.8
Central-West
11,262
706
5
12,277
1,144
8
12,741
1,894
13
168.3
130,190
19,227
12
134,200
33,743
20
132,969
43,517
25
125.7
Total
100 LC OC 90 80 70 60 50 40 30 20 10 0
Fig. 2 Cholecystectomies per 10,000 inhabitants in regions of Brazil in 2010 [5, 12]
national rate. Also, in 2012, of 43,517 identified LCs, 51.3 % were performed in hospitals that are in the 27 capitals of the Brazilian states. With respect to the progress in the use of laparoscopy, all regions had an increase in absolute numbers of laparoscopic procedures, most notably in Southeast region (Table 2). The open procedure also had an increase in the variation of absolute numbers, except for the Southeast, which showed a negative absolute variation from 2008 to 2012. The percent increase of LC was 125.7 % in Brazil during the period studied. In analyzing the regions, the Southeast was observed to have the greatest positive variation. However, although the Central-West still had fewer laparoscopic procedures performed than the national mean in 2012, that region had the second largest increase, followed by the Northeast and North. The only region that did not show this trend in the period was the South, with an increase below 100 % (Table 2). However, when the number of procedures was analyzed per 100,000 inhabitants, according to IBGE data from the last census the South region was found to have the greatest density of laparoscopic procedures for its population (32 LC/100,000
inhabitants) in 2010, followed by the Southeast (25 LC/ 100,000 inhabitants), the Central-West (9 LC/100,000 inhabitants), the Northeast (8 LC/100,000 inhabitants), and the North (4 LC/100,000 inhabitants) (Fig. 2). In general, Brazil had 18 LC/100,000 inhabitants. For comparison purposes, the rate of OC this year in Brazil was 71 per 100,000 inhabitants, with the Central-West region having the greatest density. When the total number of cholecystectomies performed in 2010 was analyzed (using the two access routes), we observed that the incidence of the procedure was greater in the South region (144 cases/100,000 inhabitants), followed by the Central-West (97 cases/100,000 inhabitants), the Southeast (87 cases/100,000 inhabitants), the Northeast (82 cases/100,000 inhabitants), and the North (73 cases/ 100,000 inhabitants). The prevalence of cholecystectomies all across Brazil in that year was 89 cases/100,000 inhabitants.
Discussion The Ministry of Health database, DATASUS, created in 1991, allows us to conduct epidemiological studies of the prevalence of diseases and treatments in Brazil, and of healthcare in both public and private hospitals that have an agreement with the SUS. The variable Regime in the database indicates the type of agreement the Hospital Unit has with the SUS: Public Regime comprise of federal, state, and municipal hospitals and Private Regime are hired, philanthropic, and union hospitals. The Hospital and Ambulatory Information Communication System (CIHA) used by DATASUS is a health information system employed by the Ministry of Health and the National Supplementary Health Agency (ANS) to keep track of and monitor admissions to all hospitals in the country, both public and private, whether they take part in the SUS or not. Therefore, DATASUS encompasses data from public hospitals and from the care network of health insurance companies, allowing epidemiological studies of the Brazilian population to monitor clinical practices [5].
123
World J Surg
However, in the survey that was carried out, one of the key fields in the study was Paid AIH (Paid Hospitalization Authorizations), a system that is used by the SUS, not by health insurance companies. Such information shows that the surveyed sample is representative of the public health system, which in 2012 accounted for 74.9 % Brazilians who had no supplementary health plan [13]. The data resulting from this study showed that the Brazilian public healthcare sector still performs laparoscopic procedures for the treatment of cholelithiasis at a very low rate. It also should be noted that despite the South being the region with the largest number of LCs performed per 100,000 inhabitants in 2010, the percent variation from 2008 to 2012 was smaller. All other regions had a greater than 100 % increase, especially the Central-West and Southeast regions. A possible reason for this phenomenon may be that, despite the implementation of video-assisted surgery in the South (where one of the states that pioneered it in Brazil in 1990 is located [14]), the services that provide cholelithiasis treatment by means of video-assisted surgery are mainly in the SUS reference hospitals. In addition, the rate of open procedures remained consistently high in the period, without any trend toward a decline. We identified possible limitations of our cross-sectional study, which may have underestimated the use of the laparoscopic access route at the SUS. When a hospitalization authorization is issued by a service provider, there may be problems with the notification of a cholecystectomy procedure, which may be entered without the description ‘‘laparoscopic.’’ Furthermore, by doing a search in DATASUS on the average amount paid for admission to a hospital that has an agreement with the SUS in the period under study, we found that the costs for laparoscopic and open procedures were similar (R$ 755.02 and R$ 756.61, respectively). This detail may explain the lack of interest in specifying the type of procedure. A possible answer to ‘‘how can we increase the rate of LC?’’ could be the judicious use of hospital admissions compared with outpatient treatment [15, 16]. A shorter hospital stay for elective LC compared with OC has an effect on hospitalization costs and on the optimization of bed management in public hospitals [17]. Despite initially increasing the rate of video-assisted surgeries by going this route, LCs will reach a plateau at which its growth will be restrained by reaching the limit of currently available services, including previously trained staff, operating rooms, and recovery beds. We believe that public health managers need to adopt a ‘‘primary attention’’ policy for video-assisted surgery, involving the technical training of both the surgeon and the staff, implementing safety protocols, and making basic technology available in hospitals that do not have it yet. Surgeons who want to provide differentiated treatment to
123
their patients, often have to acquire supplies and equipment, in addition to attending courses, at their own expense to allow video-assisted surgeries to be performed. They also have to train the staff that will assist them, from surgical instrument handlers to technicians at material sterilization centers. This practice started with the implementation of LC in Brazil in 1990, initially in the treatment of private patients, which still prevails in Brazil. When confronted with the fact that 51.3 % of LCs were performed in hospitals located in Brazilian state capitals, the deficiencies of public hospitals in rural areas are quantitatively identified. As the services for treatment of the population in public hospitals in the capitals have reached their limit, another way to increase the rate of laparoscopic cholecystectomies in Brazil would be to provide hospitals in the countryside that can perform this procedure. A task force of surgeons could travel to these remote hospitals to perform elective surgeries [18]. Another way would be to train surgeons in more remote locations to utilize laparoscopy effectively and safely. This was done to bring LC to the rural regions of Mongolia, where the limitations on physical resources, restricted opportunity of suitable training, and harsh environment often resemble the reality on the ground in Brazil [19]. It should be noted that, given the high prevalence of OC in Brazil, an increase in the use of video-assisted surgery may result in a second national learning curve, similar to the one observed in the early 1990s that led to conversions to the open procedure [20] and bile duct lesions. However, as noted by Savassi-Rocha et al. [21], until 1997 the incidence of these iatrogenic events tended to be equal to those of the open procedure in Brazilian facilities. Brazilian surgical societies must seek to supply patients with the best treatment resources, both those covered by supplementary health plans and by the public system. As our study sought to identify current shortcomings in the services provided to the Brazilian population, further studies must be conducted to evaluate whether current public health strategies have been effective. Likewise, quantitative data may be useful to compare the use of video-assisted surgery in other countries with economic characteristics that are similar to those of Brazil. Conflicts of interest
None.
References 1. Mariano MB, Tefilli MV, Fonseca GN et al (2009) Laparoscopic radical prostatectomy: 10 years experience. Int Braz J Urol 35:565–571 2. Queiroz FL, Coˆrtes MG, Neto PR et al (2010) Colorectal laparoscopic surgeries performed in the State of Minas Gerais: Brazil from 1996 to 2009. Rev Bras Coloproctol 30:61–67
World J Surg 3. Pinto JO, Fallatah B, Espalieu P et al (2010) Elective laparoscopic left colectomy for diverticular disease: a monocentric study on 205 consecutive patients. Arq Bras Cir Dig 23:234–239 4. Biscione FM, Couto RC, Pedrosa TM et al (2007) Comparison of the risk of surgical site infection after laparoscopic cholecystectomy and open cholecystectomy. Infect Control Hosp Epidemiol 28:1103–1106 5. Ministe´rio da Sau´de do Brasil (2013) DATASUS-Procedimentos hospitalares do SUS por local de internac¸a˜o. http://tabnet.datasus. gov.br/cgi/deftohtm.exe?sih/cnv/qiuf.def Accessed 16 June 2013 6. Coelho JC, Bonilha R, Pitaki SA et al (1999) Prevalence of gallstones in a Brazilian population. Int Surg 84:25–28 7. Mantovani M, Leal RF, Fontelles MJ (2001) Incidence of cholelithiasis: a necropsy study performed in Campinas university hospital, SP. Rev Col Bras Cir 28:259–263 8. Pinotti HW, Domene CE, Volpe P et al (1999) Training of surgeons in laparoscopic surgery of the digestive system. Experience in 1,818 interventions without accidents and mortality. Rev Assoc Med Bras 45:337–341 9. Na´cul MP (2004) Modern aspects about education in endoscopic surgery in Brazil: a critique analysis. Rev Bras Videocir 2:1–4 10. Instituto de Estudos de Sau´de Suplementar-IESS (2010) Study of the impact of the incorporation of technologies and costs of results for the patient—traditional cholecystectomy versus videolaparoscopic cholecystectomy. http://www.iess.org.br/html/ relatoriocolecistectomia.pdf Accessed 6 Dec 2013 11. Ministe´rio da Sau´de do Brasil (2008) Atualizac¸a˜o do rol de procedimentos e eventos em sau´de. In: Dia´rio Oficial da Unia˜o de 10/01/2008, DF, Brası´lia, p. 348 12. Instituto Brasileiro de Geografia e Estatı´stica-IBGE (2013) Censo Demogra´fico 1960, 1970, 1980, 1991, 2000, e 2010. http://www.
13.
14.
15.
16.
17.
18.
19.
20.
21.
censo2010.ibge.gov.br/sinopse/index.php?dados=8 Accessed 28 June 2013 Agencia Nacional de Sau´de Suplementar-ANS (2012) FOCO Sau´de Suplementar. http://www.ans.gov.br/images/stories/Mate riais_para_pesquisa/Perfil_setor/Foco/20130124_foco_dezem bro_web_2012.pdf Accessed 1 Jul 2013 Guilhermano LG, Schwartsmann LB, Serres JC (2010) A evoluc¸a˜o histo´rica da colecistectomia laparosco´pica. In: Pa´ginas da Histo´ria da Medicina. Porto Alegre: Edipucrs, p. 138 Callan JF, Tanaka K, Foley E (2001) Outpatient laparoscopic cholecystectomy: patient outcomes after implementation of a clinical pathway. Ann Surg 233:704–715 Ahmad NZ, Byrnes G, Naqvi AS (2008) A meta-analysis of ambulatory versus inpatient laparoscopic cholecystectomy. Surg Endosc 22:1928–1934 Kaman L, Verma GR, Sanyal S (2005) Relevance of day care laparoscopic cholecystectomy in a developing nation. Trop Gastroenterol 26:95–97 Ryan SM, Milsom P, Yang J et al (2009) Travelling surgeons: a clinical audit of laparoscopic cholecystectomy procedures in Northland, New Zealand. N Z Med J 122:34–40 Straub CM, Prince RR, Matthews D et al (2011) Expanding laparoscopic cholecystectomy to rural Mongolia. World J Surg 35:751–759. doi:10.1007/s00268-011-0965-2 Lima EC, Queiroz FL, Ladeira FN et al (2007) Factors implied with conversion to open cholecystectomy. Rev Col Bras Cir 34:321–325 Savassi-Rocha PR, Almeida SR, Sanches MD et al (2003) Iatrogenic bile duct injuries. Surg Endosc 17:1356–1361
123
