RESUMO
Introduction: Over the last decade, damage control surgery (DCS) has been emerging as a feasible alternative for the management of patients with abdominal infection and sepsis. So far, there is no consensus about the role of DCS for acute perforated diverticulitis. In this study, we present the outcome of a multi-institutional series of patients presenting with Hinchey's grade III and IV diverticulitis managed by DCS. Methods: All the participating centers were tertiary referral hospitals. A total of 34 patients with perforated diverticulitis treated with DCS during the period 2011-2017 were included in the study. During the first laparotomy, a limited resection of the diseased segment was performed followed by lavage and use of negative pressure wound therapy (NPWT). After 24/48 h of resuscitation, patients returned to the operating room for a second look. Mortality, morbidity, and restoration of bowel continuity were the primary outcomes of the study. Results: There were 15 males (44%) and 19 females (56%) with a mean age of 66.9 years (SD ± 12.7). Mean BMI was 28.42 kg/m2 (SD ± 3.33). Thirteen cases (38%) were Wasvary's modified Hinchey's stage III, and 21 cases (62%) Hinchey's stage IV. Mean Mannheim Peritonitis Index (MPI) was 25.12 (SD ± 6.28). In 22 patients (65%), ASA score was ≥ grade III. Twenty-four patients (71%) had restoration of bowel continuity, while 10 (29%) patients had an end colostomy (Hartmann's procedure). Three of these patients received a temporary loop ileostomy. One patient had an anastomotic leak. Mortality rate was 12%. Mean length of hospital stay was 21.9 days. At multivariate analysis, male gender (p = 0.010) and MPI (p = 0.034) correlated with a high percentage of Hartmann's procedures. Conclusion: DCS is a feasible procedure for patients with generalized peritonitis secondary to perforated diverticulitis, and it appears to be related to a higher rate of bowel reconstruction. Due to the open abdomen, stay in ICU with prolonged mechanical ventilation is required, but these aggressive measures may be needed by most patients undergoing surgery for perforated diverticulitis, whatever the procedure is done.
Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/métodos , Doença Diverticular do Colo/complicações , Peritonite/cirurgia , Adulto , Idoso , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Procedimentos Cirúrgicos do Sistema Digestório/normas , Doença Diverticular do Colo/cirurgia , Feminino , Humanos , Perfuração Intestinal/etiologia , Perfuração Intestinal/cirurgia , Masculino , Pessoa de Meia-Idade , Estomia/métodos , Estomia/tendências , Peritonite/etiologia , Estudos Retrospectivos , Estatísticas não Paramétricas , Resultado do TratamentoRESUMO
AIM: The main aims were to explore time trends in the management and outcome of patients with rectal cancer in a national cohort and to evaluate the possible impact of national auditing on overall outcomes. A secondary aim was to provide population-based data for appraisal of external validity in selected patient series. METHOD: Data from the Swedish ColoRectal Cancer Registry with virtually complete national coverage were utilized in this cohort study on 29 925 patients with rectal cancer diagnosed between 1995 and 2012. Of eligible patients, nine were excluded. RESULTS: During the study period, overall, relative and disease-free survival increased. Postoperative mortality after 30 and 90 days decreased to 1.7% and 2.9%. The 5-year local recurrence rate dropped to 5.0%. Resection margins improved, as did peri-operative blood loss despite more multivisceral resections being performed. Fewer patients underwent palliative resection and the proportion of non-operated patients increased. The proportions of temporary and permanent stoma formation increased. Preoperative radiotherapy and chemoradiotherapy became more common as did multidisciplinary team conferences. Variability in rectal cancer management between healthcare regions diminished over time when new aspects of patient care were audited. CONCLUSION: There have been substantial changes over time in the management of patients with rectal cancer, reflected in improved outcome. Much indirect evidence indicates that auditing matters, but without a control group it is not possible to draw firm conclusions regarding the possible impact of a quality control registry on faster shifts in time trends, decreased variability and improvements. Registry data were made available for reference.
Assuntos
Terapia Combinada/tendências , Complicações Pós-Operatórias/epidemiologia , Neoplasias Retais/terapia , Taxa de Sobrevida/tendências , Adulto , Idoso , Idoso de 80 Anos ou mais , Perda Sanguínea Cirúrgica , Quimiorradioterapia Adjuvante/tendências , Estudos de Coortes , Intervalo Livre de Doença , Feminino , Humanos , Masculino , Auditoria Médica , Pessoa de Meia-Idade , Terapia Neoadjuvante/tendências , Estomia/tendências , Cuidados Paliativos/tendências , Equipe de Assistência ao Paciente/tendências , Radioterapia Adjuvante/tendências , Neoplasias Retais/mortalidade , Suécia/epidemiologiaRESUMO
BACKGROUND: Temporary fecal diversion has been used to allow severe perianal Crohn's disease (CD) to heal. Most data on intestinal reconnection rates precede the biological era with limited patient follow-up after reconnection. We, therefore, sought to evaluate the natural history of perianal CD after fecal diversion. METHODS: We identified 49 patients with CD and perianal involvement who underwent fecal diversion between 1991 and 2011 at a tertiary referral care center. Demographics, medication use, onset and extent of disease, and surgical interventions were abstracted. We determined the percentage of patients who were able to restore intestinal continuity and assessed the sustainability of this reversal. Time to intestinal reconnection and subsequent procedures were determined. We also examined temporal trends in the proportion of patients with perianal CD undergoing diversion or management with seton/EUA/fistulotomy between 2000 and 2011. RESULTS: Fifteen of 49 patients (31%) reestablished intestinal continuity during the study follow-up period. Ten of 15 patients (67%) who had reestablished intestinal continuity required an additional procedure to divert the fecal stream. Of the 5 patients who remained reconnected, 3 patients required further procedures to control sepsis. The proportion of patients with CD requiring perianal surgical interventions declined between 2000 and 2011. CONCLUSIONS: Severe perianal CD remains a challenging problem. In patients with CD with perianal disease requiring fecal diversion, the likelihood of sustained intestinal continuity remains low, despite greater biological use. However, there has been a temporal decline in the rate of surgical interventions required for perianal CD from 2000 to 2011.
Assuntos
Doenças do Ânus/cirurgia , Doença de Crohn/cirurgia , Fezes , Estomia/tendências , Adolescente , Adulto , Idoso , Doenças do Ânus/mortalidade , Criança , Doença de Crohn/mortalidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estomia/mortalidade , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida , Adulto JovemAssuntos
Enfermeiros Clínicos/tendências , Estomia/tendências , Higiene da Pele/tendências , Formulários Farmacêuticos como Assunto , Necessidades e Demandas de Serviços de Saúde , Humanos , Estomia/instrumentação , Estomia/enfermagem , Educação de Pacientes como Assunto , Higiene da Pele/instrumentação , Higiene da Pele/enfermagemRESUMO
OBJECTIVE: To determine hospital proportional morbidity rates (HPMR) for urethral obstructions, urethral plugs or urethroliths, and urethrostomies in cats in veterinary teaching hospitals (VTH) in Canada and the United States between 1980 and 1999. DESIGN: Epidemiologic study. ANIMALS: 305,672 cats evaluated at VTH. PROCEDURES: Yearly HPMR were determined for cats with urethral obstructions, urethral plugs or urethroliths, or urethrostomies from data compiled by the Purdue Veterinary Medical Database. The test for a linear trend in proportions was used. RESULTS: Urethral obstructions were reported in 4,683 cats. Yearly HPMR for urethral obstructions declined from 19 cases/1,000 feline evaluations in 1980 to 7 cases/1,000 feline evaluations in 1999. Urethral plugs or urethroliths affected 1,460 cats. Yearly HPMR for urethral plugs or urethroliths decreased from 10 cases/1,000 feline evaluations in 1980 to 2 cases/1,000 feline evaluations in 1999. A total of 2,359 urethrostomies were performed. Yearly HPMR for urethrostomies decreased from 13 cases/1,000 feline evaluations in 1980 to 4 cases/1,000 feline evaluations in 1999. CONCLUSIONS AND CLINICAL RELEVANCE: Frequency of feline urethrostomies performed at VTH in Canada and the United States declined during the past 20 years and paralleled a similar decline in frequency of urethral obstructions and urethral plugs or urethroliths. These trends coincide with widespread use of diets to minimize struvite crystalluria in cats, which is important because struvite has consistently been the predominant mineral in feline urethral plugs during this period.
Assuntos
Doenças do Gato/cirurgia , Doenças Uretrais/veterinária , Obstrução Uretral/veterinária , Ração Animal/efeitos adversos , Ração Animal/análise , Animais , Canadá/epidemiologia , Doenças do Gato/epidemiologia , Doenças do Gato/etiologia , Gatos , Estudos Epidemiológicos , Feminino , Hospitais Veterinários/estatística & dados numéricos , Compostos de Magnésio , Masculino , Morbidade , Estomia/tendências , Estomia/veterinária , Fosfatos , Estudos Retrospectivos , Estruvita , Estados Unidos/epidemiologia , Doenças Uretrais/epidemiologia , Doenças Uretrais/etiologia , Doenças Uretrais/cirurgia , Obstrução Uretral/epidemiologia , Obstrução Uretral/etiologia , Obstrução Uretral/cirurgia , Cálculos Urinários/epidemiologia , Cálculos Urinários/etiologia , Cálculos Urinários/cirurgia , Cálculos Urinários/veterináriaRESUMO
In today's rapidly evolving health care environment in which quality, cost-effectiveness, and outcomes are among the most valued health care products, significant issues must be addressed regarding ostomy products and how persons with stomas use them. The lack of evidence-based data has a direct impact on the pocketbooks of many patients with ostomies in the United States and their quality of life. Regulators, accrediting agencies, and payers look to WOC nurses and other providers to provide a sound scientific base upon which they can develop standards and regulations that will improve the life of Americans with stomas.
Assuntos
Qualidade de Produtos para o Consumidor , Drenagem/instrumentação , Estomia/instrumentação , Estomia/tendências , Higiene da Pele/instrumentação , Centers for Medicare and Medicaid Services, U.S. , Qualidade de Produtos para o Consumidor/legislação & jurisprudência , Análise Custo-Benefício , Segurança de Equipamentos , Medicina Baseada em Evidências , Previsões , Humanos , Enfermeiros Clínicos , Estomia/economia , Estomia/enfermagem , Estomia/psicologia , Estomia/normas , Garantia da Qualidade dos Cuidados de Saúde/organização & administração , Qualidade de Vida , Estados Unidos , United States Food and Drug AdministrationRESUMO
Antecedentes: El apéndice cecal se ha utilizado con éxito en el niño para reemplazar el uréter, la uretra, para vesicostomías continentes en ciertas patologías vesicales (técnica de Mitrofanoff). Objetivo: Mostrar los resultados obtenidos con esta técnica y además abogar por la conservación del apéndice cecal. Material y métodos: Entre febrero de 1991 a octubre de 1997 se efectuaron 46 vesicostomías continentes. Se empleó la operación de Mitrofanoff utilizando el apéndice cecal en 39 casos. En los restantes, por ausencia de apéndice, se usó como tubo el uréter, íleon o colon modelados. La edad de los pacientes osciló entre los 1 y 24 años, con una media de 9 años. Se operaron 32 varones y 14 mujeres. La indicación de la vesicostomía continente fue: a) en enfermos con pobre vaciamiento vesical en cateterismo intermitente limpio, con dificultad para realizarlo por alteraciones anatómicas cérvico/uretrales (estenosis, divertículos, malformaciones, anfractuosidades) o sensibilidad uretral aumentada; b) pacientes con oclusión uretral definitiva o temporaria; c) reservorios vesicales para continencia y vaciamiento del mismo. En 41 casos la vesicostomía se asoció a otros procedimientos simultáneos (cierre del cuello vesical, ampliación vesical, tratamiento de reflujo y onfaloplastia). El tiempo de seguimiento osciló entre 6 a 82 meses con una media de 46 meses. En el período de seguimiento, 32 pacientes no presentaron complicaciones. Resultados: En 7 niños se presentó estenosis del ostoma con dificultad para el cateterismo, 5 se dilataron y 2 se corrigieron quirúrgicamente. En 5 casos (no ubicados en la cicatriz umbilical) se produjo un ectropión mucoso, que si bien no dificultó el cateterismo, por razones estéticas se resecó. Sólo un paciente con tubo realizado con un segmento ileal persiste levemen incontinente. En 2 pacientes hubo inconvenientes en el pasaje de la sonda que requirió la colocación de vesicostomía percutánea transitoria. Ningún niño mostró deterioro de su función renal atribuible al procedimiento. El vaciamiento periódico y completo redujo francamente el número de infecciones urinarias. Conclusiones: La vesicostomía continente con apéndice cecal (Técnica de Mitrofanoff) es un excelente método y de escasa morbilidad. Bien indicado facilita el vaciamiento vesical periódico y permite al niño mantenerse seco y libre de infección, mejorando su calidad de vida...
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Humanos , Masculino , Feminino , Lactente , Pré-Escolar , Adolescente , Adulto , Apêndice/transplante , Cistostomia , Procedimentos de Cirurgia Plástica/métodos , Apêndice/cirurgia , Apendicectomia/normas , Colo/cirurgia , Epispadia/cirurgia , Incontinência Fecal/cirurgia , Íleo/cirurgia , Estomia/tendências , Procedimentos de Cirurgia Plástica/efeitos adversos , Bexiga Urinária/cirurgiaAssuntos
Estomia/estatística & dados numéricos , Adulto , Distribuição por Idade , Idoso , Idoso de 80 Anos ou mais , Humanos , Pessoa de Meia-Idade , Enfermeiros Clínicos/estatística & dados numéricos , Estomia/classificação , Estomia/métodos , Estomia/enfermagem , Estomia/tendências , Seleção de Pacientes , Inquéritos e QuestionáriosRESUMO
Clinical practice guidelines affect every aspect of healthcare. Practitioners, third-party payors, regulatory bodies, governments, and accrediting agencies increasingly use these guidelines, which are developed by a wide variety of organizations. The majority of guidelines are based on consensus and a nonsystematic literature review, but some, including those developed by the Agency for Health Care Policy and Research, are evidence based. Both types of guidelines have distinct advantages and limitations. Consensus-based guidelines are less time consuming to develop but may lack crucial information and result in a wide variety of outcomes; whereas, the type of evidence used to develop strength-of-evidence ratings for evidence-based guidelines may result in ambiguous recommendations and cause ethical concerns. Outcomes research on the use of guidelines and issues related to their timeliness need to be addressed. Studies that include a wide variety of outcome indicators and care variables and contributions of clinicians are needed to develop practice guidelines that are clinically useful and improve patient care.