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OBJECTIVE: To identify how pediatric surgeons manage children with pneumonia and parapneumonic pleural effusion in Brazil. METHODS: An online cross-sectional survey with 27 questions was applied to pediatric surgeons in Brazil through the Brazilian Association of Pediatric Surgery. The questionnaire had questions about type of treatment, exams, hospital structure, and epidemiological data. RESULTS: A total of 131 respondents completed the questionnaire. The mean age of respondents was 44 ± 11 years, and more than half (51%) had been practicing pediatric surgery for more than 10 years. The majority of respondents (33.6%) reported performing chest drainage and fibrinolysis when facing a case of fibrinopurulent parapneumonic pleural effusion. A preference for video-assisted thoracic surgery instead of chest drainage plus fibrinolysis was noted only in the Northeast region. CONCLUSIONS: Chest drainage plus fibrinolysis was the treatment adopted by most of the respondents in this Brazilian sample. There was a preference for large drains; in contrast, smaller drains were preferred by those who perform chest drainage plus fibrinolysis. Respondents would rather change treatment when facing treatment failure or in critically ill children.
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Drenaje , Empiema Pleural , Pautas de la Práctica en Medicina , Humanos , Brasil/epidemiología , Estudios Transversales , Drenaje/métodos , Drenaje/estadística & datos numéricos , Masculino , Femenino , Pautas de la Práctica en Medicina/estadística & datos numéricos , Empiema Pleural/terapia , Empiema Pleural/cirugía , Adulto , Niño , Encuestas y Cuestionarios , Cirugía Torácica Asistida por Video/estadística & datos numéricos , Persona de Mediana Edad , Cirujanos/estadística & datos numéricos , Pediatría/estadística & datos numéricosRESUMEN
INTRODUCTION: Studies of adults undergoing lung resection indicated that selective omission of pleural drains is safe and advantageous. Significant practice variation exists for pleural drainage practices for children undergoing lung resection. We surveyed pediatric surgeons in a 10-hospital research consortium to understand decision-making for placement of pleural drains following lung resection in children. METHODS: Faculty surgeons at the 10 member institutions of the Western Pediatric Surgery Research Consortium completed questionnaires using a REDCap survey platform. Descriptive statistics and bivariate analyses were used to characterize responses regarding indications and management of pleural drains following lung resection in pediatric patients. RESULTS: We received 96 responses from 109 surgeons (88 %). Most surgeons agreed that use of a pleural drain after lung resection contributes to post-operative pain, increases narcotic use, and prolongs hospitalization. Opinions varied around the immediate use of suction compared to water seal, and half routinely completed a water seal trial prior to drain removal. Surgeons who completed fellowship within the past 10 years left a pleural drain after wedge resection in 45 % of cases versus 78 % in those who completed fellowship more than 10 years ago (p = 0.001). The mean acceptable rate of unplanned post-operative pleural drain placement when pleural drainage was omitted at index operation was 6.3 % (±4.6 %). CONCLUSIONS: Most pediatric surgeons use pleural drainage following lung resection, with recent fellowship graduates more often omitting it. Future studies of pleural drain omission demonstrating low rates of unplanned postoperative pleural drain placement may motivate practice changes for children undergoing lung resection. LEVEL OF EVIDENCE: V.
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Drenaje , Neumonectomía , Pautas de la Práctica en Medicina , Humanos , Drenaje/estadística & datos numéricos , Neumonectomía/métodos , Neumonectomía/efectos adversos , Niño , Pautas de la Práctica en Medicina/estadística & datos numéricos , Toma de Decisiones Clínicas , Encuestas de Atención de la Salud , Cuidados Posoperatorios/métodos , Cuidados Posoperatorios/estadística & datos numéricos , Tubos Torácicos , Encuestas y Cuestionarios , Dolor Postoperatorio/etiología , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & controlRESUMEN
Postoperative wound-site bleeding, tissue inflammation and seroma formation are well-known complications in the field of breast surgery. Hemostatic agents consisting of polysaccharides may be used intra-operatively to minimise postoperative complications. We conducted a prospective randomised-controlled, single-centre study including 136 patients undergoing breast-conserving surgery for invasive or intraductal breast cancer. Of these, 68 patients were randomised to receive an absorbable polysaccharide hemostatic agent into the wound site during surgery, while 68 patients were randomised to the control group and did not receive any hemostatic agent. Primary outcome was the total volume of postoperative drained fluid from the surgical site. Secondary outcomes were the number of days until drain removal and rate of immediate postoperative surgical site infection Patients in the intervention group had significantly higher drainage output volumes compared with the control group 85 mL (IQR 46.25-110) versus 50 mL (IQR 30-75), respectively; (P = .003). Univariable linear regression analyses showed a significant association between the surgical specimen and the primary outcome (P < .001). After multivariable analysis, the use of absorbable polysaccharide hemostatic product was no longer significantly associated with a higher drainage output and only the size of the surgical specimen remained a significant predictor. The number of days until drainage removal and the postoperative seroma formation were higher in the intervention group (P = .004) and (P = .003), respectively. In our study, intraoperative application of polysaccharide hemostatic agent during breast-conserving surgery did not decrease postoperative fluid production. Only the size of the surgical specimen was significantly associated with postoperative drainage volume.
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Neoplasias de la Mama , Hemostáticos , Mastectomía Segmentaria , Polisacáridos , Complicaciones Posoperatorias , Femenino , Humanos , Neoplasias de la Mama/tratamiento farmacológico , Neoplasias de la Mama/cirugía , Drenaje/estadística & datos numéricos , Hemostáticos/uso terapéutico , Polisacáridos/uso terapéutico , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Estudios Prospectivos , Seroma/epidemiología , Seroma/prevención & control , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/prevención & control , Mastectomía Segmentaria/efectos adversos , Persona de Mediana Edad , AncianoRESUMEN
BACKGROUND: Although endoscopic retrograde cholangiopancreatography (ERCP) is a pivotal procedure for the diagnosis and treatment of a variety of pancreatobiliary diseases, it has been known that the risk of procedure-related adverse events (AEs) is significant. OBJECTIVE: We conducted this nationwide cohort study since there have been few reports on the real-world data regarding ERCP-related AEs. METHODS: Patients who underwent ERCP were identified between 2012 and 2015 using Health Insurance Review and Assessment database generated by the Korea government. Incidence, annual trends, demographics, characteristics according to the types of procedures, and the risk factors of AEs were assessed. RESULTS: A total of 114,757 patients with male gender of 54.2% and the mean age of 65.0 ± 15.2 years were included. The most common indication was choledocholithiasis (49.4%) and the second malignant biliary obstruction (22.8%). Biliary drainage (33.9%) was the most commonly performed procedure, followed by endoscopic sphincterotomy (27.4%), and stone removal (22.0%). The overall incidence of ERCP-related AEs was 4.7% consisting of post-ERCP pancreatitis (PEP; 4.6%), perforation (0.06%), and hemorrhage (0.02%), which gradually increased from 2012 to 2015. According to the type of procedures, ERCP-related AEs developed the most commonly after pancreatic stent insertion (11.4%), followed by diagnostic ERCP (5.9%) and endoscopic sphincterotomy (5.7%). Younger age and diagnostic ERCP turned out to be independent risk factors of PEP. CONCLUSIONS: ERCP-related AEs developed the most commonly after pancreatic stent insertion, diagnostic ERCP and endoscopic sphincterotomy. Special caution should be used for young patients receiving diagnostic ERCP due to increased risk of PEP.
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Colangiopancreatografia Retrógrada Endoscópica/efectos adversos , Hemorragia/etiología , Pancreatitis/etiología , Factores de Edad , Anciano , Colangiopancreatografia Retrógrada Endoscópica/estadística & datos numéricos , Coledocolitiasis/diagnóstico por imagen , Coledocolitiasis/terapia , Colestasis/diagnóstico por imagen , Colestasis/terapia , Estudios de Cohortes , Bases de Datos Factuales , Drenaje/estadística & datos numéricos , Femenino , Humanos , Clasificación Internacional de Enfermedades , Masculino , Pancreatitis/epidemiología , República de Corea , Factores de Riesgo , Esfinterotomía Endoscópica/efectos adversos , Esfinterotomía Endoscópica/estadística & datos numéricos , Stents/efectos adversosRESUMEN
BACKGROUND AND OBJECTIVES: Treatment of retropharyngeal abscesses (RPAs) and parapharyngeal abscesses (PPAs) includes antibiotics, with possible surgical drainage. Although corticosteroids may decrease inflammation, their role in the management of RPAs and PPAs is unclear. We evaluated the association of corticosteroid administration as part of initial medical management on drainage rates and length of stay for children admitted with RPAs and PPAs. METHODS: We conducted a retrospective study using administrative data of children aged 2 months to 8 years discharged with RPAs and PPAs from 2016 to 2019. Exposure was defined as systemic corticosteroids administered as part of initial management. Primary outcome was surgical drainage. Bivariate comparisons were made between patients in the corticosteroid and noncorticosteroid groups by using Wilcoxon rank or χ2 tests. Outcomes were modeled by using generalized linear mixed-effects models. RESULTS: Of the 2259 patients with RPAs and PPAs, 1677 (74.2%) were in the noncorticosteroid group and 582 (25.8%) were in the corticosteroid group. There were no significant differences in age, sex, or insurance status. There was a lower rate of drainage in the corticosteroid cohort (odds ratio: 0.28; confidence interval: 0.22-0.36). Patients in this group were more likely to have repeat computed tomography imaging performed, had lower hospital costs, and were less likely to have opioid medications administered. The corticosteroid cohort had a higher 7-day emergency department revisit rate, but there was no difference in length of stay (rate ratio 0.97; confidence interval: 0.92-1.02). CONCLUSIONS: Corticosteroids were associated with lower odds of surgical drainage among children with RPAs and PPAs.
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Absceso/tratamiento farmacológico , Absceso/cirugía , Corticoesteroides/uso terapéutico , Enfermedades Faríngeas/tratamiento farmacológico , Enfermedades Faríngeas/cirugía , Absceso/diagnóstico , Factores de Edad , Antibacterianos/uso terapéutico , Niño , Preescolar , Terapia Combinada/métodos , Drenaje/estadística & datos numéricos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Costos de Hospital , Humanos , Lactante , Cobertura del Seguro , Tiempo de Internación , Masculino , Readmisión del Paciente/estadística & datos numéricos , Enfermedades Faríngeas/diagnóstico , Absceso Retrofaríngeo/diagnóstico , Absceso Retrofaríngeo/tratamiento farmacológico , Absceso Retrofaríngeo/cirugía , Estudios Retrospectivos , Factores Sexuales , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
BACKGROUND: Clinical equipoise remains significant for the treatment of Grade IV pancreatic injuries in stable patients (i.e., drainage vs. resection). The literature is poor in regards to experience, confirmed main pancreatic ductal injury, nuanced multidisciplinary treatment, and long-term patient quality of life (QOL). The primary aim was to evaluate the management and outcomes (including long-term QOL) associated with Grade IV pancreatic injuries. METHODS: All severely injured adult patients with pancreatic trauma (1995-2020) were evaluated (Grade IV injuries compared). Concordance of perioperative imaging, intraoperative exploration, and pathological reporting with a main pancreatic ductal injury was required. Patients with resection of Grade IV injuries were compared with drainage alone. Long-term QOL was evaluated (Standard Short Form-36). RESULTS: Of 475 pancreatic injuries, 36(8%) were confirmed as Grade IV. Twenty-four (67%) underwent a pancreatic resection (29% pancreatoduodenectomy; 71% extended distal pancreatectomy [EDP]). Patient, injury and procedure demographics were similar between resection and drainage groups (p > 0.05). Pancreas-specific complications in the drainage group included 92% pancreatic leaks, 8% pseudocyst, and 8% walled-off pancreatic necrosis. Among patients with controlled pancreatic fistulas beyond 90 days, 67% required subsequent pancreatic operations (fistulo-jejunostomy or EDP). Among patients whose fistulas closed, 75% suffered from recurrent pancreatitis (67% eventually undergoing a Frey or EDP). All patients in the resection group had fistula closure by 64 days after injury. The median number of pancreas-related health care encounters following discharge was higher in the drainage group (9 vs. 5; p = 0.012). Long-term (median follow-up = 9 years) total QOL, mental and physical health scores were higher in the initial resection group (p = 0.031, 0.022 and 0.017 respectively). CONCLUSION: The immediate, intermediate and long-term experiences for patients who sustain Grade IV pancreatic injuries indicate that resection is the preferred option, when possible. The majority of drainage patients will require additional, delayed pancreas-targeted surgical interventions and report poorer long-term QOL. LEVEL OF EVIDENCE: Epidemiology/Prognostic, Level III.
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Drenaje/estadística & datos numéricos , Páncreas/lesiones , Pancreatectomía/estadística & datos numéricos , Pancreaticoduodenectomía/estadística & datos numéricos , Calidad de Vida , Adulto , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Páncreas/cirugía , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Although intravenous tranexamic acid administration (ivTXA) has prevailed in clinical antifibrinolytic treatment, whether it increases thromboembolic risks has remained controversial. As a potent alternative to ivTXA, topical use of TXA (tTXA) has been successfully applied to attenuate blood loss in various surgical fields while minimizing systemic exposure to TXA. This meta-analysis was conducted to gather scientific evidence for tTXA efficacy on reducing postoperative drainage, blood loss, and the length of hospital stay in spine surgeries. OBJECTIVES: To examine whether topical use of TXA (tTXA) reduces postoperative drainage output and duration, hidden blood loss, hemoglobin level drop, hospital stay, and adverse event rate, we reviewed both randomized and non-randomized controlled trials that assessed the aforementioned efficacies of tTXA compared with placebo in patients undergoing cervical, thoracic, or lumbar spinal surgeries. METHODS: An exhaustive literature search was conducted in MEDLINE and EMBASE databases from January 2000 through March 2020. Measurable outcomes were pooled using Review Manager (RevMan) version 5.0 in a meta-analysis. RESULTS: Significantly reduced postoperative drainage output (weighted mean difference [WMD]= - 160.62 ml, 95% confidence interval (95% CI) [- 203.41, - 117.83]; p < .00001) and duration (WMD= - 0.75 days, 95% CI [- 1.09, - 0.40]; p < .0001), perioperative hidden blood loss (WMD= - 91.18ml, 95% CI [- 121.42, - 60.94]; p < .00001), and length of hospital stay (WMD= - 1.32 days, 95% CI [- 1.90, - 0.74]; p < .00001) were observed in tTXA group. Pooled effect for Hb level drop with tTXA vs placebo crossed the equivalent line by a mere 0.05 g/dL, with the predominant distribution of 95% confidence interval (CI) favoring tTXA use. CONCLUSIONS: With the most comprehensive literature inclusion up to the present, this meta-analysis suggests that tTXA use in spinal surgeries significantly reduces postoperative drainage, hidden blood loss, and hospital stay duration. The pooled effect also suggests that tTXA appears more effective than placebo in preserving postoperative Hb level, which needs further validation by future studies.
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Pérdida de Sangre Quirúrgica/prevención & control , Hemorragia Posoperatoria/prevención & control , Columna Vertebral/cirugía , Herida Quirúrgica/tratamiento farmacológico , Ácido Tranexámico/administración & dosificación , Administración Tópica , Ensayos Clínicos como Asunto , Drenaje/estadística & datos numéricos , Humanos , Tiempo de Internación/estadística & datos numéricos , Periodo Posoperatorio , Resultado del TratamientoRESUMEN
ABSTRACT: This study aims to identify predictive factors associated with surgical intervention and the visual outcome of orbital cellulitis and to evaluate the treatment outcomes.A retrospective study involving 66 patients (68 eyes; 64 unilateral and 2 bilateral) diagnosed with bacterial orbital cellulitis was conducted between November 2005 and May 2019.The mean (± standard deviation) age was 42.1 (± 25.8) years (range: 15 days-86âyears). Sinusitis was the most frequent predisposing factor, occurring in 25 patients (37.9%), followed by skin infection in 10 patients (15.2%), and acute dacryocystitis in 9 patients (13.6%). Subperiosteal abscesses were found in 24 eyes and orbital abscesses in 19 eyes. Surgical drainage was performed in 31 eyes. Regarding the abscess volume for surgical drainage, a cut-off of 1514 mm3 showed 71% sensitivity and 80% specificity. There was significant improvement in visual acuity (VA) and decrease in proptosis after treatment (for both, P ≤ .001). Only pre-treatment VA ≤20/200 was a significant predictor for post-treatment VA of 20/50 or worse (adjusted odds ratio: 12.0, Pâ=â.003). The presence of a relative afferent pupillary defect was the main predictor of post-treatment VA of 20/200 or worse (adjusted odds ratio: 19.0, Pâ=â.003).The most common predisposing factor for orbital cellulitis in this study was sinusitis. VA and proptosis significantly improved after treatment. We found that the abscess volume was strongly predictive of surgical intervention. Pre-treatment poor VA and the presence of relative afferent pupillary defect can predict the worst visual outcome. Hence, early detection of optic nerve dysfunction and prompt treatment could improve the visual prognosis.
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Absceso/terapia , Antibacterianos/uso terapéutico , Drenaje/estadística & datos numéricos , Celulitis Orbitaria/terapia , Sinusitis/epidemiología , Absceso/sangre , Absceso/diagnóstico , Absceso/microbiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Bacterias/aislamiento & purificación , Niño , Preescolar , Dacriocistitis/complicaciones , Dacriocistitis/epidemiología , Dacriocistitis/microbiología , Humanos , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Enfermedades del Nervio Óptico/diagnóstico , Enfermedades del Nervio Óptico/epidemiología , Enfermedades del Nervio Óptico/microbiología , Enfermedades del Nervio Óptico/terapia , Órbita/diagnóstico por imagen , Órbita/microbiología , Celulitis Orbitaria/sangre , Celulitis Orbitaria/diagnóstico , Celulitis Orbitaria/microbiología , Pronóstico , Trastornos de la Pupila/diagnóstico , Trastornos de la Pupila/epidemiología , Trastornos de la Pupila/microbiología , Trastornos de la Pupila/terapia , Estudios Retrospectivos , Sinusitis/complicaciones , Sinusitis/microbiología , Enfermedades Cutáneas Bacterianas/complicaciones , Enfermedades Cutáneas Bacterianas/epidemiología , Enfermedades Cutáneas Bacterianas/microbiología , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Agudeza Visual , Adulto JovenRESUMEN
BACKGROUND: Percutaneous catheter drainage in pancreatic necrosis with a predominant solid component has a reduced success rate. To improve the efficacy of percutaneous catheter drainage, we used streptokinase in the irrigation fluid in the present study. METHODS: In this retrospective analysis of 4 prospective randomized studies performed at our center from 2014 to 2019, 108 patients were evaluated. We assessed the safety, feasibility, and efficacy of streptokinase irrigation compared to saline irrigation. Data were also analyzed between 50,000 IU and 150,000 IU streptokinase. RESULTS: There were 53 patients in the streptokinase irrigation group and 55 in the saline irrigation group, and both groups were comparable in terms of age, sex, etiology, APACHE II score, and percutaneous catheter drainage characteristics. The modified computerised tomography severity index and modified Marshall score at the onset of pain were significantly higher in the streptokinase group. Sepsis reversal was significantly higher in the streptokinase group (75% vs 36%), and the need for necrosectomy (34% vs 54%) was also lower in the streptokinase group. Mortality was lower in the streptokinase group than in the saline group (32% vs 40%). The incidence of bleeding in the streptokinase group was lower than that in the saline group (7% vs 18%). A higher dose of streptokinase (150,000 IU) resulted in lower rates of necrosectomy, bleeding, and mortality compared to those with 50,000 IU streptokinase. CONCLUSION: Significant reductions in the need for surgery and sepsis reversal were noted in the streptokinase group. The results using 150,000 IU streptokinase were superior to those using 50,000 IU streptokinase.
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Drenaje/estadística & datos numéricos , Fibrinolíticos/administración & dosificación , Pancreatitis Aguda Necrotizante/terapia , Estreptoquinasa/administración & dosificación , Irrigación Terapéutica/estadística & datos numéricos , Adulto , Procedimientos Quirúrgicos del Sistema Digestivo , Femenino , Humanos , India/epidemiología , Masculino , Persona de Mediana Edad , Pancreatitis Aguda Necrotizante/mortalidad , Estudios RetrospectivosRESUMEN
OBJECTIVES: There are three surgical treatment options for patients with peritonsillar abscess (PTA): needle aspiration, incision and drainage (ID), and abscess tonsillectomy (ATE). The updated German national guideline (2015) included changes in the treatment of PTA. The indication for tonsillectomy (TE) in patients became more stringent and preference was given to ID in certain cases. STUDY DESIGN: Retrospective analysis. METHODS: We performed a retrospective systematic analysis of patient data using the in-house electronic patient records and considered a 4-year period from 2014 to 2017. About 584 patients were identified. Our aim was to analyze the influence of the updated guideline on clinical practice. RESULTS: 236 of 584 patients (40.4%) underwent ATE with contralateral TE. In 225 patients (38.5%), unilateral ATE was performed. Mean surgery time was significantly shortened when only unilateral ATE was performed. Concerning postoperative bleeding, we noted a tendency toward a lower incidence after ATE in comparison to ATE with contralateral TE. Less than 1% of patients who underwent ATE had to be revised surgically due to postoperative hemorrhage. After the revision of the guideline, unilateral ATE and ID were conducted more frequently. CONCLUSION: These results support that ATE in an inpatient setting is a considerably safe and effective primary therapeutic option. ID represents a favorable treatment option for patients with PTA and comorbidities, nevertheless, patient compliance is required and insufficient drainage or recurrence of PTA may occur. The revision of the guideline had a significant impact on the choice of interventions (P < .001), which is reflected by the increased number of unilateral ATE. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2706-2712, 2021.
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Drenaje/efectos adversos , Paracentesis/efectos adversos , Absceso Peritonsilar/cirugía , Hemorragia Posoperatoria/epidemiología , Tonsilectomía/efectos adversos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Drenaje/normas , Drenaje/estadística & datos numéricos , Femenino , Humanos , Lactante , Masculino , Persona de Mediana Edad , Paracentesis/normas , Paracentesis/estadística & datos numéricos , Cooperación del Paciente/estadística & datos numéricos , Hemorragia Posoperatoria/etiología , Guías de Práctica Clínica como Asunto , Recurrencia , Estudios Retrospectivos , Tonsilectomía/normas , Tonsilectomía/estadística & datos numéricos , Resultado del Tratamiento , Adulto JovenRESUMEN
INTRODUCTION: Current guidelines recommend nonoperative management (NOM) of low-grade (American Association for the Surgery of Trauma-Organ Injury Scale Grade I-II) pancreatic injuries (LGPIs), and drainage rather than resection for those undergoing operative management, but they are based on low-quality evidence. The purpose of this study was to review the contemporary management and outcomes of LGPIs and identify risk factors for morbidity. METHODS: Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010 to 2018. The primary outcome was pancreas-related complications (PRCs). Predictors of PRCs were analyzed using multivariate logistic regression. RESULTS: Twenty-nine centers submitted data on 728 patients with LGPI (76% men; mean age, 38 years; 37% penetrating; 51% Grade I; median Injury Severity Score, 24). Among 24-hour survivors, definitive management was NOM in 31%, surgical drainage alone in 54%, resection in 10%, and pancreatic debridement or suturing in 5%. The incidence of PRCs was 21% overall and was 42% after resection, 26% after drainage, and 4% after NOM. On multivariate analysis, independent risk factors for PRC were other intra-abdominal injury (odds ratio [OR], 2.30; 95% confidence interval [95% CI], 1.16-15.28), low volume (OR, 2.88; 1.65, 5.06), and penetrating injury (OR, 3.42; 95% CI, 1.80-6.58). Resection was very close to significance (OR, 2.06; 95% CI, 0.97-4.34) (p = 0.0584). CONCLUSION: The incidence of PRCs is significant after LGPIs. Patients who undergo pancreatic resection have PRC rates equivalent to patients resected for high-grade pancreatic injuries. Those who underwent surgical drainage had slightly lower PRC rate, but only 4% of those who underwent NOM had PRCs. In patients with LGPIs, resection should be avoided. The NOM strategy should be used whenever possible and studied prospectively, particularly in penetrating trauma. LEVEL OF EVIDENCE: Therapeutic Study, level IV.
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Drenaje/efectos adversos , Páncreas/lesiones , Pancreatectomía/efectos adversos , Complicaciones Posoperatorias/epidemiología , Heridas no Penetrantes/cirugía , Heridas Penetrantes/cirugía , Adulto , Tratamiento Conservador/normas , Tratamiento Conservador/estadística & datos numéricos , Drenaje/normas , Drenaje/estadística & datos numéricos , Femenino , Humanos , Incidencia , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Páncreas/cirugía , Pancreatectomía/normas , Pancreatectomía/estadística & datos numéricos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Guías de Práctica Clínica como Asunto , Estudios Retrospectivos , Factores de Riesgo , Tomografía Computarizada por Rayos X , Centros Traumatológicos/normas , Centros Traumatológicos/estadística & datos numéricos , Heridas no Penetrantes/diagnóstico , Heridas Penetrantes/diagnóstico , Adulto JovenRESUMEN
BACKGROUND: It remains no clear conclusion about which is better between robot-assisted thoracic surgery (RATS) and video-assisted thoracic surgery (VATS) for the treatment of patients with non-small cell lung cancer (NSCLC). Therefore, this meta-analysis aimed to compare the short-term and long-term efficacy between RATS and VATS for NSCLC. METHODS: Pubmed, Cochrane Library, Embase, China National Knowledge Infrastructure (CNKI), Medline, and Web of Science databases were comprehensively searched for studies published before December 2020. The quality of the articles was evaluated using the Newcastle-Ottawa Scale (NOS) and the data analyzed using the Review Manager 5.3 software. Fixed or random effect models were applied according to heterogeneity. Subgroup analysis and sensitivity analysis were conducted. RESULTS: A total of 18 studies including 11,247 patients were included in the meta-analyses, of which 5114 patients were in the RATS group and 6133 in the VATS group. Compared with VATS, RATS was associated with less blood loss (WMD = - 50.40, 95% CI -90.32 ~ - 10.48, P = 0.010), lower conversion rate (OR = 0.50, 95% CI 0.43 ~ 0.60, P < 0.001), more harvested lymph nodes (WMD = 1.72, 95% CI 0.63 ~ 2.81, P = 0.002) and stations (WMD = 0.51, 95% CI 0.15 ~ 0.86, P = 0.005), shorter duration of postoperative chest tube drainage (WMD = - 0.61, 95% CI -0.78 ~ - 0.44, P < 0.001) and hospital stay (WMD = - 1.12, 95% CI -1.58 ~ - 0.66, P < 0.001), lower overall complication rate (OR = 0.90, 95% CI 0.83 ~ 0.99, P = 0.020), lower recurrence rate (OR = 0.51, 95% CI 0.36 ~ 0.72, P < 0.001), and higher cost (WMD = 3909.87 USD, 95% CI 3706.90 ~ 4112.84, P < 0.001). There was no significant difference between RATS and VATS in operative time, mortality, overall survival (OS), and disease-free survival (DFS). Sensitivity analysis showed that no significant differences were found between the two techniques in conversion rate, number of harvested lymph nodes and stations, and overall complication. CONCLUSIONS: The results revealed that RATS is a feasible and safe technique compared with VATS in terms of short-term and long-term outcomes. Moreover, more randomized controlled trials comparing the two techniques with rigorous study designs are still essential to evaluate the value of robotic surgery for NSCLC.
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Carcinoma de Pulmón de Células no Pequeñas/cirugía , Neoplasias Pulmonares/cirugía , Neumonectomía/métodos , Procedimientos Quirúrgicos Robotizados/métodos , Cirugía Torácica Asistida por Video/métodos , Pérdida de Sangre Quirúrgica/estadística & datos numéricos , Tubos Torácicos , Conversión a Cirugía Abierta/estadística & datos numéricos , Supervivencia sin Enfermedad , Drenaje/estadística & datos numéricos , Humanos , Tiempo de Internación/estadística & datos numéricos , Escisión del Ganglio Linfático/estadística & datos numéricos , Recurrencia Local de Neoplasia/epidemiología , Neumonectomía/efectos adversos , Complicaciones Posoperatorias/epidemiología , Sesgo de Publicación , Procedimientos Quirúrgicos Robotizados/efectos adversos , Procedimientos Quirúrgicos Robotizados/estadística & datos numéricos , Cirugía Torácica Asistida por Video/efectos adversos , Cirugía Torácica Asistida por Video/estadística & datos numéricos , Resultado del TratamientoRESUMEN
PURPOSE: To analyse acute cholecystitis (AC) management during the first pandemic outbreak after the recommendations given by the surgical societies estimating: morbidity, length of hospital stay, mortality and hospital-acquired SARS-CoV-2 infection rate. METHODS: Multicentre-combined (retrospective-prospective) cohort study with AC patients in the Community of Madrid between 1st March and 30th May 2020. 257 AC patients were involved in 16 public hospital. Multivariant binomial logistic regression (MBLR) was applied to mortality. RESULTS: Of COVID-19 patients, 30 were diagnosed at admission and 12 patients were diagnosed during de admission or 30 days after discharge. In non-COVID-19 patients, antibiotic therapy was received in 61.3% of grade I AC and 40.6% of grade II AC. 52.4% of grade III AC were treated with percutaneous drainage (PD). Median hospital stay was 5 [3-8] days, which was higher in the non-surgical treatment group with 7.51 days (p < 0.001) and a 3.25% of mortality rate (p < 0.21). 93.3% of patients with SARS-CoV-2 infection at admission were treated with non-surgical treatment (p = 0.03), median hospital stay was 11.0 [7.5-27.5] days (p < 0.001) with a 7.5% of mortality rate (p > 0.05). In patients with hospital-acquired SARS-CoV-2 infection, 91.7% of grade I-II AC were treated with non-surgical treatment (p = 0.037), with a median hospital stay of 16 [4-21] days and a 18.2% mortality rate (p > 0.05). Hospital-acquired infection risk when hospital stay is > 7 days is OR 4.7, CI 95% (1.3-16.6), p = 0.009. COVID-19 mortality rate was 11.9%, AC severity adjusted OR 5.64 (CI 95% 1.417-22.64). In MBLR analysis, age (OR 1.15, CI 95% 1.02-1.31), SARS-CoV-2 infection (OR 14.49, CI 95% 1.33-157.81), conservative treatment failure (OR 8.2, CI 95% 1.34-50.49) and AC severity were associated with an increased odd of mortality. CONCLUSION: In our population, during COVID-19 pandemic, there was an increase of non-surgical treatment which was accompanied by an increase of conservative treatment failure, morbidity and hospital stay length which may have led to an increased risk hospital-acquired SARS-CoV-2 infection. Age, SARS-CoV-2 infection, AC severity and conservative treatment failure were mortality risk factors.
Asunto(s)
Antibacterianos/uso terapéutico , COVID-19 , Colecistectomía/estadística & datos numéricos , Colecistitis Aguda , Tratamiento Conservador , Infección Hospitalaria , Control de Infecciones , COVID-19/diagnóstico , COVID-19/mortalidad , COVID-19/prevención & control , Colecistitis Aguda/diagnóstico , Colecistitis Aguda/epidemiología , Colecistitis Aguda/terapia , Estudios de Cohortes , Comorbilidad , Tratamiento Conservador/métodos , Tratamiento Conservador/estadística & datos numéricos , Infección Hospitalaria/epidemiología , Infección Hospitalaria/virología , Drenaje/métodos , Drenaje/estadística & datos numéricos , Femenino , Humanos , Control de Infecciones/métodos , Control de Infecciones/organización & administración , Control de Infecciones/normas , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Evaluación de Procesos y Resultados en Atención de Salud , Medición de Riesgo , SARS-CoV-2 , España/epidemiologíaRESUMEN
OBJECTIVES: To evaluate comparative outcomes of routine abdominal drainage (RAD) and non-routine abdominal drainage (NRAD) during elective hepatic resection for hepatic neoplasms. MATERIALS AND METHODS: We systematically searched MEDLINE, EMBASE, The Cochrane Library, Web of Science. The searching phrases included "liver resection," "hepatic resection," "hepatectomy," "abdominal drainage," "surgical drainage," "prophylactic drainage," "intraperitoneal drainage," "drainage tube," "hepatectomy," "abdominal drainage" and "drainage tube." Two independent reviewers critically screened literature, extracted data and assessed the risk of bias. Post-operative morbidity and mortality were the outcome parameters. Combined overall effect sizes were calculated using fixed-effect or random-effect model. RESULTS: We have identified 9 RCTs and 3 comparative studies reporting total of 5726 patients undergoing elective hepatectomy under RAD (nâ=â3084) or NRAD (NRAD group, nâ=â2642). RAD was associated with significantly higher overall complication rate [odds risk â=â1.79, 95% CI (1.10, 2.93), Pâ=â.02] and biliary leakage rate [odds risk â=â2.41, 95% CI (1.48, 3.91), Pâ=â.0004] compared with NRAD. Moreover, it significantly increased hospital stays [mean difference â=â0.95, 95% CI (0.02, 1.87), Pâ=â.04] compared with NRAD. RAD showed no difference regarding intra-abdominal hemorrhage, wound complications, liver failure, subphrenic complications, pulmonary complications, infectious complications, reoperation and mortality compared with NRAD. CONCLUSIONS: Although routine abdominal drainage may help surgeons to observe post-operative complication, it seems to be associated with increased post-operative morbidity and longer hospital stays. Non-routine abdominal drainage may be an appropriate option in selected patients undergoing hepatic resection. Higher level of evidence is needed.
Asunto(s)
Ascitis , Drenaje , Hepatectomía , Neoplasias Hepáticas , Complicaciones Posoperatorias , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Cavidad Abdominal/patología , Ascitis/epidemiología , Ascitis/etiología , Ascitis/cirugía , Drenaje/métodos , Drenaje/estadística & datos numéricos , Procedimientos Quirúrgicos Electivos/métodos , Hepatectomía/efectos adversos , Hepatectomía/métodos , Tiempo de Internación/estadística & datos numéricos , Neoplasias Hepáticas/cirugía , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/prevención & control , Ensayos Clínicos Controlados Aleatorios como Asunto , Reoperación/estadística & datos numéricos , Metaanálisis como Asunto , Revisiones Sistemáticas como AsuntoRESUMEN
Objectives. Mediastinal chest tubes are considered to be a significant factor causing postoperative pain after cardiac surgery. The aim of the study was to ascertain whether the duration of mediastinal drainage is associated with postoperative pain and opioid consumption. Design. A total of 468 consecutive patients undergoing cardiac surgery at the Tampere University Hospital between December 2015 and August 2016 were retrospectively analyzed. The first 252 patients were treated according to short and the following 216 patients according to extended drainage protocol, in which the mediastinal chest tubes were habitually removed on the first and second postoperative day, respectively. The oxycodone hydrochloride consumption, as well as daily mean pain scores assessed by numeric/visual rating scales, were compared between the groups. Results. The mean daily pain scores and cumulative opioid consumption were similar in both groups. Patients with reduced ejection fraction, diabetes, and peripheral vascular disease reported lower initial pain scores. The median cumulative oxycodone hydrochloride consumption did not differ according to the drainage protocol but was higher in males, smokers, and after aortic surgery. In contrast, patients with advanced age, hypertension, and peripheral vascular disease had lower consumption. In multivariable analysis, male sex and aortic surgery were associated with higher and advanced age with lower opioid use. Conclusions. The length of mediastinal chest tube drainage is not associated with the amount of postoperative pain or need for opioids after cardiac surgery. Male sex and aortic surgery were associated with higher and advanced age with lower overall opioid consumption.
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Analgésicos Opioides , Procedimientos Quirúrgicos Cardíacos , Tubos Torácicos , Drenaje , Dolor Postoperatorio , Analgésicos Opioides/administración & dosificación , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Drenaje/efectos adversos , Drenaje/estadística & datos numéricos , Duración de la Terapia , Femenino , Humanos , Masculino , Dolor Postoperatorio/etiología , Estudios RetrospectivosRESUMEN
OBJECTIVE: To determine predictors of increased drain output following type I thyroplasty for glottic insufficiency. STUDY DESIGN: Retrospective chart review. METHODS: A retrospective review was conducted for patients who underwent type I thyroplasty for glottic insufficiency from 2014-2019. The primary outcome was 24-hour drain output. Increased drain output was defined as >50th percentile for the sample. Univariate logistic regression models and linear regression models were used. RESULTS: There were 84 patients with a mean age of 58.9 (SD 16.9) years. Twenty-four-hour drain output ranged from 0 to 29 mL with a mean of 9.47 (SD 6.49) mL. Patients with a history of tobacco use (OR 3.33; 95% CI, 1.24-8.95; P = .017) and prior neck surgery (OR 3.52; 95% CI, 1.26 to 9.83; P = .016) were significantly more likely to have increased drain output following surgery; these patients had a mean increase in 24-hour drain output of 3.51 mL (95% CI, 0.52 to 6.51; P = .022) and 1.74 mL (95% CI, -1.41 to 4.89; P = .274), respectively. Type of implant (Gore-Tex vs. Silastic; P = .425) and operative technique (unilateral vs. bilateral; P = .506) were not significantly associated with drain output. CONCLUSION: History of tobacco use and prior surgery of the neck predict increased drain output following type I thyroplasty surgery. These patients may derive the most benefit from surgical drain placement. More research is needed to confirm these findings and elucidate potential mechanisms. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1557-1560, 2021.
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Drenaje/estadística & datos numéricos , Glotis/cirugía , Enfermedades de la Laringe/cirugía , Laringoplastia/estadística & datos numéricos , Adulto , Anciano , Dimetilpolisiloxanos , Femenino , Glotis/fisiopatología , Humanos , Enfermedades de la Laringe/fisiopatología , Laringoplastia/instrumentación , Laringoplastia/métodos , Masculino , Persona de Mediana Edad , Disección del Cuello/estadística & datos numéricos , Politetrafluoroetileno , Periodo Posoperatorio , Prótesis e Implantes , Estudios Retrospectivos , Factores de Riesgo , Uso de Tabaco/epidemiología , Resultado del TratamientoRESUMEN
The purpose of this retrospective study was to assess whether tranexamic acid (TXA) reduces blood loss in cementless total knee arthroplasty (TKA) comparable to levels observed with cemented fixation. After exclusions from 109 consecutive TKAs, 76 cementless knees were matched to 78 cemented knees of identical implant and surgeon. Blood loss with and without TXA was compared. There was no difference between cohorts in sex, age, body mass index, American Society of Anesthesiologists Physical Status classification, or preoperative hemoglobin (p ≥ 0.119). Use of TXA reduced median drain output by only 205 mL in cementless knees compared to 470 mL in cemented knees (p < 0.001). Median drain output per hour was highest in cementless knees without TXA (39.5 mL) followed by cemented knees without TXA (38.2 mL), cementless knees with TXA (28.5 mL), and cemented knees with TXA (12.7 mL; p < 0.001). Hemoglobin drop and total blood loss did not differ between cohorts regardless of TXA use. Cementless fixation in TKA resulted in greater intra-articular blood loss as measured by drain output, despite the use of TXA. Further research is warranted to examine whether a higher TXA dose, TXA delivery method, or the application of bone wax sealant would mitigate blood loss in cementless TKA, and subsequently whether intra-articular blood accumulation resulting in postoperative hemarthrosis affects recovery, function, and clinical outcomes.
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Antifibrinolíticos/administración & dosificación , Artroplastia de Reemplazo de Rodilla/métodos , Pérdida de Sangre Quirúrgica/estadística & datos numéricos , Ácido Tranexámico/administración & dosificación , Adulto , Anciano , Cementos para Huesos , Drenaje/estadística & datos numéricos , Femenino , Humanos , Masculino , Análisis por Apareamiento , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
BACKGROUND: Literature on pediatric breast abscesses is sparse; therefore, treatment is based on adult literature which has shifted from incision and drainage (I&D) to needle aspiration. However, children may require different treatment due to different risk factors and the presence of a developing breast bud. We sought to characterize pediatric breast abscesses and compare outcomes. MATERIALS AND METHODS: A retrospective review of patients presenting with a primary breast abscess from January 2008 to December 2018 was conducted. Primary outcome was persistent disease. Antibiotic utilization, treatment required, and risk factors for abscess and recurrence were also assessed. A follow-up survey regarding scarring, deformity, and further procedures was administered. Fisher's exact and Kruskal-Wallis tests for group comparisons and multivariable regression to determine associations with recurrence were performed. RESULTS: Ninety-six patients were included. The median age was 12.8 y [IQR 4.9, 14.3], 81% were women, and 51% were African-American. Most commonly, patients were treated with antibiotics alone (47%), followed by I&D (27%), and aspiration (26%). Twelve patients (13%) had persistent disease. There was no difference in demographic or clinical characteristics between those with persistent disease and those who responded to initial treatment. The success rates of primary treatment were 80% with antibiotics alone, 90% with aspiration, and 96% with I&D (P = 0.35). The median time to follow-up survey was 6.5 y [IQR 4.4, 8.5]. Four patients who underwent I&D initially reported significant scarring. CONCLUSIONS: Treatment modality was not associated with persistent disease. A trial of antibiotics alone may be considered to minimize the risk of breast bud damage and adverse cosmetic outcomes with invasive intervention.