RESUMEN
The treatment of any causal, procedure-specific and/or concomitant acute pain is an essential quality feature in any surgical subspecialty. An interdisciplinary and interprofessional pain therapy aims for an immediate improvement of the patients' quality of life, a reduction of the risk of postoperative morbidity and mortality in the medium term, prevention of any pain chronification in the long run as well as a reduction of hospitalization and sick leave. The "Agreement of the Professional Association of German Anesthesiologists and the Professional Association of German Surgeons for the Organization of Postoperative Pain Therapy" exists since 1992. In view of the continuously developing scientific evidence, updated guideline recommendations and interprofessionally designed treatment pathways, these agreements have been adapted to the current requirements and structural conditions of the German healthcare system. Thus, both aforementioned professional associations promote an up to date version of an "Agreement for the Organization of Pain Therapy for Surgical Patients", a precise recommendation and a manual for the acting partners in order to realize the abovementioned goals.
Asunto(s)
Anestesiólogos , Manejo del Dolor , Dolor Postoperatorio , Cirujanos , Alemania , Humanos , Manejo del Dolor/normas , Dolor Postoperatorio/tratamiento farmacológico , Calidad de Vida , SociedadesRESUMEN
The treatment of any causal, procedure-specific and/or concomitant acute pain is an essential quality feature in any surgical subspecialty. An interdisciplinary and interprofessional pain therapy aims for an immediate improvement of the patients' quality of life, a reduction of the risk of postoperative morbidity and mortality in the medium term, prevention of any pain chronification in the long run as well as a reduction of hospitalization and sick leave. The "Agreement of the Professional Association of German Anesthesiologists and the Professional Association of German Surgeons for the Organization of Postoperative Pain Therapy" exists since 1992. In view of the continuously developing scientific evidence, updated guideline recommendations and interprofessionally designed treatment pathways, these agreements have been adapted to the current requirements and structural conditions of the German healthcare system. Thus, both aforementioned professional associations promote an up to date version of an "Agreement for the Organization of Pain Therapy for Surgical Patients", a precise recommendation and a manual for the acting partners in order to realize the abovementioned goals.
Asunto(s)
Anestesiólogos , Dolor Postoperatorio , Cirujanos , Humanos , Dolor Postoperatorio/terapia , Guías de Práctica Clínica como Asunto , Calidad de Vida , Sociedades MédicasRESUMEN
BACKGROUND: Dipyrone (metamizole) is widely used for perioperative pain management in countries where it is marketed; however, uncertainty exists concerning the safe use of this drug, specifically considering the rare adverse event of an agranulocytosis. METHODS: As evidence from published studies was lacking, an expert panel developed recommendations for the perioperative use of dipyrone. After a formal, structured consensus process, the recommendations were approved by the involved medical societies. RESULTS: The panel agreed that blood cell counts shall not be standard for short-term perioperative use in patients unless they are at risk for neutropenia. The medical staff shall be aware of the symptoms and course of action when agranulocytosis is suspected. Patients shall be informed about the risks and benefits of dipyrone and about potential alternatives. The expert group concluded that dipyrone has a relatively positive risk-benefit ratio compared to other nonopioid analgesics. The group strongly recommended educating patients about the symptoms of agranulocytosis if they have received dipyrone over several days and/or treatment is to be continued after discharge, because agranulocytosis can occur several days after discontinuation of metamizole. Further recommendations refer to the information of the physician taking over the patient's care after discharge and the avoidance of re-exposure in patients having previously suffered from dipyrone-induced agranulocytosis. CONCLUSION: The group's recommendations shall be communicated in order to raise medical staff's and patients' awareness of the appropriate use of dipyrone in the perioperative period.
Asunto(s)
Dolor Agudo/tratamiento farmacológico , Agranulocitosis/inducido químicamente , Analgésicos no Narcóticos/uso terapéutico , Dipirona/uso terapéutico , Periodo Perioperatorio , Sociedades Médicas , Analgésicos no Narcóticos/efectos adversos , Anestesiología , Dipirona/efectos adversos , Alemania , Humanos , SuizaRESUMEN
The treatment of any causal, procedure-specific and/or concomitant acute pain is an essential quality feature in any surgical subspecialty. An interdisciplinary and interprofessional pain therapy aims for an immediate improvement of the patients' quality of life, a reduction of the risk of postoperative morbidity and mortality in the medium term, prevention of any pain chronification in the long run as well as a reduction of hospitalization and sick leave. The "Agreement of the Professional Association of German Anesthesiologists and the Professional Association of German Surgeons for the Organization of Postoperative Pain Therapy" exists since 1992. In view of the continuously developing scientific evidence, updated guideline recommendations and interprofessionally designed treatment pathways, these agreements have been adapted to the current requirements and structural conditions of the German healthcare system. Thus, both aforementioned professional associations promote an up to date version of an "Agreement for the Organization of Pain Therapy for Surgical Patients", a precise recommendation and a manual for the acting partners in order to realize the abovementioned goals.
Asunto(s)
Anestesiología , Manejo del Dolor/normas , Dolor Postoperatorio/terapia , Sociedades Médicas , Anestesiólogos , Alemania , Humanos , CirujanosRESUMEN
BACKGROUND: Dipyrone (metamizole) is widely used for perioperative pain management in countries where it is marketed; however, uncertainty exists concerning the safe use of this drug, specifically considering the rare adverse event of an agranulocytosis. METHODS: As evidence from published studies was lacking, an expert panel developed recommendations for the perioperative use of dipyrone. After a formal, structured consensus process, the recommendations were approved by the involved medical societies. RESULTS: The panel agreed that blood cell counts shall not be standard for short-term perioperative use in patients unless they are at risk for neutropenia. The medical staff shall be aware of the symptoms and course of action when agranulocytosis is suspected. Patients shall be informed about the risks and benefits of dipyrone and about potential alternatives. The expert group concluded that dipyrone has a relatively positive risk-benefit ratio compared to other nonopioid analgesics. The group strongly recommended educating patients about the symptoms of agranulocytosis if they have received dipyrone over several days and/or treatment is to be continued after discharge, because agranulocytosis can occur several days after discontinuation of metamizole. Further recommendations refer to the information of the physician taking over the patient's care after discharge and the avoidance of re-exposure in patients having previously suffered from dipyrone-induced agranulocytosis. CONCLUSION: The group's recommendations shall be communicated in order to raise medical staff's and patients' awareness of the appropriate use of dipyrone in the perioperative period.
Asunto(s)
Dolor Agudo , Anestesiología , Antiinflamatorios no Esteroideos , Dipirona , Dolor Agudo/tratamiento farmacológico , Analgésicos , Antiinflamatorios no Esteroideos/uso terapéutico , Cuidados Críticos , Dipirona/uso terapéutico , HumanosRESUMEN
BACKGROUND: Dipyrone (metamizole) is widely used for perioperative pain management in countries where it is marketed; however, uncertainty exists concerning the safe use of this drug, specifically considering the rare adverse event of an agranulocytosis. METHODS: As evidence from published studies was lacking, an expert panel developed recommendations for the perioperative use of dipyrone. After a formal, structured consensus process, the recommendations were approved by the involved medical societies. RESULTS: The panel agreed that blood cell counts shall not be standard for short-term perioperative use in patients unless they are at risk for neutropenia. The medical staff shall be aware of the symptoms and course of action when agranulocytosis is suspected. Patients shall be informed about the risks and benefits of dipyrone and about potential alternatives. The expert group concluded that dipyrone has a relatively positive risk-benefit ratio compared to other nonopioid analgesics. The group strongly recommended educating patients about the symptoms of agranulocytosis if they have received dipyrone over several days and/or treatment is to be continued after discharge, because agranulocytosis can occur several days after discontinuation of metamizole. Further recommendations refer to the information of the physician taking over the patient's care after discharge and the avoidance of re-exposure in patients having previously suffered from dipyrone-induced agranulocytosis. CONCLUSION: The group's recommendations shall be communicated in order to raise medical staff's and patients' awareness of the appropriate use of dipyrone in the perioperative period.
Asunto(s)
Agranulocitosis , Dipirona , Dolor Agudo/tratamiento farmacológico , Dolor Agudo/prevención & control , Agranulocitosis/inducido químicamente , Agranulocitosis/prevención & control , Analgésicos/administración & dosificación , Analgésicos/efectos adversos , Anestesiología/normas , Asociación , Cuidados Críticos , Dipirona/administración & dosificación , Dipirona/efectos adversos , Humanos , Periodo PerioperatorioRESUMEN
The treatment of any causal, procedure-specific and/or concomitant acute pain is an essential quality feature in any surgical subspecialty. An interdisciplinary and interprofessional pain therapy aims for an immediate improvement of the patients' quality of life, a reduction of the risk of postoperative morbidity and mortality in the medium term, prevention of any pain chronification in the long run as well as a reduction of hospitalization and sick leave. The "Agreement of the Professional Association of German Anesthesiologists and the Professional Association of German Surgeons for the Organization of Postoperative Pain Therapy" exists since 1992. In view of the continuously developing scientific evidence, updated guideline recommendations and interprofessionally designed treatment pathways, these agreements have been adapted to the current requirements and structural conditions of the German healthcare system. Thus, both aforementioned professional associations promote an up to date version of an "Agreement for the Organization of Pain Therapy for Surgical Patients", a precise recommendation and a manual for the acting partners in order to realize the abovementioned goals.
Asunto(s)
Dolor Postoperatorio/terapia , Competencia Clínica , Humanos , Monitoreo Fisiológico , Manejo del Dolor/métodos , Atención al PacienteRESUMEN
Approximately 20 % of the population are affected by gastroesophageal reflux disease (GERD). The subjective clinical and objective pathological extent of the disease is highly variable and the underlying pathophysiological mechanisms extraordinarily diverse. The importance of hiatus hernia for GERD has been intensively debated for decades. Hiatus hernia was initially considered to be at the center of the pathophysiology but later the function of the lower esophageal sphincter was increasingly considered to be of importance. Currently, additional relevant pathophysiological cofactors are being detected with the continuous improvement in diagnostic methods and used for therapeutic decision-making. Despite standardization of the operative technique and increasing criticism on long-term proton pump inhibitor (PPI) therapy, antireflux surgery still requires a very critical assessment of indications based on a comprehensive diagnostic evaluation.
Asunto(s)
Esfínter Esofágico Inferior/fisiopatología , Reflujo Gastroesofágico/fisiopatología , Reflujo Gastroesofágico/terapia , Hernia Hiatal/fisiopatología , Hernia Hiatal/terapia , Algoritmos , Diagnóstico Diferencial , Esfínter Esofágico Superior/fisiopatología , Fundoplicación , Reflujo Gastroesofágico/diagnóstico , Hernia Hiatal/diagnóstico , Humanos , Inhibidores de la Bomba de Protones/uso terapéuticoRESUMEN
Pain is no fundamental illness nor should it be a concomitant handicap in any medical treatment. Nevertheless there still is a huge discrepancy between the fundamentally existing medical options of an adequate pain therapy and the actual everyday care of affected patients. An adequate pain therapy in the perioperative or posttraumatic setting represents a basic prerequisite for a rapid recovery and a reduction of any postinterventional risk of morbidity and mortality. An immediate improvement in quality of life secondary to an adequate acute pain therapy increases the chances of an early mobilization, reduces the duration of hospitalization, and thus supports the physical and social rehabilitation of patients. Above that an adequate acute pain therapy will reduce the risk of the development of any chronic pain syndrome as secondary or late effect following operative interventions. These complex interrelations finally also lead to a direct means of cost reduction in the health care system.
Asunto(s)
Dolor Agudo/terapia , Manejo del Dolor/métodos , Dolor Postoperatorio/terapia , Heridas y Lesiones/terapia , Dolor Agudo/clasificación , Dolor Crónico/clasificación , Dolor Crónico/terapia , Ética Médica , Alemania , Adhesión a Directriz , Humanos , Manejo del Dolor/ética , Dolor Postoperatorio/clasificación , Cuidados Paliativos/ética , Cuidados Paliativos/métodosRESUMEN
BACKGROUND: Early function diagnostics and problem-oriented management are basic requirements in cases of functional problems and complications following antireflux surgery for gastroesophageal reflux disease (GERD). HISTORY, DIAGNOSTICS, AND THERAPEUTIC MANAGEMENT: A detailed history with a focus on the development of symptoms before and after the initial antireflux operation are fundamental prerequisites for a good diagnostic work-up. The data of preoperative function tests should always be reconsidered when re-evaluating a patient and be compared to the current findings. Thus, an analysis of the indications of any previous antireflux operation and an analysis of potential new or aggravated functional defects are essential. The general criteria indicating an operative procedure in gastroesophageal reflux disease do not change following such operation. Beyond these, symptomatic functional disorders caused by an antireflux operation may represent a new indication for an operative revision. INDICATION FOR RE-OPERATION: In the case of a symptomatic reflux recurrence, three essential criteria indicate an operative procedure: (i)âa progressive type of GERD (proven functional defects, hiatal hernia, presence of typical reflux symptoms, necessity of increasing PPI dosage), (ii)ânon acid-dependent symptoms in spite of adequate medication (aspiration, volume reflux, pulmonary symptoms) and (iii)âan alternative to medical therapy (preference, dependence, side effects, quality of life). In addition to these, symptomatic mechanical problems are important additional criteria for a redo procedure: the dissolution of the fundoplication wrap, the telescope-like slippage of the fundoplication around the proximal stomach ("slipped Nissen"), a paraesophageal herniation, and the transhiatal migration of an intact fundoplication. Finally, the rather seldom occurring wrong construction of the fundoplication and a not detected primary motility disorder (e.âg., achalasia) are indications for redo surgery in most cases. CONCLUSION: The decision for any redo surgery following antireflux operations should always be based on a sound balance between symptomatic impairment and objective findings in functional disorders. This analysis allows for a responsible decision process since any redo surgery holds the risk of a lower success rate than the initial operation.
Asunto(s)
Fundoplicación , Reflujo Gastroesofágico/diagnóstico , Reflujo Gastroesofágico/cirugía , Hernia Hiatal/diagnóstico , Hernia Hiatal/cirugía , Laparoscopía/métodos , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/cirugía , Humanos , Recurrencia , Reoperación , Factores de RiesgoRESUMEN
The introduction of the DRG (diagnosis-related groups) system as basis for reimbursement in the German health-care system has led to a mentality of quality orientation and verification of therapeutic results. An immediate result was the formation of medical "centres" on rather different levels and consequently the inauguration of institutions, authorities, and organisations to review these centres. Finally, a range of certifications was installed in order to stratify the rather diverse aims of different centres. This review critically evaluates the current situation in the field of general and abdominal surgery in Germany.
Asunto(s)
Cirugía General/organización & administración , Cirugía General/tendencias , Especialidades Quirúrgicas/organización & administración , Especialidades Quirúrgicas/tendencias , Centros Quirúrgicos/organización & administración , Centros Quirúrgicos/tendencias , Vísceras/cirugía , Certificación , Análisis Costo-Beneficio/tendencias , Grupos Diagnósticos Relacionados/economía , Grupos Diagnósticos Relacionados/tendencias , Predicción , Cirugía General/economía , Alemania , Necesidades y Demandas de Servicios de Salud/economía , Necesidades y Demandas de Servicios de Salud/organización & administración , Necesidades y Demandas de Servicios de Salud/tendencias , Humanos , Programas Nacionales de Salud/economía , Programas Nacionales de Salud/tendencias , Garantía de la Calidad de Atención de Salud/economía , Garantía de la Calidad de Atención de Salud/tendencias , Indicadores de Calidad de la Atención de Salud/economía , Indicadores de Calidad de la Atención de Salud/tendencias , Mecanismo de Reembolso/economía , Mecanismo de Reembolso/tendencias , Sociedades Médicas , Especialidades Quirúrgicas/economía , Centros Quirúrgicos/economíaRESUMEN
BACKGROUND: Reflux recurrence is the most common long-term complication of fundoplication. Its frequency was independent from the type of fundoplication in randomized studies. Results for different techniques of laparoscopic antireflux surgery were retrospectively evaluated after 10 years. METHODS: From 1992 to 1997, 120 patients had primary laparoscopic fundoplication with a "tailored approach" (type of wrap chosen according to esophageal peristalsis): 88 received a Nissen, 22 an anterior, and 10 a Toupet fundoplication. Follow-up of 87% of the patients included disease-related questions and the gastrointestinal quality-of-life index (GIQLI). RESULTS: Of the patients, 89% would select surgery again. Heartburn was reported by 30% of the patients. Regurgitations were noted from 15% of patients after a Nissen, 44% after anterior fundoplication, and 10% after a Toupet (p = 0.04). Twenty-eight percent were on acid-suppressive drugs again. Following Nissen fundoplication, proton pump inhibitors were less frequently used (p = 0.01) and on postoperative pH-metry reflux recurrence rate was lower (p = 0.04). The GIQLI was 110 +/- 24 without significant differences for the type of fundoplication. DISCUSSION: Ten years after laparoscopic fundoplication, overall outcome is good. A quarter of the patients are on acid-suppressive drugs. Nissen fundoplication appears to control reflux better than a partial fundoplication.
Asunto(s)
Fundoplicación/métodos , Reflujo Gastroesofágico/cirugía , Laparoscopía/métodos , Calidad de Vida , Adulto , Estudios de Casos y Controles , Femenino , Estudios de Seguimiento , Fundoplicación/efectos adversos , Determinación de la Acidez Gástrica , Reflujo Gastroesofágico/diagnóstico , Humanos , Laparoscopía/efectos adversos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Dolor Postoperatorio/fisiopatología , Cuidados Posoperatorios/métodos , Cuidados Preoperatorios/métodos , Probabilidad , Estudios Retrospectivos , Medición de Riesgo , Índice de Severidad de la Enfermedad , Estadísticas no Paramétricas , Resultado del TratamientoRESUMEN
BACKGROUND: Reflux recurrence is the most common long-term complication following fundoplication. Results for different techniques of laparoscopic antireflux surgery were retrospectively compared after 10 years. METHODS: From 1992 to 1997, the 120 patients studied had laparoscopic fundoplication with 'tailored' approaches: 88 Nissen, 22 anterior, and ten Toupet fundoplications. Follow-up of 87% of these patients included disease-related questions and the gastrointestinal quality of life index (GIQLI). RESULTS: Of the patients, 89% would select surgery again. Regurgitations after fundoplication were noted from 15% of patients after Nissen, 44% after anterior, and 10% after Toupet types (P=0.04). Twenty-eight percent were on acid suppression therapy. Proton pump inhibitors were used less frequently following Nissen fundoplication (P=0.01). The GIQLI score was 110+/-24 without significant differences for type of fundoplication. DISCUSSION: Overall results are satisfactory after 10 years of experience with fundoplication. Total fundoplication appears to control reflux better than partial fundoplication.
Asunto(s)
Fundoplicación/métodos , Reflujo Gastroesofágico/cirugía , Laparoscopía/métodos , Complicaciones Posoperatorias/prevención & control , Anciano , Femenino , Estudios de Seguimiento , Reflujo Gastroesofágico/etiología , Reflujo Gastroesofágico/prevención & control , Humanos , Masculino , Persona de Mediana Edad , Satisfacción del Paciente , Complicaciones Posoperatorias/etiología , Prevención SecundariaAsunto(s)
Endoscopía , Esofagoscopía , Reflujo Gastroesofágico/cirugía , Gastroscopía , Animales , Esofagoscopía/métodos , Gastroscopía/métodos , HumanosRESUMEN
It was the aim of this study to analyze whether a shorter measuring period would render the same diagnostic information on esophageal motility as a circadian measuring period in ambulatory esophageal manometry. In an investigation on normal volunteers (n = 10), patients with gastroesophageal reflux disease without esophageal motility disorders (n = 13), and patients with esophageal motility disorders (n = 14), a comparison was performed between a 5-hr and a 24-hr motility study. An analysis was performed on inter- and intraindividual reproducibility of time periods, prandial phases, and motility sequences (Wilcoxon and Spearman test). There was no significant difference between the two analyzed measuring periods in all three groups with regard to the diagnostic information on esophageal motility in 44 of 45 comparisons for intraindividual variability. A measuring period restricted to 5 hr offers the same diagnostic information on esophageal peristaltic activity as a 24-hr motility study.
Asunto(s)
Trastornos de la Motilidad Esofágica/fisiopatología , Esófago/fisiopatología , Adulto , Anciano , Ritmo Circadiano , Femenino , Reflujo Gastroesofágico/fisiopatología , Humanos , Masculino , Manometría , Persona de Mediana Edad , Peristaltismo , Factores de TiempoRESUMEN
Columnar-lined epithelium with specialized intestinal metaplasia of the esophagus (i.e., Barrett's esophagus) is a premalignant condition caused by chronic gastroesophageal reflux disease. Progression of intestinal metaplasia may be avoided by antireflux surgery, whereas regeneration of esophageal mucosa could be achieved by endoscopic argon plasma coagulation (EAPC). The aim of this prospective study was to show the early results of a combination of EAPC and antireflux surgery. Thirty patients with Barrett's esophagus were treated between August 1996 and December 1999. Regeneration of esophageal mucosa was achieved with several sessions of EAPC under general anesthesia. All patients were receiving a double dose of proton pump inhibitors. Endoscopic follow-up was performed 6 to 8 weeks after the last session. Antireflux surgery (Nissen [n = 26] or Toupet [n = 4] fundoplication) followed complete regeneration of the squamous epithelium in the esophagus. One year after laparoscopic fundoplication and EAPC follow-up with endoscopy and quadrant biopsies of the esophagus, 24-hour pH monitoring and esophageal manometry were performed. All 30 patients showed complete regeneration of the squamous epithelium after a median of two sessions (range 1 to 7) of EAPC. Twenty-two patients underwent 1-year follow-up studies. All showed endoscopically an intact fundic wrap. Recurrence of a 1 cm segment of Barrett's epithelium without dysplasia was present in two patients, both of whom had recurrent acid reflux due to failure of their antireflux procedure. Our results indicate that the combination of EAPC and antireflux surgery is an effective treatment option in patients with Barrett's esophagus with gastroesophageal reflux disease. Long-term follow-up of this therapy is necessary to evaluate its effect on cancer risk in Barrett's esophagus.
Asunto(s)
Esófago de Barrett/cirugía , Electrocoagulación/métodos , Esofagoscopía/métodos , Fundoplicación/métodos , Reflujo Gastroesofágico/cirugía , Laparoscopía/métodos , Adulto , Anciano , Argón , Esófago de Barrett/etiología , Esófago de Barrett/patología , Biopsia , Terapia Combinada , Progresión de la Enfermedad , Femenino , Reflujo Gastroesofágico/complicaciones , Reflujo Gastroesofágico/diagnóstico , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Estudios Prospectivos , Recurrencia , Factores de Riesgo , Resultado del TratamientoRESUMEN
Reconstruction modes following gastrectomy. Results of experimental and clinical controlled trials. In animal experiments four reconstruction methods following gastrectomy were compared: Roux-en Y reconstruction with (n = 33) and without pouch (n = 50) and isoperistaltic jejunum interposition with (n = 26) and without pouch (n = 55). The results were mostly influenced by the extent of esophagitis, documenting the reflux reduction by a pouch. Weight gain was slightly higher following jejunum interposition.Roux-en Y pouch reconstruction with jejunum interposition with pouch was compared in a randomized controlled trial. The additional operative effort of jejunum interposition did not achieve benefits in outcome. Therefore, Roux-en Y reconstruction should be advocated as standard reconstruction. The second randomized controlled trial compared Roux-en Y reconstruction with and without pouch. After more than three years, there was an advantage in life quality for patients with pouch indicating that patients with a favorable prognosis following gastrectomy should be reconstructed with a pouch.