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2.
Lancet ; 395(10217): 33-41, 2020 01 04.
Artículo en Inglés | MEDLINE | ID: mdl-31908284

RESUMEN

BACKGROUND: Adhesions are the most common driver of long-term morbidity after abdominal surgery. Although laparoscopy can reduce adhesion formation, the effect of minimally invasive surgery on long-term adhesion-related morbidity remains unknown. We aimed to assess the impact of laparoscopy on adhesion-related readmissions in a population-based cohort. METHODS: We did a retrospective cohort study of patients of any age who had abdominal or pelvic surgery done using laparoscopic or open approaches between June 1, 2009, and June 30, 2011, using validated population data from the Scottish National Health Service. All patients who had surgery were followed up until Dec 31, 2017. The primary outcome measure was the incidence of hospital readmissions directly related to adhesions in the laparoscopic and open surgery cohorts at 5 years. Readmissions were categorised as directly related to adhesions, possibly related to adhesions, and readmissions for an operation that was potentially complicated by adhesions. We did subgroup analyses of readmissions by anatomical site of surgery and used Kaplan-Meier analyses to assess differences in survival across subgroups. We used multivariable Cox-regression analysis to determine whether surgical approach was an independent and significant risk factor for adhesion-related readmissions. FINDINGS: Between June 1, 2009, and June 30, 2011, 72 270 patients had an index abdominal or pelvic surgery, of whom 21 519 (29·8%) had laparoscopic index surgery and 50 751 (70·2%) had open surgery. Of the 72 270 patients who had surgery, 2527 patients (3·5%) were readmitted within 5 years of surgery for disorders directly related to adhesions, 12 687 (17·6%) for disorders possibly related to adhesions, and 9436 (13·1%) for operations potentially complicated by adhesions. Of the 21 519 patients who had laparoscopic surgery, 359 (1·7% [95% CI 1·5-1·9]) were readmitted for disorders directly related to adhesions compared with 2168 (4·3% [4·1-4·5]) of 50 751 patients in the open surgery cohort (p<0·0001). 3443 (16·0% [15·6-16·4]) of 21 519 patients in the laparoscopic surgery cohort were readmitted for disorders possibly related to adhesions compared with 9244 (18·2% [17·8-18·6]) of 50 751 patients in the open surgery cohort (p<0·005). In multivariate analyses, laparoscopy reduced the risk of directly related readmissions by 32% (hazard ratio [HR] 0·68, 95% CI 0·60-0·77), and of possibly related readmissions by 11% (HR 0·89, 0·85-0·94) compared with open surgery. Procedure type, malignancy, sex, and age were also independently associated with risk of adhesion-related readmissions. INTERPRETATION: Laparoscopic surgery reduces the incidence of adhesion-related readmissions. However, the overall burden of readmissions associated with adhesions remains high. With further increases in the use of laparoscopic surgery expected in the future, the effect at the population level might become larger. Further steps remain necessary to reduce the incidence of adhesion-related postsurgical complications. FUNDING: Dutch Adhesion Group and Nordic Pharma.


Asunto(s)
Laparoscopía/efectos adversos , Readmisión del Paciente/estadística & datos numéricos , Procedimientos Quirúrgicos Operativos/efectos adversos , Adherencias Tisulares/etiología , Abdomen/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Incidencia , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Pelvis/cirugía , Complicaciones Posoperatorias/epidemiología , Reoperación/efectos adversos , Estudios Retrospectivos , Adherencias Tisulares/cirugía , Adulto Joven
3.
Anaesthesia ; 75 Suppl 1: e121-e133, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31903567

RESUMEN

The epidemiology of peri-operative acute kidney injury varies depending on the definition, type of surgery and acute and chronic comorbidities. Haemodynamic instability, disturbance of the microcirculation, endothelial dysfunction, inflammation and tubular cell injury are the main factors contributing to the pathogenesis. There are no specific therapies. The most effective strategies to protect renal function during the peri-operative period are: the avoidance of nephrotoxic insults; optimisation of haemodynamics; prevention of hypotension; and meticulous fluid management, including avoidance of both hypovolaemia and hypervolaemia. Peri-operative acute kidney injury is associated with an increased risk of short- and long-term postoperative complications, including a longer stay in hospital, development of premature chronic kidney disease and increased mortality. Resource utilisation and healthcare costs are also higher. In future, the development of advanced clinical prediction scores, new imaging and monitoring techniques and the application of new biomarkers for acute kidney injury have the prospect of identifying acute kidney injury earlier and allowing a more personalised management approach with the aim of reducing the global burden of acute kidney injury.


Asunto(s)
Lesión Renal Aguda/etiología , Anestesia/efectos adversos , Complicaciones Posoperatorias/etiología , Procedimientos Quirúrgicos Operativos/efectos adversos , Humanos , Factores de Riesgo
4.
JAMA ; 323(3): 225-236, 2020 01 21.
Artículo en Inglés | MEDLINE | ID: mdl-31961418

RESUMEN

Importance: It is not known if use of colloid solutions containing hydroxyethyl starch (HES) to correct for intravascular deficits in high-risk surgical patients is either effective or safe. Objective: To evaluate the effect of HES 130/0.4 compared with 0.9% saline for intravascular volume expansion on mortality and postoperative complications after major abdominal surgery. Design, Setting, and Participants: Multicenter, double-blind, parallel-group, randomized clinical trial of 775 adult patients at increased risk of postoperative kidney injury undergoing major abdominal surgery at 20 university hospitals in France from February 2016 to July 2018; final follow-up was in October 2018. Interventions: Patients were randomized to receive fluid containing either 6% HES 130/0.4 diluted in 0.9% saline (n = 389) or 0.9% saline alone (n = 386) in 250-mL boluses using an individualized hemodynamic algorithm during surgery and for up to 24 hours on the first postoperative day, defined as ending at 7:59 am the following day. Main Outcomes and Measures: The primary outcome was a composite of death or major postoperative complications at 14 days after surgery. Secondary outcomes included predefined postoperative complications within 14 days after surgery, durations of intensive care unit and hospital stays, and all-cause mortality at postoperative days 28 and 90. Results: Among 826 patients enrolled (mean age, 68 [SD, 7] years; 91 women [12%]), 775 (94%) completed the trial. The primary outcome occurred in 139 of 389 patients (36%) in the HES group and 125 of 386 patients (32%) in the saline group (difference, 3.3% [95% CI, -3.3% to 10.0%]; relative risk, 1.10 [95% CI, 0.91-1.34]; P = .33). Among 12 prespecified secondary outcomes reported, 11 showed no significant difference, but a statistically significant difference was found in median volume of study fluid administered on day 1: 1250 mL (interquartile range, 750-2000 mL) in the HES group and 1500 mL (interquartile range, 750-2150 mL) in the saline group (median difference, 250 mL [95% CI, 83-417 mL]; P = .006). At 28 days after surgery, 4.1% and 2.3% of patients had died in the HES and saline groups, respectively (difference, 1.8% [95% CI, -0.7% to 4.3%]; relative risk, 1.76 [95% CI, 0.79-3.94]; P = .17). Conclusions and Relevance: Among patients at risk of postoperative kidney injury undergoing major abdominal surgery, use of HES for volume replacement therapy compared with 0.9% saline resulted in no significant difference in a composite outcome of death or major postoperative complications within 14 days after surgery. These findings do not support the use of HES for volume replacement therapy in such patients. Trial Registration: ClinicalTrials.gov Identifier: NCT02502773.


Asunto(s)
Abdomen/cirugía , Fluidoterapia/métodos , Derivados de Hidroxietil Almidón/uso terapéutico , Complicaciones Posoperatorias/prevención & control , Solución Salina/uso terapéutico , Procedimientos Quirúrgicos Operativos/efectos adversos , Lesión Renal Aguda/prevención & control , Anciano , Método Doble Ciego , Femenino , Humanos , Cuidados Intraoperatorios , Masculino , Persona de Mediana Edad , Cuidados Posoperatorios , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/mortalidad , Estadísticas no Paramétricas
5.
J Surg Res ; 246: 131-138, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31580983

RESUMEN

BACKGROUND: Wound classification helps predict wound-related complications and is useful in stratifying surgical site infection reporting. We sought to evaluate misclassification among commonly performed surgeries that are at least clean-contaminated. MATERIALS AND METHODS: The National Surgical Quality Improvement Program database was queried from 2005 to 2016 by Current Procedural Terminology codes identifying common surgeries that are, by definition, not clean: colectomy, cholecystectomy, hysterectomy, and appendectomy. Univariate analysis and multivariate logistic regression were performed. RESULTS: Of the 1,208,544 operative cases reviewed, 22,925 (1.90%) were misclassified as clean. Hysterectomy was the most commonly misclassified operation (3.11%), and colectomy the least (0.82%). Misclassification was higher in laparoscopic cases (1.92% versus 1.82%; P < 0.01). Misclassification increased from 2005 to 2016 (0.22% versus 3.11%; P < 0.01). Misclassified patients were younger (46.7 versus 47.7 y; P < 0.01); had lower rates of hypertension, chronic obstructive pulmonary disease, smoking history, and steroid use (P < 0.01); and had shorter length of stay (2.2 versus 3.2 d; P < 0.01), lower 30-d readmission rates (3.7% versus 5.0%; P < 0.01), and less surgical site infections (1.7% versus 3.4%; P < 0.01). Open hysterectomy was the most significant positive predictor for misclassification (odds ratio 3.34; P < 0.01). Open appendectomy was the most significant negative predictor (odds ratio 0.20; P < 0.01). CONCLUSIONS: There is an increasing trend of misclassifying wounds as clean. Misclassified patients have better outcomes, and misclassification may be affected by patient characteristics, operative approach, and type of procedure rather than reflecting the true infectious burden. Further research is warranted.


Asunto(s)
Procedimientos Quirúrgicos Operativos/clasificación , Infección de la Herida Quirúrgica/epidemiología , Herida Quirúrgica/clasificación , Factores de Edad , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Readmisión del Paciente/estadística & datos numéricos , Factores de Riesgo , Procedimientos Quirúrgicos Operativos/efectos adversos , Herida Quirúrgica/complicaciones , Infección de la Herida Quirúrgica/etiología
6.
J Surg Res ; 246: 106-112, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31563830

RESUMEN

BACKGROUND: Nongovernmental organizations conduct short-term surgical outreach to lessen the substantial global burden of surgical disease. Long-term outcomes of short-term surgical missions (STSMs) are underreported, raising concern for clinical sequelae and patient satisfaction with essential general surgeries. This study aims to describe long-term follow-up results of one general surgical nongovernmental organization's provision of care in rural Ghana with focus on patient-related outcomes and satisfaction. METHODS: From 2013 to 2018, Tetteh Quarshie Memorial Hospital in Mampong, Ghana, was the host site of annual 1-wk International Surgical Health Initiative (ISHI) STSMs. Beginning in 2016, an ISHI provider-hosted follow-up clinics augmented by mobile telephone support. Surgical patients from 2013 to 2016 were contacted by the local nursing staff and evaluated for long-term outcomes and self-reported satisfaction. RESULTS: Sixty-nine of 256 patients (27%) responded; 39 patients (57%) were interviewed and examined by an ISHI physician, whereas 30 patients (43%) received mobile telephone follow-up. Mean age was 47 (±18) y, with 44% female patients, and mean duration of follow-up was 1.5 (±1) y. Eleven patients (16%) had surgical and anesthesia complications. All patients reported improvement in symptoms and activity level. Eighty-six patients reported complete satisfaction (5/5). Factors associated with reduced patient satisfaction (<5/5) included increased age and complications. CONCLUSIONS: To our knowledge, this is one of the first studies focusing on patient-reported outcomes for the evaluation of long-term follow-up of general surgery STSMs. With mobile technology, long-term follow-up is achievable toward obtaining meaningful outcomes. Complications in this series are within an acceptable range, whereas symptom improvement and overall satisfaction are high.


Asunto(s)
Altruismo , Misiones Médicas/estadística & datos numéricos , Satisfacción del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Procedimientos Quirúrgicos Operativos/efectos adversos , Adulto , Anciano , Femenino , Estudios de Seguimiento , Ghana/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Medición de Resultados Informados por el Paciente , Complicaciones Posoperatorias/etiología , Población Rural/estadística & datos numéricos , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos , Resultado del Tratamiento
7.
Int J Cancer ; 146(5): 1324-1332, 2020 03 01.
Artículo en Inglés | MEDLINE | ID: mdl-31523804

RESUMEN

Modern cancer therapy has led to a growing number of pediatric and young adult cancer survivors, who are prone to increased morbidities caused by the late effects of therapy. The aim of our study was to investigate pediatric and young adult cancer survivors' morbidity due to renal and bone metabolism diseases and especially to study bone metabolism in cancer survivors with renal disease. Patients were identified from the Finnish Cancer Registry, and the cohort consisted of 13,860, 5-year survivors of cancer diagnosed below the age of 35 years. Healthy siblings were used as the comparison cohort. Information on the main outcomes was linked from the national Care Register for Health Care. Hazard ratios (HRs) comparing cancer survivors to siblings were calculated for various outcomes. The patient cohort was separated into two age groups, pediatric (0-19 years) and young adults (20-34 years). Significantly elevated HRs (p < 0.0001) in survivors were observed in both age groups for scoliosis (HR 1.6, 95% confidence interval [CI] 1.3-2.0), osteoporosis (HR 5.2, 95% CI 2.4-11.4), osteonecrosis (HR 12.7, 95% CI 5.4-29.7), nephritis (HR 1.9, 95% CI 1.5-2.2) and kidney failure (HR 3.6, 95% CI 2.4-5.3) for all. For cancer survivors with a renal outcome, the risk for developing any outcome of bone metabolism was increased (HR 2.3, 95% CI 1.4-3.6). These results show that pediatric and young adult cancer survivors have an elevated risk for long-term, adverse outcomes related to renal function and bone metabolism. These results suggest follow-up care for young cancer patients.


Asunto(s)
Enfermedades Óseas Metabólicas/epidemiología , Supervivientes de Cáncer/estadística & datos numéricos , Enfermedades Renales/epidemiología , Neoplasias/terapia , Adolescente , Antineoplásicos/efectos adversos , Enfermedades Óseas Metabólicas/etiología , Niño , Preescolar , Femenino , Finlandia/epidemiología , Estudios de Seguimiento , Estado de Salud , Humanos , Incidencia , Lactante , Recién Nacido , Enfermedades Renales/etiología , Masculino , Neoplasias/complicaciones , Neoplasias/mortalidad , Modelos de Riesgos Proporcionales , Radioterapia/efectos adversos , Sistema de Registros/estadística & datos numéricos , Factores de Riesgo , Hermanos , Procedimientos Quirúrgicos Operativos/efectos adversos , Adulto Joven
8.
Ann R Coll Surg Engl ; 102(2): 84-93, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31233334

RESUMEN

OBJECTIVE: Elastofibroma is a rare soft-tissue tumour. This study retrospectively analysed and summarised the clinical, imaging and typical pathological features, together with the short- and long-term surgical outcomes of patients with pathologically confirmed soft-tissue elastofibroma to improve their management. MATERIALS AND METHODS: We enrolled 73 patients with pathologically confirmed soft-tissue elastofibroma from January 2010 to December 2018. The general, clinical, diagnostic and treatment-related data, operation notes, pathological examination results and follow-up status were obtained by reviewing inpatient medical records. Disease onset age, sex, tumour location and size were statistically analysed using the chi square and rank sum tests. RESULTS: A total of 90 lesions from 73 patients were examined. Among these, 56 patients had single lesions: 27 were under the right scapula, 26 were under the left scapula, 1 at the umbilicus, 1 on the aortic valve, 1 on the right hip and 17 at the bilateral inferior angles of the scapula. The average age at onset was 56.4 years (range: 6-82 years). The male-to-female incidence ratio was about one to three. Tumour diameter and follow-up duration ranged from 2cm to 12cm and from one month to nine years, respectively; recurrence was not observed. The main postoperative complication was wound effusion, occurring in 24 sites among the 90 lesions, corresponding to an incidence rate of 26.7%. CONCLUSIONS: A correct diagnosis of elastofibroma can be made prior to surgical resection by examining typical clinical features and characteristic imaging findings. Short- and long-term outcomes of local excision are good, with no further recurrence.


Asunto(s)
Fibroma/cirugía , Recurrencia Local de Neoplasia/epidemiología , Complicaciones Posoperatorias/epidemiología , Procedimientos Quirúrgicos Operativos/efectos adversos , Adulto , Edad de Inicio , Anciano , Anciano de 80 o más Años , Niño , Femenino , Fibroma/epidemiología , Fibroma/patología , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/prevención & control , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Factores Sexuales , Resultado del Tratamiento , Adulto Joven
9.
J Surg Res ; 245: 629-635, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31522036

RESUMEN

BACKGROUND: Emergency general surgery (EGS) accounts for more than 2 million U.S. hospital admissions annually. Low-income EGS patients have higher rates of postoperative adverse events (AEs) than high-income patients. This may be related to health care segregation (a disparity in access to high-quality centers). The emergent nature of EGS conditions and the limited number of EGS providers in rural areas may result in less health care segregation and thereby less variability in EGS outcomes in rural areas. The objective of this study was to assess the impact of income on AEs for both rural and urban EGS patients. MATERIALS AND METHODS: The National Inpatient Sample (2007-2014) was queried for patients receiving one of 10 common EGS procedures. Multivariate regression models stratified by income quartiles in urban and rural cohorts adjusting for sociodemographic, clinical, and other hospital-based factors were used to determine the rates of surgical AEs (mortality, complications, and failure to rescue [FTR]). RESULTS: 1,687,088 EGS patients were identified; 16.60% (n = 280,034) of them were rural. In the urban cohort, lower income quartiles were associated with higher odds of AEs (mortality OR, 1.21 [95% CI, 1.15-1.27], complications, 1.07 [1.06-1.09]; FTR, 1.17 [1.10-1.24] P < 0.001). In the rural context, income quartiles were not associated with the higher odds of AE (mortality OR, 1.14 [0.83-1.55], P = 0.42; complications, 1.06 [0.97-1,16], P = 1.17; FTR, 1.12 [0.79-1.59], P = 0.52). CONCLUSIONS: Lower income is associated with higher postoperative AEs in the urban setting but not in a rural environment. This socioeconomic disparity in EGS outcomes in urban settings may reflect health care segregation, a differential access to high-quality health care for low-income patients.


Asunto(s)
Tratamiento de Urgencia/efectos adversos , Disparidades en Atención de Salud/economía , Renta/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Procedimientos Quirúrgicos Operativos/efectos adversos , Adolescente , Adulto , Servicio de Urgencia en Hospital/estadística & datos numéricos , Tratamiento de Urgencia/estadística & datos numéricos , Fracaso de Rescate en Atención a la Salud/estadística & datos numéricos , Femenino , Accesibilidad a los Servicios de Salud/economía , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Disparidades en Atención de Salud/estadística & datos numéricos , Mortalidad Hospitalaria , Hospitales Rurales/estadística & datos numéricos , Hospitales Urbanos/estadística & datos numéricos , Humanos , Pacientes Internos/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Población Rural/estadística & datos numéricos , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos , Estados Unidos/epidemiología , Población Urbana/estadística & datos numéricos , Adulto Joven
10.
J Surg Res ; 245: 295-301, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31421376

RESUMEN

BACKGROUND: One-per-mil tumescent technique could provide local anesthesia in surgical procedures despite using low lidocaine concentration. Tumescence environment within the tissue may play a role in supporting local anesthesia effect. This study aims to delineate whether the tumescence environment, created by one-per-mil solution without a local anesthetic agent, had a local anesthesia effect. METHODS: Four different compositions and volumes of tumescent solutions containing 1:1,000,000 epinephrine were injected into 50 Swiss Webster mice. The animals were divided into five groups: group A, a tumescent solution with 0.2% lidocaine; group B, a tumescent solution with 0.04% lidocaine; group C, a tumescent solution without lidocaine; group D, a doubled volume of tumescent solution without lidocaine; and group E, controls. Local anesthesia effects were tested by using the formalin test (n = 25) and tail immersion test (n = 25). Pain response behavior in the form of paw licking duration and tail withdrawal latency was observed. The analysis of variance and Kruskal-Wallis tests were used to test the statistical difference. Significance was set at P < 0.05. RESULTS: The four interventional groups showed less pain response behavior and significantly longer tail withdrawal latency (P < 0.05) than the control group. However, the groups showed nonsignificantly shorter paw licking duration than the control (P > 0.05). Group A had the fastest onset of the local anesthesia effect. CONCLUSIONS: The tumescence environment was potentially able to provide a local anesthesia effect, although the solution did not contain a local anesthetic agent as proved by the tail immersion test.


Asunto(s)
Anestesia Local/métodos , Anestésicos Locales/administración & dosificación , Epinefrina/administración & dosificación , Dolor/prevención & control , Animales , Modelos Animales de Enfermedad , Relación Dosis-Respuesta a Droga , Inyecciones Subcutáneas , Lidocaína/administración & dosificación , Masculino , Ratones , Dolor/diagnóstico , Dolor/etiología , Dimensión del Dolor , Procedimientos Quirúrgicos Operativos/efectos adversos
11.
J Surg Res ; 245: 315-320, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31421379

RESUMEN

BACKGROUND: Transplant patients are at the risk of serious sequelae from medical and surgical intervention. The incidence and burden of emergency general surgery (EGS) in transplant patients are scarcely known. This study aims to identify predictors of outcomes in transplant patients with EGS needs. METHODS: The Nationwide Inpatient Sample (2007-2011) was queried for adult patients (aged ≥16 y) who underwent abdominal visceral transplantation. These were further queried for a secondary diagnosis of an American Association for the Surgery of Trauma-defined EGS condition. Outcome measures included mortality, complications, length of stay, and cost of care. Propensity scores were used to match patients across baseline characteristics. Multivariate analysis was used to further adjust propensity score quintiles and hospital-level characteristics. RESULTS: A total of 35,573 transplant patients were identified. Of these, 30% (n = 10,676) developed an EGS condition. Most common EGS conditions were resuscitation (7.7%), intestinal obstruction (7.3%), biliary conditions (3.9%), and hernias (3.2%). Patients with public insurance, those in the highest income quartile, and those treated at larger hospitals had a lower likelihood of developing an EGS condition (P < 0.05). Patients with an EGS condition had a ninefold higher likelihood of mortality and a threefold higher likelihood of developing complications (odds ratio [95% confidence interval (CI)]: 9.21 [1.80-10.89] and 3.17 [3.02-3.34], respectively). Transplant patients after EGS had a longer risk-adjusted length of stay and cost of index hospitalization (Absolute difference [95% CI]: 12.70 [12.14-13.26] and $57,797 [55,415-60,179], respectively]). CONCLUSIONS: Transplant patients fare poorly after developing an EGS condition. The results of this study will help in identifying at-risk patients and determining outcomes.


Asunto(s)
Servicio de Urgencia en Hospital/estadística & datos numéricos , Tratamiento de Urgencia/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos , Receptores de Trasplantes/estadística & datos numéricos , Adulto , Anciano , Bases de Datos Factuales/estadística & datos numéricos , Tratamiento de Urgencia/efectos adversos , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Puntaje de Propensión , Estudios Retrospectivos , Procedimientos Quirúrgicos Operativos/efectos adversos , Estados Unidos
12.
Rev. bras. cir. plást ; 34(4): 458-467, oct.-dec. 2019. ilus, tab
Artículo en Inglés, Portugués | LILACS | ID: biblio-1047901

RESUMEN

Introdução: A lipoaspiração tem sido submetida à evolução constante desde a sua consolidação e emprego sistemático. O auxílio de tecnologia ultrassônica de terceira geração, VASER® (Vibration Amplification of Sound Energy at Resonance), se destina a facilitar a execução da lipoaspiração e trazer maior segurança e resultados satisfatórios, especialmente na busca por maior definição e lipoaspiração superficial. Métodos: No período de 2015 a 2017, 76 pacientes foram submetidas à lipoaspiração para melhora de contorno corporal no Centro Hospitalar Santa Mônica em Erechim. Foram avaliados os resultados obtidos, as possíveis complicações e a segurança do emprego do VASER®. Resultados: A utilização rotineira do VASER® gera aperfeiçoamento de resultados em contorno corporal. A emulsificação gerada pelo dispositivo associada à lipoaspiração em diversos níveis permite uma maior definição e evidenciação dos marcos anatômicos. Conclusão: Lipoaspiração associada ao VASER® permite ao cirurgião plástico o refinamento de seus resultados com a preservação da segurança do paciente.


Introduction: Liposuction has been improved continuously since it was first introduced. The third-generation ultrasound technology VASERTM (Vibration Amplification of Sound Energy at Resonance) facilitates liposuction, providing improved safety and satisfactory results, especially in the search for greater definition and superficial liposuction. Methods: From 2015 to 2017, 76 patients underwent liposuction to improve their body contour at the Santa Monica Hospital Center in Erechim, Rio Grande do Sul, Brazil. The results, complications, and the safety of VASERTM were evaluated. Results: The routine use of VASERTM improves body contour. The emulsification generated by the device, along with liposuction, resulted in greater definition and revelation of the anatomical landmarks. Conclusion: Liposuction associated with VASERTM allows plastic surgeons to refine the results better while ensuring patient safety is maintained.


Asunto(s)
Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Anciano , Historia del Siglo XXI , Complicaciones Posoperatorias/cirugía , Procedimientos Quirúrgicos Operativos , Lipectomía , Tejido Adiposo , Grasa Subcutánea/cirugía , Seguridad del Paciente/normas , Contorneado Corporal , Lipodistrofia , Complicaciones Posoperatorias , Procedimientos Quirúrgicos Operativos/efectos adversos , Procedimientos Quirúrgicos Operativos/métodos , Lipectomía/métodos , Tejido Adiposo/cirugía , Grasa Subcutánea , Seguridad del Paciente , Contorneado Corporal/efectos adversos , Contorneado Corporal/métodos , Lipodistrofia/cirugía , Lipodistrofia/complicaciones
13.
Rev. bras. cir. plást ; 34(4): 436-444, oct.-dec. 2019. ilus, tab
Artículo en Inglés, Portugués | LILACS | ID: biblio-1047896

RESUMEN

Introdução: O número de pacientes classificados com sobrepeso ou obesos e, com isso, dos pacientes pós-bariátricas vem aumentando, gerando uma demanda por ritidoplastias neste perfil de público. O objetivo é expor a rotina e táticas cirúrgicas em um hospital de ensino, o perfil destes pacientes, além de um comparativo superficial histológico da pele, tecido celular subcutâneo e SMAS, entre os pacientes pós e não pós-bariátrica. Métodos: Foi realizado revisão de dados do centro cirúrgico e de prontuário entre os anos de 2012 e 2016 em um hospital público na cidade de Goiânia-GO, com levantamento de 32 casos. Resultados: A tática de ritidoplastia utilizada nos pacientes pós-bariátrica não apresenta grandes diferenças entre a utilizada nos pacientes não pós-bariátrica. A análise histopatológica das amostras colhidas evidenciou diferenças marcantes entre os pacientes pós e não pós-bariátrica. Conclusão: Percebeu-se que a técnica operatória na ritidoplastia do paciente pós-bariátrica sustentou detalhes específicos, com resultado cirúrgico pós-operatório satisfatório, uma pele de pior qualidade histológica, com complicações perioperatórias dentro do esperado e com necessidade de maiores estudos para avaliar durabilidade do procedimento.


Introduction: The number of patients classified as overweight or obese has resulted in an increased number of post-bariatric patients, generating a demand for rhytidoplasty in this public profile. The objective is to expose the routine and surgical tactics in a teaching hospital, patient profiles, subcutaneous cellular tissue, and the superficial musculoaponeurotic system are compared between post-bariatric and non-post-bariatric patients, as well as histological superficial comparison of the skin. Methods: A review of the data of 32 cases treated in 2012­2016 was conducted in a public hospital in Goiânia-GO. Results: The tactics of rhytidoplasty used in post-bariatric patients do not differ significantly from those used in nonpost- bariatric patients. A histopathological analysis of the collected samples showed marked differences between post-bariatric and non-post-bariatric patients. Conclusion: The surgical technique of rhytidoplasty of post-bariatric patients sustained specific details with satisfactory postoperative surgical results, skin with worse histological quality, perioperative complications within the expected range, and the need for further studies to assess the procedure's durability


Asunto(s)
Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Anciano , Historia del Siglo XXI , Complicaciones Posoperatorias , Piel , Procedimientos Quirúrgicos Operativos , Estudio Comparativo , Ritidoplastia , Conductas Terapéuticas , Cirugía Bariátrica , Cara , Complicaciones Posoperatorias/cirugía , Complicaciones Posoperatorias/terapia , Piel/anatomía & histología , Piel/patología , Procedimientos Quirúrgicos Operativos/efectos adversos , Procedimientos Quirúrgicos Operativos/métodos , Ritidoplastia/efectos adversos , Ritidoplastia/métodos , Conductas Terapéuticas/normas , Cutis Laxo , Cutis Laxo/terapia , Cirugía Bariátrica/efectos adversos , Cirugía Bariátrica/métodos , Cara/anatomía & histología , Cara/patología
14.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(11): 1027-1033, 2019 Nov 25.
Artículo en Chino | MEDLINE | ID: mdl-31770833

RESUMEN

Objective: To understand the prevalence, diagnosis and treatment of chronic critical illness (CCI) in China. Methods: The clinical data of 472 adult patients admitted to ICU in 53 hospitals, including basic information, disease-related data, nutrition program, etc., were collected on May 10, 2019, by means of multi-center cross-sectional study. If surgical intervention was needed or the occurrence of the disease was directly related to the surgery, ICU patients were regarded as surgical ICU cases (n=211). In this study, the diagnostic criteria for CCI were: (1) admission to ICU >14 days;(2) combined with persistent organ dysfunction. The prevalence,distribution and treatment of CCI and surgery-related CCI were recorded and analyzed. The Mann-Whitney U test, chi-square test or Fisher exact test were used for comparative analysis. Results: Among the 472 ICU patients from 53 hospitals, 326 were male (69.1%) and 146 were female (30.9%). The prevalence of CCI was 30.7% (145/472). Among 211 surgery-related ICU patients, 57 developed CCI with a prevalence of 27.0%. As compared to non-CCI patients, higher APACHE II score [median (IQR) 13.5 (10.0, 18.3) vs. 11.0 (7.0, 16.0), U=2970.000, P=0.007], higher Charlson comorbidity index [median (IQR) 4.0 (2.0, 7.0) vs. 3.0 (1.0, 5.0), U= 3570.000, P=0.036] and higher ratio of breath dysfunction [68.4% (39/57) vs. 48.1% (74/154), χ(2)=6.939, P=0.008] and renal dysfunction [42.1% (24/57) vs. 18.2% (28/154), χ(2)=12.821, P<0.001] were found in surgery-related CCI patients. While SOFA score, Glasgow coma score and other visceral function were not significantly different between surgery-related CCI and non-CCI patients (all P>0.05). NUTRIC score showed that surgery-related CCI patients had higher nutritional risk [43.9% (25/57) vs. 26.6%(41/154), U=5.750, P=0.016] and higher ratio of mechanical ventilation [66.7% (38/57) vs. 52.3% (79/154), χ(2)=3.977, P=0.046] than non-CCI patients. On the survey day, the daily caloric requirements of 50.2% (106/211) of surgery-related ICU patients were calculated according to the standard adult caloric intake index (104.6 to 125.5 kJ·kg(-1)·d(-1), 1 kJ=0.239 kcal), and the daily caloric requirements of 46.4% (98/211) of patients were calculated by physicians according to the severity of the patient's condition. 60.2% (127/211) of nutritional support therapy was enteral nutrition (including a combination of enteral and parenteral nutrition), while the remaining patients received parenteral nutrition (24.6%, 52/211), simple glucose infusion (9.0%, 19/211), or oral diet (6.2%, 13/211). The target calorie of CCI group was 104.6 (87.9, 125.5) kJ·kg(-1)·d(-1), and the actual calorie intake accounted for 0.98 (0.80, 1.00) of the target calory. In the non-CCI group, the target calorie was 104.6 (87.9, 125.5) kJ·kg(-1)·d(-1), and the actual calorie consumed accounted for 0.91 (0.66, 1.00) of the target calorie. There was no statistically significant difference between two groups (P=0.248, P=0.150). Conclusion: The prevalence of CCI and surgery-related CCI in ICU is high, along with severe complications, respiratory and renal dysfunction and mechanical ventilation. Surgical patients admitted to ICU are at high nutritional risk, and active and correct nutritional support is essential for such patients.


Asunto(s)
Enfermedad Crítica/epidemiología , Enfermedad Crítica/terapia , Adulto , China/epidemiología , Enfermedad Crónica/epidemiología , Enfermedad Crónica/terapia , Estudios Transversales , Femenino , Humanos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Masculino , Apoyo Nutricional/estadística & datos numéricos , Procedimientos Quirúrgicos Operativos/efectos adversos
15.
Br J Nurs ; 28(21): 1358-1364, 2019 Nov 28.
Artículo en Inglés | MEDLINE | ID: mdl-31778327

RESUMEN

This article describes the development of a scoring system for general surgical patients to highlight those at greater risk of developing acute kidney injury (AKI). Following a search of the literature on current practice, a list of common variables was composed. Hospital Episode Statistics (HES) data from two random hospital trusts was used. With the help of a risk analysis system (CRAB Medical module, CRAB Clinical Informatics Ltd) it was possible to examine the relationship between potential risk factors and the incidence of AKI. Using Analyse-it for Excel a binary logistic model was created, which led to the development of a logistic regression equation and consequently a scoring system. The sensitivity and specificity of the model was tested using the receiver operating characteristic (ROC) curve. There was good correlation across the whole risk spectrum with an area under ROC curve of 0.806 (95% confidence intervals 0.787-0.825). The scoring system was developed into an admission checklist for general surgical patients to highlight a patient's risk of developing AKI. In a ward setting a checklist that immediately assesses the patient and produces a rapid indication as to whether the patient is at high risk or low risk would seem to be the ideal tool.


Asunto(s)
Lesión Renal Aguda/epidemiología , Medición de Riesgo/métodos , Procedimientos Quirúrgicos Operativos/efectos adversos , Humanos
16.
Crit Care Resusc ; 21(4): 243-50, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31778630

RESUMEN

BACKGROUND: Mechanical ventilation is mandatory in patients undergoing general anaesthesia for major surgery. Tidal volumes higher than 10 mL/kg of predicted body weight have been advocated for intraoperative ventilation, but recent evidence suggests that low tidal volumes may benefit surgical patients. To date, the impact of low tidal volume compared with conventional tidal volume during surgery has only been assessed in clinical trials that also combine different levels of positive end-expiratory pressure (PEEP) in each arm. We aimed to assess the impact of low tidal volume compared with conventional tidal volume during general anaesthesia for surgery on the incidence of postoperative respiratory complications in adult patients receiving moderate levels of PEEP. STUDY DESIGN AND METHODS: Single-centre, two-arm, randomised clinical trial. In total, 1240 adult patients older than 40 years scheduled for at least 2 hours of surgery under general anaesthesia and routinely monitored with an arterial line were included. Patients were ventilated intraoperatively with a moderate level of PEEP (5 cmH2O) and randomly assigned to tidal volume of 6 mL/kg predicted body weight (low tidal volume) or 10 mL/kg predicted body weight (conventional tidal volume in Australia). MAIN OUTCOME MEASURE: The primary outcome is the occurrence of postoperative respiratory complications, recorded as a composite endpoint of adverse respiratory events during the first 7 postoperative days. RESULTS AND CONCLUSIONS: This is the first well powered study comparing the effect of low tidal volume ventilation versus high tidal volume ventilation during surgery on the incidence of postoperative respiratory complications in adult patients receiving moderate levels of PEEP. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN12614000790640).


Asunto(s)
Anestesia General , Respiración con Presión Positiva , Volumen de Ventilación Pulmonar/efectos de los fármacos , Adulto , Anestesia General/efectos adversos , Australia , Humanos , Respiración con Presión Positiva/efectos adversos , Ensayos Clínicos Controlados Aleatorios como Asunto , Respiración Artificial , Procedimientos Quirúrgicos Operativos/efectos adversos , Procedimientos Quirúrgicos Operativos/métodos , Volumen de Ventilación Pulmonar/fisiología
17.
N Z Med J ; 132(1503): 13-24, 2019 10 04.
Artículo en Inglés | MEDLINE | ID: mdl-31581178

RESUMEN

AIM: To assess the incidence of pre-operative anaemia in patients presenting for general surgery and determine the relationship between pre-operative anaemia, transfusion and post-operative metrics including length of stay (LOS) and infectious complications. METHOD: A retrospective cohort of 1,186 patients. Stratification into two groups with and without pre-operative anaemia through propensity score matching. Logistic regression was used to determine the relationship between pre-operative anaemia, blood transfusion and infectious complications. RESULTS: The incidence of pre-operative anaemia was 17.4%. Red blood cell (RBC) transfusion was greater in those with PA than those without, 13.1% versus 0.7% (OR 21.7 (2.9-166.7, p<0.001)). In the propensity matched cohort, pre-operative anaemia was associated with an increase in LOS from 2.1 to 3.0 days (p=0.006) and increased infectious complications from 6.4% to 18.4%, (OR 3.3 (1.4-7.7), p=0.004). The risk of infectious complications was amplified in the patients receiving RBC transfusion. After adjustment for transfusion, in patients with pre-operative anaemia the OR for infectious complications became 2.3 (0.95-5.7, p=0.06) for those not transfused and 5.5 (2.0-15.3, p=0.001) for those transfused. CONCLUSION: Pre-operative anaemia is associated with an increase in hospital LOS and infectious complications. When adjusted for transfusion the effect of pre-operative anaemia alone on hospital LOS and infectious complications is not statistically significant. Expeditious investigation and treatment of PA could reduce complications and save resources.


Asunto(s)
Anemia , Transfusión Sanguínea , Atención Perioperativa , Complicaciones Posoperatorias , Procedimientos Quirúrgicos Operativos , Adulto , Anemia/diagnóstico , Anemia/epidemiología , Anemia/etiología , Transfusión Sanguínea/métodos , Transfusión Sanguínea/estadística & datos numéricos , Femenino , Cirugía General , Hemoglobinas/análisis , Humanos , Tiempo de Internación , Masculino , Nueva Zelanda/epidemiología , Atención Perioperativa/métodos , Atención Perioperativa/estadística & datos numéricos , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/terapia , Estudios Retrospectivos , Factores de Riesgo , Procedimientos Quirúrgicos Operativos/efectos adversos , Procedimientos Quirúrgicos Operativos/métodos , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos
18.
Endocrinology ; 160(12): 2892-2902, 2019 12 01.
Artículo en Inglés | MEDLINE | ID: mdl-31589305

RESUMEN

Insulin resistance is an independent negative predictor of outcome after elective surgery and increases mortality among surgical patients in intensive care. The incretin hormone glucagon-like peptide-1 (GLP-1) potentiates glucose-induced insulin release from the pancreas but may also increase insulin sensitivity in skeletal muscle and directly suppress hepatic glucose release. Here, we investigated whether a perioperative infusion of GLP-1 could counteract the development of insulin resistance after surgery. Pigs were randomly assigned to three groups; surgery/control, surgery/GLP-1, and sham/GLP-1. Both surgery groups underwent major abdominal surgery. Whole-body glucose disposal (WGD) and endogenous glucose release (EGR) were assessed preoperatively and postoperatively using D-[6,6-2H2]-glucose infusion in combination with hyperinsulinemic euglycemic step-clamping. In the surgery/control group, peripheral insulin sensitivity (i.e., WGD) was reduced by 44% relative to preoperative conditions, whereas the corresponding decline was only 9% for surgery/GLP-1 (P < 0.05). Hepatic insulin sensitivity (i.e., EGR) remained unchanged in the surgery/control group but was enhanced after GLP-1 infusion in both surgery and sham animals (40% and 104%, respectively, both P < 0.05). Intraoperative plasma glucose increased in surgery/control (∼20%) but remained unchanged in both groups receiving GLP-1 (P < 0.05). GLP-1 diminished an increase in postoperative glucagon levels but did not affect skeletal muscle glycogen or insulin signaling proteins after surgery. We show that GLP-1 improves intraoperative glycemic control, diminishes peripheral insulin resistance after surgery, and suppresses EGR. This study supports the use of GLP-1 to prevent development of postoperative insulin resistance.


Asunto(s)
Péptido 1 Similar al Glucagón/administración & dosificación , Incretinas/administración & dosificación , Resistencia a la Insulina , Atención Perioperativa/métodos , Procedimientos Quirúrgicos Operativos/efectos adversos , Animales , Glucemia , Evaluación Preclínica de Medicamentos , Femenino , Técnica de Clampeo de la Glucosa , Glucógeno/metabolismo , Infusiones Intravenosas , Insulina/sangre , Hígado/metabolismo , Músculo Esquelético/metabolismo , Periodo Perioperatorio , Distribución Aleatoria , Porcinos
19.
Rev Lat Am Enfermagem ; 27: e2939, 2019.
Artículo en Portugués, Inglés, Español | MEDLINE | ID: mdl-31596404

RESUMEN

OBJECTIVE: to estimate the prevalence and avoidability of surgical adverse events in a teaching hospital and to classify the events according to the type of incident and degree of damage. METHOD: cross-sectional retrospective study carried out in two phases. In phase I, nurses performed a retrospective review on a simple randomized sample of 192 records of adult patients using the Canadian Adverse Events Study form for case tracking. Phase II aimed at confirming the adverse event by an expert committee composed of physicians and nurses. Data were analyzed by univariate descriptive statistics. RESULTS: the prevalence of surgical adverse events was 21.8%. In 52.4% of the cases, detection occurred on outpatient return. Of the 60 cases analyzed, 90% (n = 54) were preventable and more than two thirds resulted in mild to moderate damage. Surgical technical failures contributed in approximately 40% of the cases. There was a prevalence of the infection category associated with health care (50%, n = 30). Adverse events were mostly related to surgical site infection (30%, n = 18), suture dehiscence (16.7%, n = 10) and hematoma/seroma (15%, n = 9). CONCLUSION: the prevalence and avoidability of surgical adverse events are challenges faced by hospital management.


Asunto(s)
Hospitales de Enseñanza/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Procedimientos Quirúrgicos Operativos/efectos adversos , Adulto , Brasil/epidemiología , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Seguridad del Paciente , Complicaciones Posoperatorias/prevención & control , Periodo Posoperatorio , Estudios Retrospectivos , Procedimientos Quirúrgicos Operativos/normas , Dehiscencia de la Herida Operatoria/epidemiología , Infección de la Herida Quirúrgica/epidemiología
20.
Heart Surg Forum ; 22(5): E423-E428, 2019 Oct 01.
Artículo en Inglés | MEDLINE | ID: mdl-31596724

RESUMEN

Although many believe that the phrase "First, do no harm" was part of the Hippocratic Oath, in fact it was not. This phrase, often written in Latin ("Primum non Nocere"), seems to have first appeared in medical writing in the 17th century. However, it is obvious that many therapeutic interventions do cause at least some harm with hopes of benefitting patients in the long run. This balancing of initial harm in hope of eventual benefit is never more apparent than in the case of invasive procedures, though other examples abound, such as the administration of chemotherapy. The ethical concept of nonmaleficence, which traces its origins to the concept of primum non nocere, accurately acknowledges the concept of the need to strive to do more good than harm. Thus, it is apparent that, in a surgical operation, the surgeon is proposing to cause harm, initially, to the patient in hopes of creating an outcome that results in more good than harm. Therefore, the process of obtaining consent from the patient for a surgical operation acknowledges the fact that harm will, in fact, be inflicted on that patient, with the hope that, on balance, this harm will result in a greater overall good for the patient. It is for this reason that the modern concepts of informed consent have developed.


Asunto(s)
Juramento Hipocrático , Consentimiento Informado , Procedimientos Quirúrgicos Operativos , Comunicación , Documentación , Humanos , Consentimiento Informado/ética , Consentimiento Informado/legislación & jurisprudencia , Educación del Paciente como Asunto , Cuidados Preoperatorios , Procedimientos Quirúrgicos Operativos/efectos adversos , Resultado del Tratamiento , Negativa del Paciente al Tratamiento , Revelación de la Verdad
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