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1.
PLoS One ; 16(8): e0254698, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34383776

RESUMO

BACKGROUND: Pneumonia is a common and severe complication of abdominal surgery, it is associated with increased length of hospital stay, healthcare costs, and mortality. Further, pulmonary complication rates have risen during the SARS-CoV-2 pandemic. This study explored the potential cost-effectiveness of administering preoperative chlorhexidine mouthwash versus no-mouthwash at reducing postoperative pneumonia among abdominal surgery patients. METHODS: A decision analytic model taking the South African healthcare provider perspective was constructed to compare costs and benefits of mouthwash versus no-mouthwash-surgery at 30 days after abdominal surgery. We assumed two scenarios: (i) the absence of COVID-19; (ii) the presence of COVID-19. Input parameters were collected from published literature including prospective cohort studies and expert opinion. Effectiveness was measured as proportion of pneumonia patients. Deterministic and probabilistic sensitivity analyses were performed to assess the impact of parameter uncertainties. The results of the probabilistic sensitivity analysis were presented using cost-effectiveness planes and cost-effectiveness acceptability curves. RESULTS: In the absence of COVID-19, mouthwash had lower average costs compared to no-mouthwash-surgery, $3,675 (R 63,770) versus $3,958 (R 68,683), and lower proportion of pneumonia patients, 0.029 versus 0.042 (dominance of mouthwash intervention). In the presence of COVID-19, the increase in pneumonia rate due to COVID-19, made mouthwash more dominant as it was more beneficial to reduce pneumonia patients through administering mouthwash. The cost-effectiveness acceptability curves shown that mouthwash surgery is likely to be cost-effective between $0 (R0) and $15,000 (R 260,220) willingness to pay thresholds. CONCLUSIONS: Both the absence and presence of SARS-CoV-2, mouthwash is likely to be cost saving intervention for reducing pneumonia after abdominal surgery. However, the available evidence for the effectiveness of mouthwash was extrapolated from cardiac surgery; there is now an urgent need for a robust clinical trial on the intervention on non-cardiac surgery.


Assuntos
Abdome/cirurgia , Clorexidina/uso terapêutico , Modelos Teóricos , Pneumonia/prevenção & controle , COVID-19 , Análise Custo-Benefício , Humanos , Antissépticos Bucais , Pandemias , Complicações Pós-Operatórias/prevenção & controle , Cuidados Pré-Operatórios , Estudos Prospectivos , África do Sul
4.
J Clin Oncol ; 39(1): 66-78, 2021 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-33021869

RESUMO

PURPOSE: As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19-free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS: This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19-free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS: Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19-free surgical pathways. Patients who underwent surgery within COVID-19-free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19-free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score-matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19-free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION: Within available resources, dedicated COVID-19-free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks.


Assuntos
COVID-19/prevenção & controle , Cuidados Críticos/métodos , Procedimentos Cirúrgicos Eletivos/métodos , Neoplasias/cirurgia , Complicações Pós-Operatórias/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , COVID-19/epidemiologia , COVID-19/virologia , Estudos de Coortes , Epidemias , Feminino , Humanos , Cooperação Internacional , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde/métodos , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Complicações Pós-Operatórias/virologia , SARS-CoV-2/fisiologia
5.
BMJ Evid Based Med ; 26(2): 51-52, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-32576569

RESUMO

INTRODUCTION: Complete reporting of systematic reviews of interventions is essential to the interpretation of research findings and the reproducibility of research results. The Template for Intervention Description and Replication (TIDieR) checklist-and the version specific to systematic reviews (TIDieR-SR)-was created to provide authors and researchers an evidence-based guide for reporting trial and systematic review interventions. In this study, we apply TIDieR-SR to Cochrane systematic reviews of surgical interventions. METHODS: We searched the Cochrane Database for relevant systematic reviews. Two investigators applied inclusion/exclusion criteria to all titles/abstracts and full texts. These same investigators extracted all data in duplicate while masked to the other's data. The primary outcome was adherence to TIDieR-SR items. RESULTS: Two hundred and thirty-eight systematic reviews were included. Overall, included SRs adhered to a median of 6 (IQR 5-7) out of eight TIDieR-SR items. The item with the lowest adherence was item 7 (share intervention materials, 1/238 (0.4%). DISCUSSION: Our results are encouraging, but the generalisability of our findings is compromised by the inclusion of only Cochrane systematic reviews. Future reporting of intervention materials is likely to improve the application of effective surgical interventions in the clinical practice.

6.
J Surg Oncol ; 123(4): 1057-1066, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33368277

RESUMO

BACKGROUND: Primary mesenteric soft tissue sarcomas (STS) are rare and limited evidence is available to inform management. Surgical resection is challenging due to the proximity of vital structures and a need to preserve enteric function. OBJECTIVES: To determine the overall survival (OS) and recurrence-free survival (RFS) for patients undergoing primary resection for mesenteric STS. METHODS: The Trans-Atlantic Australasian Retroperitoneal Sarcoma Working Group (TARPSWG) is an intercontinental collaborative comprising specialist sarcoma centers. Data were collected retrospectively for all patients with mesenteric STS undergoing primary resection between 2000 and 2019. RESULTS: Fifty-six cases from 15 institutions were included. The spectrum of pathology was similar to the retroperitoneum, although of a higher grade. R0/R1 resection was achieved in 87%. Median OS was 56 months. OS was significantly shorter in higher-grade tumors (p = .018) and extensive resection (p < .001). No significant association between OS and resection margin or tumor size was detected. Rates of local recurrence (LR) and distant metastases (DM) at 5 years were 60% and 41%, respectively. Liver metastases were common (60%), reflecting portal drainage of the mesentery. CONCLUSION: Primary mesenteric sarcoma is rare, with a modest survival rate. LR and DM are frequent events. Liver metastases are common, highlighting the need for surveillance imaging.


Assuntos
Mesentério/patologia , Recidiva Local de Neoplasia/mortalidade , Neoplasias Retroperitoneais/mortalidade , Sarcoma/mortalidade , Idoso , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/patologia , Recidiva Local de Neoplasia/cirurgia , Prognóstico , Neoplasias Retroperitoneais/patologia , Neoplasias Retroperitoneais/cirurgia , Estudos Retrospectivos , Sarcoma/patologia , Sarcoma/cirurgia , Taxa de Sobrevida
7.
Health Technol Assess ; 23(39): 1-166, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31392958

RESUMO

BACKGROUND: Surgical site infection (SSI) affects up to 20% of people with a primary closed wound after surgery. Wound dressings may reduce SSI. OBJECTIVE: To assess the feasibility of a multicentre randomised controlled trial (RCT) to evaluate the effectiveness and cost-effectiveness of dressing types or no dressing to reduce SSI in primary surgical wounds. DESIGN: Phase A - semistructured interviews, outcome measure development, practice survey, literature reviews and value-of-information analysis. Phase B - pilot RCT with qualitative research and questionnaire validation. Patients and the public were involved. SETTING: Usual NHS care. PARTICIPANTS: Patients undergoing elective/non-elective abdominal surgery, including caesarean section. INTERVENTIONS: Phase A - none. Phase B - simple dressing, glue-as-a-dressing (tissue adhesive) or 'no dressing'. MAIN OUTCOME MEASURES: Phase A - pilot RCT design; SSI, patient experience and wound management questionnaires; dressing practices; and value-of-information of a RCT. Phase B - participants screened, proportions consented/randomised; acceptability of interventions; adherence; retention; validity and reliability of SSI measure; and cost drivers. DATA SOURCES: Phase A - interviews with patients and health-care professionals (HCPs), narrative data from published RCTs and data about dressing practices. Phase B - participants and HCPs in five hospitals. RESULTS: Phase A - we interviewed 102 participants. HCPs interpreted 'dressing' variably and reported using available products. HCPs suggested practical/clinical reasons for dressing use, acknowledged the weak evidence base and felt that a RCT including a 'no dressing' group was acceptable. A survey showed that 68% of 1769 wounds (727 participants) had simple dressings and 27% had glue-as-a-dressing. Dressings were used similarly in elective and non-elective surgery. The SSI questionnaire was developed from a content analysis of existing SSI tools and interviews, yielding 19 domains and 16 items. A main RCT would be valuable to the NHS at a willingness to pay of £20,000 per quality-adjusted life-year. Phase B - from 4 March 2016 to 30 November 2016, we approached 862 patients for the pilot RCT; 81.1% were eligible, 59.4% consented and 394 were randomised (simple, n = 133; glue, n = 129; no dressing, n = 132); non-adherence was 3 out of 133, 8 out of 129 and 20 out of 132, respectively. SSI occurred in 51 out of 281 participants. We interviewed 55 participants. All dressing strategies were acceptable to stakeholders, with no indication that adherence was problematic. Adherence aids and patients' understanding of their allocated dressing appeared to be key. The SSI questionnaire response rate overall was 67.2%. Items in the SSI questionnaire fitted a single scale, which had good reliability (test-retest and Cronbach's alpha of > 0.7) and diagnostic accuracy (c-statistic = 0.906). The key cost drivers were hospital appointments, dressings and redressings, use of new medicines and primary care appointments. LIMITATIONS: Multiple activities, often in parallel, were challenging to co-ordinate. An amendment took 4 months, restricting recruitment to the pilot RCT. Only 67% of participants completed the SSI questionnaire. We could not implement photography in theatres. CONCLUSIONS: A main RCT of dressing strategies is feasible and would be valuable to the NHS. The SSI questionnaire is sufficiently accurate to be used as the primary outcome. A main trial with three groups (as in the pilot) would be valuable to the NHS, using a primary outcome of SSI at discharge and patient-reported SSI symptoms at 4-8 weeks. TRIAL REGISTRATION: Phase A - Current Controlled Trials ISRCTN06792113; Phase B - Current Controlled Trials ISRCTN49328913. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 39. See the NIHR Journals Library website for further project information. Funding was also provided by the Medical Research Council ConDuCT-II Hub (reference number MR/K025643/1).


Assuntos
Bandagens/classificação , Análise Custo-Benefício , Infecção da Ferida Cirúrgica/prevenção & controle , Inquéritos e Questionários , Abdome/cirurgia , Adulto , Idoso , Bandagens/microbiologia , Cesárea/efeitos adversos , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Anos de Vida Ajustados por Qualidade de Vida , Reprodutibilidade dos Testes , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Infecção da Ferida Cirúrgica/microbiologia
8.
JSLS ; 23(2)2019.
Artigo em Inglês | MEDLINE | ID: mdl-31285651

RESUMO

Background and Objectives: Patients with sickle cell anemia (SCA) may have elevated inflammatory markers in health, and this may be heightened after open operations. The inflammatory response of patients with SCA after minimally invasive surgeries has not been fully explored. Patients and Methods: Consecutive patients with SCA and with hemoglobin AA (HbAA) undergoing laparoscopic cholecystectomy for acute cholecystitis were recruited into the study. Blood samples were taken before induction of anesthesia (0-h); at 4, 12, 24, and 48 h; and on postoperative day 7. Samples were analyzed for serum C-reactive protein and interleukin (IL)-1 through IL-18. Results: Twenty-three patients, including 9 with SCA and 14 with HbAA, were recruited with 4 cases performed by open laparotomy. At 0-h, proinflammatory IL-1 levels (6.1 versus 4.8) and C-reactive protein levels (32.5 versus 26.6) were higher in patients with hemoglobin SS (HbSS) than in patients with HbAA, respectively. Over time, inflammatory markers were generally higher at each time-point for patients with HbSS compared with patients with HbAA for both proinflammatory and anti-inflammatory cytokines, rising immediately after surgery and up to 48 hours, then returning to baseline by postoperative day 7. There was a higher mean IL-1 level across all time-points in the HbSS group than in the HbAA group (P = .04). Conclusion: This exploratory study found an enhanced inflammatory response to cholecystectomy in patients with SCA compared with patients with HbAA. Minimally invasive surgical strategies for this patient group may help to mediate this response.


Assuntos
Anemia Falciforme/complicações , Colecistectomia Laparoscópica/efeitos adversos , Colecistite Aguda/complicações , Colecistite Aguda/cirurgia , Complicações Pós-Operatórias/etiologia , Adulto , Idoso , Anemia Falciforme/sangue , Proteína C-Reativa/metabolismo , Colecistite Aguda/sangue , Citocinas/sangue , Feminino , Hemoglobina A , Humanos , Mediadores da Inflamação/sangue , Interleucinas/sangue , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/sangue
11.
Clin Neurol Neurosurg ; 164: 67-71, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-29197281

RESUMO

OBJECTIVES: Maximal surgical resection of high grade brain tumours is associated with improved overall survival (OS). It carries the risk of neurological deterioration leading to worsening performance status (PS), which may affect overall survival and preclude patients from adjuvant therapy. We aim to review the changes in performance status of patients undergoing resection of high grade tumours and metastases and the impact of changes on overall survival. PATIENTS AND METHODS: A prospective study of the perioperative performance status of 75 patients who underwent primary resection of malignant primary brain tumour or solitary metastasis in a single centre. Data on patients' demographics, tumour histology and overall survival were also collected. WHO performance status was recorded pre-operatively and at intervals following surgery. RESULTS: Of the 75 patients (35 males, 40 females, median age 61 years at diagnosis), 50 had primary malignant brain tumours, 25 had metastasis. Although PS dropped at postoperative day 1 in 14 patients (18.7%), 28% improved by day 5 and there was significant improvement by day 14 (41%, p=0.02). The number of patients with PS 3 or worse changed from 4% pre-operatively (n=3) to 8% (n=6). Overall survival is better in those whose PS remained improved or unchanged at 2 weeks after surgery compared to those whose PS deteriorated; high grade glioma median survival 15.67 vs. 2.4 months (p=0.005) and metastasis median survival 8.53 vs.2.33 months (p=0.001). CONCLUSION: Our data demonstrates that although PS may deteriorate immediately after surgery, the majority of patients regain their baseline PS or improve by 2 weeks postoperatively; decisions on fitness for adjuvant treatment should therefore be delayed until then. In those patients whose PS declines following surgery overall survival is poor.


Assuntos
Neoplasias Encefálicas/mortalidade , Neoplasias Encefálicas/cirurgia , Glioma/mortalidade , Glioma/cirurgia , Assistência Perioperatória/tendências , Desempenho Psicomotor/fisiologia , Adulto , Idoso , Neoplasias Encefálicas/diagnóstico , Estudos de Coortes , Craniotomia/tendências , Feminino , Glioma/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Estudos Prospectivos , Taxa de Sobrevida/tendências , Adulto Jovem
12.
Postgrad Med J ; 93(1106): 730-735, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28701324

RESUMO

PURPOSE OF STUDY: To demonstrate a model for delivery of an international surgical training event, and demonstrate its educational and economic outcomes. STUDY DESIGN: The Association of Surgeons in Training (ASiT) ran a course series on 16 January 2016 across the UK and Ireland. A mandatory, self-reported, online questionnaire collected delegate feedback, using 5-point Likert Scales, and a NetPromoter feedback tool. Precourse and postcourse matched questionnaires were collected for 'Foundation Skills in Surgery' (FSS) courses. Paired economic analysis was performed. Statistical analysis was carried out using RStudio (V.3.1.1 Boston, Massachusetts, USA). RESULTS: Forty courses were held across the UK and Ireland (65.0% technical, 35.0% non-technical), with 184 faculty members. Of 570 delegates, 529 fully completed the feedback survey (92.8% response rate); 56.5% were male. The median age was 26 years (range: 18-67 years). The mean overall course NetPromoter Score was 8.7 out of 10. On logistic regression high NetPromoter Score was associated with completing a Foundation Skills in Surgery course (R=0.44, OR: 1.49, p=0.025) and having clear learning outcomes (R=0.72, OR: 2.04, p=0.029) but not associated with specialty, course style or teaching style. For Foundation Skills in Surgery courses, delegates reported increased commitment to a career in surgery (p<0.001), confidence with basic surgical skills (p<0.001) and confidence with assisting in theatre (p<0.001). A comparable cost saving of £231,462.37 was calculated across the 40 courses. CONCLUSION: The ASiT '40-4-40' event demonstrated the diversity and depth of surgical training, with 40 synchronous technical and non-technical courses, demonstrable educational benefit and a significant cost saving to surgical trainees.


Assuntos
Competência Clínica , Educação Médica/organização & administração , Cirurgia Geral/educação , Internacionalidade , Modelos Educacionais , Adolescente , Adulto , Idoso , Escolha da Profissão , Competência Clínica/economia , Currículo , Educação Médica/economia , Avaliação Educacional , Humanos , Irlanda , Pessoa de Meia-Idade , Inquéritos e Questionários , Reino Unido
15.
Postgrad Med J ; 93(1104): 581-586, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28408726

RESUMO

OBJECTIVES: This study aimed to explore variations in the provision of integrated academic surgical training across the UK. DESIGN: This is an online cross-sectional survey (consisting of 44 items with a range of free-text, binomial and 5-point Likert scale responses) developed by the Association of Surgeons in Training. SETTING: A self-reported survey instrument was distributed to academic surgical trainees across the UK (n=276). PARTICIPANTS: 143 (51.9%) responses were received (81% male, median age: 34 years), spanning all UK regions and surgical specialties. Of the 143 trainees, 29 were core trainees (20.3%), 99 were specialty trainees (69.2%) and 15 (10.5%) described themselves as research fellows. RESULTS: The structure of academic training varied considerably, with under a third of trainees receiving guaranteed protected time for research. Despite this, however, 53.1% of the respondents reported to be satisfied with how their academic training was organised. Covering clinical duties during academic time occurred commonly (72.7%). Although most trainees (n=88, 61.5%) met with their academic supervisor at least once a month, six (4.2%) never had an academic supervisory meeting. Most trainees (n=90, 62.9%) occupied a full-time rota slot and only 9.1% (n=13) described their role as 'supernumerary'. Although 58.7% (n=84) of the trainees were satisfied with their clinical competence, 37.8% (n=54) felt that clinical time focused more on service provision than the acquisition of technical skills. 58 (40.6%) had experienced some form of negative sentiment relating to their status as an academic trainee. CONCLUSIONS: Integrated academic training presents unique challenges and opportunities within surgery. This survey has identified variation in the quality of current programmes, meaning that the future provision of integrated surgical academic training should be carefully considered.


Assuntos
Educação de Pós-Graduação em Medicina/organização & administração , Cirurgia Geral/educação , Especialidades Cirúrgicas/educação , Adulto , Pesquisa Biomédica/educação , Competência Clínica , Estudos Transversais , Currículo , Feminino , Humanos , Masculino , Inquéritos e Questionários , Reino Unido
16.
Ann Vasc Surg ; 38: 323-331, 2017 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-27531090

RESUMO

BACKGROUND: The aim of this study was to review the literature on the association between hypothermia and outcomes in open and endovascular abdominal aortic aneurysm (AAA) repair. The secondary aim was to determine whether there is a difference in body temperature in patients undergoing either transperitoneal (TP), retroperitoneal (RP), or endovascular surgical repair of the abdominal aorta (EVAR). METHODS: MEDLINE, Web of Science, and Trip searched for all studies on temperature in the context of aortic surgery or endovascular aortic interventions. To be included in the review, the papers had to be related to intraoperative or postoperative hypothermia and/or normothermia, with regards to either open or endovascular repair of the abdominal aorta. Thoracic or thoracoabdominal aortic repairs were not included for review. RESULTS: Eight studies involving 765 patients were eligible. Of these, 6 studies looked at open elective AAA repair involving 605 patients. Only 2 studies investigated emergency AAA repair and consisted of 160 patients where only 35 of those patients underwent emergency EVAR. Normothermic patients had a shorter length of stay in the intensive care unit (P = 0.0008), while hypothermia was independently associated with higher rates of organ dysfunction, in-hospital mortality, and prolonged hospital length of stay. In ruptured AAAs, the lowest average intraoperative temperature was recorded in open repair compared with EVAR (P = 0.02). There was no statistically significant difference in postoperative temperature between patients undergoing elective RP repair and those having TP surgery. CONCLUSIONS: The studies identified in this review have shown that hypothermia has numerous deleterious effects on outcomes in AAA repair - whether or not these adverse outcomes are those such as higher rates of organ dysfunction, mortality or prolonged hospital length of stay, can only be done at the single paper level and not at a literature review level, due to multiple confounding variables. Despite these limitations, the benefits of this review are numerous. This article highlights the importance of core body temperature and outcomes of AAA repair. Furthermore, it brings forth the need to standardize the method of core body temperature measurement and method of rewarming. Given the body of evidence so far, these standardized data collection points will be important for national vascular quality improvement initiatives. Only through rigorous analysis of standardized dataset can firm recommendation regarding peri- and postoperative temperature management be made.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Regulação da Temperatura Corporal , Procedimentos Endovasculares/efeitos adversos , Hipotermia/etiologia , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Aneurisma da Aorta Abdominal/diagnóstico , Aneurisma da Aorta Abdominal/mortalidade , Aneurisma da Aorta Abdominal/fisiopatologia , Procedimentos Endovasculares/mortalidade , Mortalidade Hospitalar , Humanos , Hipotermia/diagnóstico , Hipotermia/mortalidade , Hipotermia/fisiopatologia , Tempo de Internação , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/mortalidade
19.
PLoS One ; 10(9): e0138745, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26389785

RESUMO

BACKGROUND: The incidence of incisional hernias (IHs) following midline abdominal incisions is difficult to estimate. Furthermore recent analyses have reported inconsistent findings on the superiority of absorbable versus non-absorbable sutures. OBJECTIVE: To estimate the mean IH rate following midline laparotomy from the published literature, to identify variables that predict IH rates and to analyse whether the type of suture (absorbable versus non-absorbable) affects IH rates. METHODS: We undertook a systematic review according to PRISMA guidelines. We sought randomised trials and observational studies including patients undergoing midline incisions with standard suture closure. Papers describing two or more arms suitable for inclusion had data abstracted independently for each arm. RESULTS: Fifty-six papers, describing 83 separate groups comprising 14,618 patients, met the inclusion criteria. The prevalence of IHs after midline incision was 12.8% (range: 0 to 35.6%) at a weighted mean of 23.7 months. The estimated risk of undergoing IH repair after midline laparotomy was 5.2%. Two meta-regression analyses (A and B) each identified seven characteristics associated with increased IH rate: one patient variable (higher age), two surgical variables (surgery for AAA and either surgery for obesity surgery (model A) or using an upper midline incision (model B)), two inclusion criteria (including patients with previous laparotomies and those with previous IHs), and two circumstantial variables (later year of publication and specifying an exact significance level). There was no significant difference in IH rate between absorbable and non-absorbable sutures either alone or in conjunction with either regression analysis. CONCLUSIONS: The IH rate estimated by pooling the published literature is 12.8% after about two years. Seven factors account for the large variation in IH rates across groups. However there is no evidence that suture type has an intrinsic effect on IH rates.


Assuntos
Parede Abdominal/cirurgia , Hérnia Incisional/epidemiologia , Laparotomia/métodos , Complicações Pós-Operatórias/epidemiologia , Técnicas de Fechamento de Ferimentos Abdominais , Humanos , Incidência , Hérnia Incisional/etiologia , Laparotomia/efeitos adversos , Estudos Observacionais como Assunto , Complicações Pós-Operatórias/etiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Análise de Regressão , Fatores de Risco , Técnicas de Sutura
20.
BMJ Open ; 5(7): e008811, 2015 Jul 20.
Artigo em Inglês | MEDLINE | ID: mdl-26195471

RESUMO

INTRODUCTION: Obesity is increasingly prevalent among patients undergoing surgery. Conflicting evidence exists regarding the impact of obesity on postoperative complications. This multicentre study aims to determine whether obesity is associated with increased postoperative complications following general surgery. METHODS AND ANALYSIS: This prospective, multicentre cohort study will be performed utilising a collaborative methodology. Consecutive adults undergoing open or laparoscopic, elective or emergency, gastrointestinal, bariatric or hepatobiliary surgery will be included. Day case patients will be excluded. The primary end point will be the overall 30-day major complication rate (Clavien-Dindo grade III-V complications). Data will be collected to risk-adjust outcomes for potential confounding factors, such as preoperative cardiac risk. This study will be disseminated through structured medical student networks using established collaborative methodology. The study will be powered to detect a two-percentage point increase in the major postoperative complication rate in obese versus non-obese patients. ETHICS AND DISSEMINATION: Following appropriate assessment, an exemption from full ethics committee review has been received, and the study will be registered as a clinical audit or service evaluation at each participating hospital. Dissemination will take place through national and local research collaborative networks.


Assuntos
Cirurgia Bariátrica/efeitos adversos , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Obesidade/complicações , Complicações Pós-Operatórias/etiologia , Índice de Massa Corporal , Humanos , Estudos Prospectivos , Projetos de Pesquisa , Risco Ajustado , Fatores de Risco , Estudantes de Medicina
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