RESUMO
OBJECTIVE: Esophageal perforation is a life-threatening condition associated with high mortality and morbidity. Ambiguous clinical presentation is one of the most common causes of delayed and difficult diagnosis of esophageal perforation. In this retrospective single-center study, we reviewed the outcome of primary closure in patients with esophageal perforation between 2009 and 2017. METHODS: The data of 65 patients attending our department of thoracic surgery (from 2009 to 2017) for esophageal perforation were reviewed. Primary repair was attempted in 63 patients irrespective of the site of perforation and time interval between injury and hospital admission. In intrathoracic lesions, continuous mediastinal and pleural irrigation was undertaken, whereas in cervical perforations, gauze packing and local irrigation were performed. Jejunotomy was carried out in patients with inadequate healing. RESULTS: Of the 65 patients, 63 underwent primary closure and 2 were left to heal spontaneously. The majority of patients ( n = 44) had an esophageal perforation at the thoracic level, and only one was admitted early (<24 h after injury). Among the 63 patients managed with primary closure, 55 had satisfactory healing with one surgery. Healing was delayed in the other 10 patients. No mortality was reported. CONCLUSIONS: Esophageal perforation can be well managed by primary closure, irrespective of the time interval between injury and hospital admission and the site of perforation. Conservative management might lead to an increased rate of complications such as empyema or necrotizing mediastinitis, and increased morbidity and mortality.
Assuntos
Tratamento Conservador/métodos , Perfuração Esofágica/cirurgia , Técnicas de Sutura , Irrigação Terapêutica , Tratamento Conservador/efeitos adversos , Tratamento Conservador/mortalidade , Perfuração Esofágica/diagnóstico por imagem , Perfuração Esofágica/etiologia , Perfuração Esofágica/mortalidade , Humanos , Estudos Retrospectivos , Fatores de Risco , Técnicas de Sutura/efeitos adversos , Técnicas de Sutura/mortalidade , Irrigação Terapêutica/efeitos adversos , Irrigação Terapêutica/mortalidade , Fatores de Tempo , Tempo para o Tratamento , Tomografia Computadorizada por Raios X , Resultado do Tratamento , CicatrizaçãoRESUMO
BACKGROUND: Chronic subdural hematoma (cSDH) is one of the most common conditions encountered in neurosurgical practice. Recurrence, observed in 5-30% of patients, is a major clinical problem. The temperature of the irrigation fluid used during evacuation of the hematoma might theoretically influence recurrence rates since irrigation fluid at body temperature (37 oC) may beneficially influence coagulation and cSDH solubility when compared to irrigation fluid at room temperature. Should no difference in recurrence rates be observed when comparing irrigation-fluid temperatures, there is no need for warmed fluids during surgery. Our main aim is to investigate the effect of irrigation-fluid temperature on recurrence rates and clinical outcomes after cSDH evacuation using a multicenter randomized controlled trial design. METHODS: The study will be conducted in three neurosurgical departments with population-based catchment areas using a similar surgical strategy. In total, 600 patients fulfilling the inclusion criteria will randomly be assigned to either intraoperative irrigation with fluid at body temperature or room temperature. The power calculation is based on a retrospective study performed at our department showing a recurrence rate of 5% versus 12% when comparing irrigation fluid at body temperature versus fluid at room temperature (unpublished data). The primary endpoint is recurrence rate of cSDH analyzed at 6 months post treatment. Secondary endpoints are mortality rate, complications and health-related quality of life. DISCUSSION: Irrigation-fluid temperature might influence recurrence rates in the evacuation of chronic subdural hematomas. We present a study protocol for a multicenter randomized controlled trial investigating our hypothesis that irrigation fluid at body temperature is superior to room temperature in reducing recurrence rates following evacuation of cSDH. TRIALS REGISTRATION: ClinicalTrials.gov, ID: NCT02757235 . Registered on 2 May 2016.
Assuntos
Hematoma Subdural Crônico/terapia , Soluções Isotônicas/administração & dosagem , Temperatura , Irrigação Terapêutica/métodos , Temperatura Corporal , Protocolos Clínicos , Drenagem , Hematoma Subdural Crônico/diagnóstico , Hematoma Subdural Crônico/mortalidade , Humanos , Soluções Isotônicas/efeitos adversos , Qualidade de Vida , Recidiva , Projetos de Pesquisa , Lactato de Ringer , Suécia , Irrigação Terapêutica/efeitos adversos , Irrigação Terapêutica/mortalidade , Fatores de Tempo , Resultado do TratamentoRESUMO
PURPOSE: The aim of this study was to explore the treatment strategies for patients with obstructive colorectal cancer at different sites. METHODS: Treatment strategies were adopted according to the location of colorectal cancer and the condition of the patients when they were admitted to the hospital. Among a total of 134 patients, 29 patients were subjected to stent placement to relieve the obstruction before undergoing colorectal resection, 15 patients underwent per anum ileus catheterization to alleviate the symptoms of obstruction and waited for removal of the tumor within a limited time; 39 underwent intraoperative colonic lavage and colon resection with anastomosis and the remaining 51 patients were subjected to emergency surgery due to strangulation of the bowel, perforation, septic shock or other conditions before surgery. RESULTS: Stent placement was successfully performed on 23 patients, with a success rate of 79%. Ninety-five of 134 patients (71% had stage I anastomosis and only one case had anastomotic fistula. Infection of incision happened in 9 (7%) cases and 2 (1.5%) patients died of infection. CONCLUSIONS: Individualized treatment for patients with obstructive colorectal cancer can lead to tumor resection and stage I anastomosis, thereby avoiding the suffering of second-stage surgery or colostomy.
Assuntos
Cateterismo , Colectomia , Neoplasias Colorretais/terapia , Obstrução Intestinal/terapia , Stents , Irrigação Terapêutica , Adulto , Idoso , Idoso de 80 Anos ou mais , Cateterismo/efeitos adversos , Cateterismo/mortalidade , Colectomia/efeitos adversos , Colectomia/mortalidade , Neoplasias Colorretais/complicações , Neoplasias Colorretais/diagnóstico , Neoplasias Colorretais/mortalidade , Neoplasias Colorretais/cirurgia , Feminino , Humanos , Obstrução Intestinal/diagnóstico , Obstrução Intestinal/etiologia , Obstrução Intestinal/mortalidade , Obstrução Intestinal/cirurgia , Masculino , Pessoa de Meia-Idade , Cuidados Paliativos , Fatores de Risco , Irrigação Terapêutica/efeitos adversos , Irrigação Terapêutica/mortalidade , Fatores de Tempo , Resultado do TratamentoRESUMO
The aim of this study was to determine the efficacy and safety of remote magnetic navigation (RMN) with open-irrigated catheter vs. manual catheter navigation (MCN) in performing atrial fibrillation (AF) ablation. We searched in PubMed (1948-2013) and EMBASE (1974-2013) studies comparing RMN with MCN. Outcomes considered were AF recurrence (primary outcome), pulmonary vein isolation (PVI), procedural complications, and data on procedure's performance. Odds ratios (OR) and mean difference (MD) were extracted and pooled using a random-effect model. Confidence in the estimates of the obtained effects (quality of evidence) was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. We identified seven controlled trials, six non-randomized and one randomized, including a total of 941 patients. Studies were at high risk of bias. No difference was observed between RMN and MCN on AF recurrence [OR 1.18, 95% confidence interval (CI) 0.85 to 1.65, P = 0.32] or PVI (OR 0.41, 95% CI 0.11-1.47, P = 0.17). Remote magnetic navigation was associated with less peri-procedural complications (Peto OR 0.41, 95% CI 0.19-0.88, P = 0.02). Mean fluoroscopy time was reduced in RMN group (-22.22 min; 95% CI -42.48 to -1.96, P = 0.03), although the overall duration of the procedure was longer (60.91 min; 95% CI 31.17 to 90.65, P < 0.0001). In conclusion, RMN is not superior to MCN in achieving freedom from recurrent AF at mid-term follow-up or PVI. The procedure implies less peri-procedural complications, requires a shorter fluoroscopy time but a longer total procedural time. For the low quality of the available evidence, a proper designed randomized controlled trial could turn the direction and the effect of the dimensions explored.
Assuntos
Fibrilação Atrial/mortalidade , Fibrilação Atrial/cirurgia , Ablação por Cateter/mortalidade , Complicações Pós-Operatórias/mortalidade , Cirurgia Assistida por Computador/mortalidade , Irrigação Terapêutica/mortalidade , Fibrilação Atrial/diagnóstico , Comorbidade , Humanos , Incidência , Magnetismo , Pessoa de Meia-Idade , Fatores de Risco , Taxa de Sobrevida , Irrigação Terapêutica/psicologia , Resultado do TratamentoRESUMO
OBJECTIVES: Deep sternal wound infections are significant and severe complications following cardiac surgery and substantially influence perioperative morbidity and mortality. We present the experience of our department using two different surgical treatments over a three-year period. METHODS: Between January 2009 and December 2011, a total of 3274 cardiac procedures with complete median sternotomy were performed in our department. In 94 patients (3%), a deep sternal wound infection occurred, including sternal instability with consecutive surgical treatment. The patients either received wound debridement with sternum refixation and suction-irrigation drainage (SID; n = 72) or sternum refixation only (RF; n = 22) if there was sternal instability with limited signs of infection. SID was routinely installed for 7 days: the irrigation solution contained neomycin. In all cases, swabs were taken and analysed. The different methods were evaluated in respect of their clinical outcomes. RESULTS: The success rate-defined as single, uncomplicated procedure-of the SID treatment was 74%, compared with 59% of the isolated sternum refixation. Complications included continuous infection, recurrence of sternal instability and wound necrosis. Eighty-eight percent of the swabs in the SID group were positive, compared with 32% in the sternal refixation only group. The dominating pathogenic germs were coagulase-negative staphylococci and staphylococcus aureus. Mortality was 10% for the SID group and 5% for the RF group. CONCLUSIONS: Contrary to accepted opinion, the suction-irrigation drainage is an appropriate therapy for deep sternal wound infections. Nevertheless, deep sternal wound infections after cardiac surgery remain severe complications and are related to increased morbidity and mortality.
Assuntos
Antibacterianos/administração & dosagem , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Neomicina/administração & dosagem , Esternotomia/efeitos adversos , Sucção , Infecção da Ferida Cirúrgica/terapia , Irrigação Terapêutica , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Cardíacos/mortalidade , Distribuição de Qui-Quadrado , Terapia Combinada , Desbridamento , Feminino , Humanos , Masculino , Estudos Retrospectivos , Esternotomia/mortalidade , Sucção/efeitos adversos , Sucção/mortalidade , Infecção da Ferida Cirúrgica/diagnóstico , Infecção da Ferida Cirúrgica/microbiologia , Infecção da Ferida Cirúrgica/mortalidade , Irrigação Terapêutica/efeitos adversos , Irrigação Terapêutica/mortalidade , Fatores de Tempo , Resultado do TratamentoRESUMO
INTRODUCTION: Higher current density at the proximal end of a six-hole catheter is not irrigated and thus could lead to uneven heating and possibly coagulum and charring. This study tested a novel 12-hole irrigated catheter with six additional holes at the proximal end that provides more uniform cooling during atrial flutter (AFL) ablation. METHODS: A total of 188 patients (28 females, 66 ± 11 years) were treated for typical AFL at 22 sites in the USA and Canada using Cool Path Duo at 50 W and 45 °C at an irrigation rate of 13 ml/min. The results were compared to historical data from an AFL study which used a six-hole catheter with similar design. RESULTS: A total of 2,725 RF lesions were applied in 188 patients with a mean RF duration of 18.2 ± 11.7 min per procedure. Procedural success was achieved in 96.3 % (181 of 188) acutely and 98.3 % (173 of 176) patients at 3 months. Steam pops occurred in 0.6 % of lesions (15 of 2,725) without coagulum or charring Compared to the six-hole irrigated tip catheter, the Cool Path Duo catheter delivered more power (33.8 ± 5.9 vs. 29.7 ± 5.2 W, p < 0.0001) at a lower average tip temperature (34.7 ± 1.5 vs. 37.2 ± 2.1 °C, p < 0.0001) with no statistical differences in either 3-month AFL recurrence or complications. CONCLUSION: Cool Path Duo™ irrigated tip catheter is safe and effective in treating typical AFL. When compared to a six-hole irrigated tip catheter, the Cool Path Duo catheter delivers more power at a lower temperature.
Assuntos
Flutter Atrial/mortalidade , Flutter Atrial/cirurgia , Ablação por Cateter/instrumentação , Ablação por Cateter/mortalidade , Irrigação Terapêutica/instrumentação , Irrigação Terapêutica/mortalidade , Idoso , Canadá/epidemiologia , Desenho de Equipamento , Análise de Falha de Equipamento , Feminino , Humanos , Masculino , Medição de Risco , Análise de Sobrevida , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Perforated diverticulitis is a condition associated with substantial morbidity. Recently published reports suggest that laparoscopic lavage has fewer complications and shorter hospital stay. So far no randomised study has published any results. METHODS: DILALA is a Scandinavian, randomised trial, comparing laparoscopic lavage (LL) to the traditional Hartmann's Procedure (HP). Primary endpoint is the number of re-operations within 12 months. Secondary endpoints consist of mortality, quality of life (QoL), re-admission, health economy assessment and permanent stoma. Patients are included when surgery is required. A laparoscopy is performed and if Hinchey grade III is diagnosed the patient is included and randomised 1:1, to either LL or HP. Patients undergoing LL receive > 3L of saline intraperitoneally, placement of pelvic drain and continued antibiotics. Follow-up is scheduled 6-12 weeks, 6 months and 12 months. A QoL-form is filled out on discharge, 6- and 12 months. Inclusion is set to 80 patients (40+40). DISCUSSION: HP is associated with a high rate of complication. Not only does the primary operation entail complications, but also subsequent surgery is associated with a high morbidity. Thus the combined risk of treatment for the patient is high. The aim of the DILALA trial is to evaluate if laparoscopic lavage is a safe, minimally invasive method for patients with perforated diverticulitis Hinchey grade III, resulting in fewer re-operations, decreased morbidity, mortality, costs and increased quality of life. TRIAL REGISTRATION: British registry (ISRCTN) for clinical trials ISRCTN82208287http://www.controlled-trials.com/ISRCTN82208287.
Assuntos
Colectomia , Doença Diverticular do Colo/terapia , Perfuração Intestinal/terapia , Laparoscopia , Projetos de Pesquisa , Irrigação Terapêutica/métodos , Doença Aguda , Antibacterianos/uso terapêutico , Colectomia/efeitos adversos , Colectomia/economia , Colectomia/mortalidade , Colostomia , Análise Custo-Benefício , Doença Diverticular do Colo/economia , Doença Diverticular do Colo/mortalidade , Doença Diverticular do Colo/cirurgia , Drenagem , Custos de Cuidados de Saúde , Humanos , Perfuração Intestinal/economia , Perfuração Intestinal/mortalidade , Perfuração Intestinal/cirurgia , Laparoscopia/efeitos adversos , Laparoscopia/economia , Laparoscopia/mortalidade , Readmissão do Paciente , Qualidade de Vida , Reoperação , Medição de Risco , Fatores de Risco , Inquéritos e Questionários , Suécia , Irrigação Terapêutica/efeitos adversos , Irrigação Terapêutica/economia , Irrigação Terapêutica/mortalidade , Fatores de Tempo , Resultado do TratamentoRESUMO
PURPOSE: Whether primary anastomosis should be performed after segmental resection with intraoperative colonic irrigation or subtotal colectomy is not yet established in the surgical treatment of obstructive left colon carcinoma. In this prospective, nonrandomized study, we present the results of 66 patients undergoing one-stage surgery for obstructed left colon carcinoma. PATIENTS AND METHODS: We compared two techniques, subtotal colectomy (35 patients) and intraoperative colonic irrigation with segmental resection and immediate anastomosis (31 patients). RESULTS: The mortality rate was similar in both groups, 8.5 percent in the subtotal colectomy group and 3.2 percent in the intraoperative colonic irrigation group. The surgical complication rate was significantly higher in the intraoperative colonic irrigation group (41.9 percent) than in the subtotal colectomy group (14.2 percent; P < 0.05). Mean operating time was significantly lower in the subtotal colectomy group than in the intraoperative colonic irrigation group (P < 0.05). Both groups had a similar mean duration of hospital stay. Ten patients who underwent subtotal colectomy (31.2 percent) presented with diarrhea in the immediate postoperative period, which disappeared spontaneously or with antidiarrheal medication; a disabling diarrhea persisted in two patients only (6.2 percent). CONCLUSION: We believe that subtotal colectomy is the treatment of choice for obstructed left-sided colonic carcinoma. Segmental resection with intraoperative colonic irrigation is more appropriate than subtotal colectomy only in patients with carcinomas of the rectosigmoid junction or with previous anal incontinence to avoid the appearance of postoperative diarrhea.