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1.
Anaesthesia ; 75(1): 21-26, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31236918

RESUMO

Previous studies on the safety of peri-operative transoesophageal echocardiography seem to suggest a low rate of associated morbidity and mortality. That said, there has been a paucity of prospective multicentre studies in this important area of clinical practice. We carried out a one-year prospective study in 2017, co-ordinated by the Association of Cardiothoracic Anaesthesia and Critical Care, to determine the rate and severity of complications associated with peri-operative transoesophageal echocardiography in anaesthetised cardiology and cardiac surgical patients. With the help of clinicians from 28 centres across the UK and Ireland, we recorded the total number of examinations conducted in anaesthetised patients during the study period. All major complications at each centre were prospectively reported and recorded. Of the 22,314 examinations, there were 17 patients diagnosed with a major complication which caused either palatal injury or gastro-oesophageal disruption. This corresponds to an incidence of 0.08% (95%CI 0.05-0.13%) or approximately 1:1300 examinations. There were seven deaths reported during the study period which were directly attributed to these complications, corresponding to an incidence of 0.03% (95%CI 0.01-0.07%) or approximately 1:3000. These figures are higher than previously reported and suggest a high probability of death following the development of a complication (~40%). Most complications occurred in patients without known risk factors for transoesophageal echocardiography associated gastro-oesophageal injury. We suggest clinicians and departments review their procedural guidelines, especially in relation to probe insertion techniques, together with the information communicated to patients when the risks and benefits of such examinations are discussed.


Assuntos
Anestesia em Procedimentos Cardíacos , Procedimentos Cirúrgicos Cardíacos , Ecocardiografia Transesofagiana/efeitos adversos , Auditoria Médica/estatística & dados numéricos , Assistência Perioperatória/efeitos adversos , Idoso , Ecocardiografia Transesofagiana/estatística & dados numéricos , Feminino , Humanos , Irlanda , Masculino , Assistência Perioperatória/métodos , Assistência Perioperatória/estatística & dados numéricos , Estudos Prospectivos , Fatores de Risco , Índice de Gravidade de Doença , Sociedades Médicas , Reino Unido
2.
Ann R Coll Surg Engl ; 101(7): 495-500, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31219318

RESUMO

INTRODUCTION: Early detection and treatment of anastomotic leak may mitigate its consequences. Within an enhanced recovery setting, the subtle signs of a leak can be more apparent. There are multiple treatment options for anastomotic leak following anterior resection. This study aimed to determine when leaks are diagnosed in enhanced recovery, and whether the choice of intervention affects outcomes. MATERIALS AND METHODS: We conducted a retrospective study of a prospectively maintained database of complications of anterior resections for rectal cancer in a district general hospital in the UK. Data were extracted on day of leak diagnosis, length of stay, intensive care admission, mortality and ileostomy reversal rate. Statistical analysis was performed using Student's t, Mann-Whitney U and chi square tests. RESULTS: A total of 323 patients underwent anterior resection for colorectal cancer between 1 January 2007 and 1 October 2015. The leak rate was 10.8% (35/323). Patients were diagnosed in hospital with leaks on median day 4 compared with day 11 for patients diagnosed with leaks after readmission from home (P < 0.001). Defunctioned patients diagnosed with a leak had a longer median length of stay (24 vs 18.0 days, P = 0.31) but were more frequently managed non-operatively (100% vs 19.0%, P < 0.001) and had a lower admission rate to intensive care (9.5% vs 42.9%, P = 0.02) than patients who were not defunctioned at time of resection. Overall mortality from anastomotic leak was 2.9% (1/35). Ileostomies were reversed in 73.5% of patients (25/34). DISCUSSION: Enhanced recovery enables early diagnosis of leaks following anterior resection. Defunctioning of patients with anastomotic leak lowers mortality.


Assuntos
Fístula Anastomótica/diagnóstico , Ileostomia/estatística & dados numéricos , Assistência Perioperatória/métodos , Neoplasias Retais/cirurgia , Reoperação/estatística & dados numéricos , Idoso , Anastomose Cirúrgica/efeitos adversos , Anastomose Cirúrgica/métodos , Fístula Anastomótica/etiologia , Fístula Anastomótica/mortalidade , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória/estatística & dados numéricos , Estudos Prospectivos , Reto/cirurgia , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do Tratamento , Reino Unido/epidemiologia
3.
World J Gastroenterol ; 25(22): 2743-2751, 2019 Jun 14.
Artigo em Inglês | MEDLINE | ID: mdl-31235997

RESUMO

Gastrectomy with radical lymph node dissection is the most promising treatment avenue for patients with gastric cancer. However, this procedure sometimes induces excessive intraoperative blood loss and requires perioperative allogeneic blood transfusion. There are lasting discussions and controversies about whether intraoperative blood loss or perioperative blood transfusion has adverse effects on the prognosis in patients with gastric cancer. We reviewed laboratory and clinical evidence of these associations in patients with gastric cancer. A large amount of clinical evidence supports the correlation between excessive intraoperative blood loss and adverse effects on the prognosis. The laboratory evidence revealed three possible causes of such adverse effects: anti-tumor immunosuppression, unfavorable postoperative conditions, and peritoneal recurrence by spillage of cancer cells into the pelvis. Several systematic reviews and meta-analyses have suggested the adverse effects of perioperative blood transfusions on prognostic parameters such as all-cause mortality, recurrence, and postoperative complications. There are two possible causes of adverse effects of blood transfusions on the prognosis: Anti-tumor immunosuppression and patient-related confounding factors (e.g., preoperative anemia). These factors are associated with a worse prognosis and higher requirement for perioperative blood transfusions. Surgeons should make efforts to minimize intraoperative blood loss and transfusions during gastric cancer surgery to improve patients' prognosis.


Assuntos
Perda Sanguínea Cirúrgica , Gastrectomia/efeitos adversos , Recidiva Local de Neoplasia/diagnóstico , Neoplasias Gástricas/cirurgia , Reação Transfusional/imunologia , Transfusão de Sangue/estatística & dados numéricos , Gastrectomia/métodos , Humanos , Excisão de Linfonodo/efeitos adversos , Excisão de Linfonodo/métodos , Recidiva Local de Neoplasia/imunologia , Assistência Perioperatória/estatística & dados numéricos , Prognóstico , Neoplasias Gástricas/imunologia , Neoplasias Gástricas/mortalidade , Transplante Homólogo/efeitos adversos , Evasão Tumoral/imunologia , Microambiente Tumoral/imunologia
4.
J Infect Chemother ; 25(7): 567-570, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31005565

RESUMO

We performed a questionnaire-based, retrospective, nationwide survey on perioperative management and antimicrobial prophylaxis for mid-urethral sling surgery for stress urinary incontinence in Japan to realize the clinical practice and risk factors for SSI. Records of women receiving transobturator tape (TOT) and tension-free vaginal tape (TVT) surgeries from 2010 to 2012 were obtained from hospitals belonging to the Japanese Society of Pelvic Organ Prolapse Surgery. The questionnaire addressed hospital volume, perioperative management, and SSI. Risk factors for SSI were investigated by comparing cases with and without SSI. The data from 97 hospitals and a total 1627 TOT and 1045 TVT surgeries were analyzed. Mean case volumes of TOT and TVT surgeries were 7.3 ± 14.9 and 7.1 ± 17.8 cases per year, respectively. Preoperative hair removal, bowel preparation, and urine culture were routinely performed at 44 (45.3%), 31 (32.0%), and 22 (22.7%) hospitals, respectively. First-generation (51.5%) or second-generation (34.0%) cephalosporin was mostly used for antimicrobial prophylaxis. SSI was reported only in 6 patients (0.22%) and none of them developed abscesses. None of the factors we could evaluate from the questionnaire were found to be significantly associated with SSI. SSI after mid-urethral slings rarely occurred in Japan (0.22%) and no parameters about perioperative managements significantly increased SSI. However, further studies with more detail information of each patient and operation are required to confirm their appropriate perioperative managements for mid-urethral slings.


Assuntos
Assistência Perioperatória/estatística & dados numéricos , Slings Suburetrais/efeitos adversos , Infecção da Ferida Cirúrgica/epidemiologia , Incontinência Urinária por Estresse/cirurgia , Procedimentos Cirúrgicos Urológicos/efeitos adversos , Antibacterianos/uso terapêutico , Antibioticoprofilaxia/estatística & dados numéricos , Monitoramento Epidemiológico , Feminino , Hospitais/estatística & dados numéricos , Humanos , Japão/epidemiologia , Assistência Perioperatória/métodos , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/prevenção & controle , Inquéritos e Questionários/estatística & dados numéricos , Procedimentos Cirúrgicos Urológicos/instrumentação
5.
Aging Clin Exp Res ; 31(12): 1735-1741, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30993661

RESUMO

BACKGROUND: Elderly patients are at a higher risk for hip fracture. Moreover, hospitalized elderly patients with hip fracture are vulnerable to adverse outcomes including higher mortality rate and long-term disability. Treatment decision-making with respect to surgical procedure and perioperative management of these patients is typically challenging owing to the presence of multiple comorbid conditions. AIMS: The purpose of this study was to investigate the relationship between comorbidities in elderly patients with hip fracture and the treatment decision-making. METHODS: 884 geriatric patients (age ≥ 60 years) with hip fracture were included. Comorbidities related to age were measured using the Charlson Co-morbidity Index (CCI) and age-adjusted CCI. The CCI of each geriatric hip fracture patient was calculated based on data retrieved from the medical records. The relationship of CCI and age-adjusted CCI with surgical procedure, time-to-surgery, length of hospital stay, and perioperative management (transfusion, anti-coagulation, and analgesia) was assessed. RESULTS: Mean age of patients was 78.01 ± 8.62 years. The mean CCI was 0.79 ± 0.036; the mean age-adjusted CCI was 4.15 ± 0.047. The CCI was significantly associated with time-to-surgery (P = 0.004), surgical treatment (P < 0.001), and transfusion (P = 0.023). The age-adjusted CCI was significantly associated with surgical treatment (P < 0.001), analgesia (P = 0.003) and transfusion (P < 0.001). The length of hospital stay was associated with both CCI (P = 0.041), age-adjusted CCI (P = 0.002), and hypertension (P = 0.012). Hospital expenses showed a significant association with CCI (P = 0.000), age-adjusted CCI (P = 0.029), osteoprosis (P = 0.007), and hypertension (P = 0.001). CONCLUSION: In this study, comorbidities were positively associated with surgical procedure and perioperative management of elderly patients with hip fracture.


Assuntos
Tomada de Decisão Clínica , Fraturas do Quadril/cirurgia , Idoso , Idoso de 80 Anos ou mais , Transfusão de Sangue/estatística & dados numéricos , Comorbidade , Estudos Transversais , Feminino , Fraturas do Quadril/epidemiologia , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória/métodos , Assistência Perioperatória/estatística & dados numéricos , Fatores de Risco , Fatores de Tempo
6.
In Vivo ; 33(3): 855-862, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31028208

RESUMO

AIM: The purpose of this study was to survey the current opinions of hospitals and medical practices concerning the perioperative management of patients undergoing direct oral anticoagulant therapy (DOAC) and discuss recommendations for the clinical practice. MATERIALS AND METHODS: A questionnaire with 13 topics and multiple ordinal-polytomous subitems was designed and sent to 120 Departments of Oral and Maxillofacial Surgery in Austria, Switzerland and Germany, as well as to 85 oral and maxillofacial/oral surgeons in medical offices in Hamburg, Germany. The data were statistically evaluated by Chi-square, Fisher's exact and Jonckheere-Terpstra tests. RESULTS: The rate of response was 42%. Thirty-seven percent of respondents reported treating over 50 patients per year with undergoing DOAC therapy and only 18% assess a high bleeding risk [33% for vitamin K antagonists (VKA)]. In contrast to that, 62% of respondents would interrupt the DOAC therapy for extraction of one tooth, while 94% would continue VKA therapy. Significantly more clinicians apply suture than those in a medical office. The use of additional hemostatic measures varied between clinic and medical practice. There was a clear request for more detailed guidelines. CONCLUSION: The study shows the current opinion for perioperative management of patients undergoing DOAC therapy. Multi-centric studies under controlled conditions are needed for a safer treatment of anticoagulated patients as therapy strategies differ greatly between institutions and therefore a complication analysis is hardly possible.


Assuntos
Anticoagulantes/administração & dosagem , Assistência Perioperatória/estatística & dados numéricos , Cirurgia Bucal/estatística & dados numéricos , Administração Oral , Gerenciamento Clínico , Alemanha/epidemiologia , Pesquisas sobre Serviços de Saúde , Humanos , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/epidemiologia , Fatores de Risco , Cirurgia Bucal/métodos , Inquéritos e Questionários
7.
J Pediatr Surg ; 54(8): 1595-1600, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30962020

RESUMO

BACKGROUND: The impact of perioperative care interventions on postreconstructive complications and short-term colorectal outcome in patients with anorectal malformation (ARM) type rectovestibular fistula is unknown. METHODS: An ARM-Net consortium multicenter retrospective cohort study was performed including 165 patients with a rectovestibular fistula. Patient characteristics, perioperative care interventions, timing of reconstruction, postreconstructive complications and the colorectal outcome at one year of follow-up were registered. RESULTS: Overall complications were seen in 26.8% of the patients, of which 41% were regarded major. Differences in presence of enterostomy, timing of reconstruction, mechanical bowel preparation, antibiotic prophylaxis and postoperative feeding regimen had no impact on the occurrence of overall complications. However, mechanical bowel preparation, antibiotic prophylaxis ≥48 h and postoperative nil by mouth showed a significant reduction in major complications. The lowest rate of major complications was found in the group having these three interventions combined (5.9%). Multivariate analyses did not show independent significant results of any of the perioperative care interventions owing to center-specific combinations. At one year follow-up, half of the patients experienced constipation and this was significantly higher among those with preoperative mechanical bowel preparation. CONCLUSIONS: Differences in perioperative care interventions do not seem to impact the incidence of overall complications in a large cohort of European rectovestibular fistula-patients. Mechanical bowel preparation, antibiotic prophylaxis ≥48 h, and postoperative nil by mouth showed the least major complications. Independency could not be established owing to center-specific combinations of interventions. TYPE OF STUDY: Treatment study. LEVEL OF EVIDENCE: III.


Assuntos
Malformações Anorretais/cirurgia , Assistência Perioperatória , Complicações Pós-Operatórias/epidemiologia , Fístula Retal/cirurgia , Antibioticoprofilaxia , Humanos , Assistência Perioperatória/métodos , Assistência Perioperatória/estatística & dados numéricos , Estudos Retrospectivos
8.
S Afr Med J ; 109(3): 178-181, 2019 Feb 26.
Artigo em Inglês | MEDLINE | ID: mdl-30834875

RESUMO

BACKGROUND: Venous thromboembolism (VTE) is a common complication during and after hospitalisation, and is regarded as the most common cause of preventable death in hospitalised patients worldwide. Despite its importance, there are few data on VTE risk and adherence to prophylaxis prescription guidelines in surgical patients from the South African (SA) public sector, especially from low-resource environments such as Eastern Cape Province. OBJECTIVES: To evaluate the risk and prescription of VTE prophylaxis to surgical patients at a tertiary government hospital in the Eastern Cape. METHODS: A cross-sectional clinical audit of general surgical inpatients was performed on two dates during July and August 2017. Patients' VTE risk was calculated by using the Caprini risk assessment model (RAM) and thromboprophylaxis prescription evaluated accordingly. RESULTS: A total of 179 patients were included in the study, of whom 56% were male and 44% female. The average age was 45 (range 18 - 83) years. Of the total number of participants, 33% were elective cases and 67% were emergency admissions. With application of RAM, 77% of patients were at risk of VTE (Caprini score ≥2), with 81% of elective and 74% of emergency patients being at risk. The most prevalent risk factors for VTE were major surgery (34%), age 41 - 60 years (30%), age 61 - 74 years (20%) and sepsis during the previous month (27%). A contraindication to chemoprophylaxis was recorded in 30% of patients, with the most prevalent being renal dysfunction (40%), peptic ulcer disease (34%), active bleeding (17%), liver dysfunction (17%), coagulopathy (6%) and recent cerebral haemorrhage (6%). With regard to VTE risk profile and contraindications to chemoprophylaxis, the correct thromboprophylactic treatment was prescribed to 26% of at-risk patients, with 21% of elective and 27% of emergency admission patients receiving the correct therapy. CONCLUSIONS: Despite a high proportion of patients being at risk of VTE, the rate of adequate thromboprophylaxis prescription for surgical inpatients at Frere Hospital, East London, SA is very low. Increased availability of mechanical prophylaxis, as well as interventions to improve the rate of adequate prophylaxis prescription, needs to be evaluated for feasibility and effect in this hospital and other SA public hospitals.


Assuntos
Anticoagulantes/uso terapêutico , Fibrinolíticos/uso terapêutico , Fidelidade a Diretrizes/estatística & dados numéricos , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/prevenção & controle , Padrões de Prática Médica/estatística & dados numéricos , Tromboembolia Venosa/prevenção & controle , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Auditoria Clínica , Estudos Transversais , Feminino , Hospitalização , Humanos , Masculino , Trombólise Mecânica/estatística & dados numéricos , Pessoa de Meia-Idade , Assistência Perioperatória/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Guias de Prática Clínica como Assunto , Medição de Risco , Fatores de Risco , África do Sul , Centros de Atenção Terciária , Tromboembolia Venosa/etiologia , Adulto Jovem
9.
Ulus Travma Acil Cerrahi Derg ; 25(1): 66-70, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30742289

RESUMO

BACKGROUND: The aim of our study was to determine the efficacy and cost-effectiveness of intraoperative autotransfusion that uses the cell saver system (CSS) in patients undergoing posterior instrumentation and fusion of thoracic and lumbar vertebral fractures. METHODS: We divided 121 patients who were to undergo posterior instrumentation and fusion due to thoracic and lumbar vertebral fractures into two groups: 59 patients (23 males and 36 females) were in the cell saver group, and 62 patients (22 males and 40 females) were in the control group. Hemoglobin, hematocrit, and red blood cell (RBC) values were recorded for all patients preoperatively, on the postoperative first, second, and third days, and on the hospital discharge day. Transfusion rates and numbers of allogeneic erythrocyte transfusions, as well as the costs of transfused total auto- and allogeneic transfusions were compared. RESULTS: The numbers of erythrocyte suspensions transfused perioperatively were 0.2±0.6 units in the cell saver group and 0.7±1.4 units in the control group (p=0.01). Statistically significant differences were noted between the two groups on the postoperative first, second, and third days in terms of hemoglobin, hematocrit, and RBC values. These differences had disappeared by the hospital discharge day. The average cost of perioperative blood transfusions was $431±27.4 in the cell saver group and $34.5±66.25 in the control group (p<0.001). CONCLUSION: The use of the CSS was not cost-effective, but it was particularly successful at reducing the rate and the number of units of postoperative allogenic blood transfusions.


Assuntos
Transfusão de Sangue Autóloga , Assistência Perioperatória , Fusão Vertebral , Transfusão de Sangue Autóloga/economia , Transfusão de Sangue Autóloga/estatística & dados numéricos , Análise Custo-Benefício , Feminino , Humanos , Masculino , Assistência Perioperatória/economia , Assistência Perioperatória/estatística & dados numéricos , Fusão Vertebral/efeitos adversos , Fusão Vertebral/economia , Fusão Vertebral/estatística & dados numéricos
10.
Gynecol Oncol ; 153(1): 63-67, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30635213

RESUMO

OBJECTIVES: To determine whether perioperative red blood cell transfusion (PRBCT) affects infection, thrombosis, or survival rates in epithelial ovarian cancer (EOC) patients undergoing neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS). METHODS: Demographics, operative characteristics, and outcome data were abstracted from records of stage IIIC-IV EOC patients managed with NACT-IDS from 01/2010-07/2015. Associations of PRBCT with morbidity and oncologic outcomes were evaluated. RESULTS: Of 270 patients, 136 (50.4%) received PRBCT. Patients with preoperative anemia and higher estimated blood loss (EBL) were more likely to undergo PRBCT (OR,95%CI 1.80, 1.02-3.17) and (OR,95%CI 1.00, 1.002-1.004), respectively. There were no significant differences in PRBCT based on patient age, Charlson Comorbidity Index, or stage. When compared to low complexity operations, patients with moderate and high complexity surgeries were more likely to receive PRBCT (OR,95%CI 1.81, 1.05-3.09) and (OR,95%CI 2.25, 1.13-4.50), respectively. On univariate analysis, PRBCT was associated with intraabdominal infection (OR,95%CI 8.31, 1.03-67.41), but not wound complications (OR,95%CI 1.57, 0.76-3.23) or venous thromboembolism/pulmonary embolism (VTE/PE) (OR,95%CI 2.02, 0.49-8.23). After adjusting for surgical complexity and preoperative anemia, PRBCT was not independently associated with intraabdominal infection (OR,95%CI 7.66, 0.92-63.66), wound complications (OR,95%CI 1.70, 0.80-3.64), or VTE/PE (OR,95%CI 2.15, 0.51-9.09). When comparing patients undergoing PRBCT versus those who did not, there were no significant differences in median progression-free survival (PFS) or median overall survival (OS) on univariate analysis after adjusting for age, stage and residual disease. CONCLUSIONS: Among patients undergoing NACT-IDS, intraabdominal infection, wound complication and VTE/PE rates are similar, regardless of PRBCT. PRBCT does not impact PFS or OS.


Assuntos
Carcinoma Epitelial do Ovário/cirurgia , Procedimentos Cirúrgicos de Citorredução/estatística & dados numéricos , Transfusão de Eritrócitos/estatística & dados numéricos , Infecções Intra-Abdominais/epidemiologia , Embolia Pulmonar/epidemiologia , Infecção da Ferida Cirúrgica/epidemiologia , Tromboembolia Venosa/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma Epitelial do Ovário/sangue , Carcinoma Epitelial do Ovário/tratamento farmacológico , Quimioterapia Adjuvante , Procedimentos Cirúrgicos de Citorredução/efeitos adversos , Procedimentos Cirúrgicos de Citorredução/métodos , Feminino , Humanos , Infecções Intra-Abdominais/etiologia , Pessoa de Meia-Idade , Terapia Neoadjuvante , Assistência Perioperatória/métodos , Assistência Perioperatória/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Intervalo Livre de Progressão , Embolia Pulmonar/genética , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/etiologia , Taxa de Sobrevida , Resultado do Tratamento , Tromboembolia Venosa/etiologia
11.
J Clin Anesth ; 55: 7-12, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30583114

RESUMO

STUDY OBJECTIVES: There is growing evidence internationally to support Enhanced Recovery After Surgery (ERAS) pathways. The impact of pathway compliance and the relative importance of individual components, however, remains less clear. Our institution implemented a multimodal ERAS protocol for elective colorectal surgery in November 2013. The objectives of this study were to investigate the impact of the introduction of the pathway, the relationship between pathway adherence and patient outcomes, and the relative importance of individual components. DESIGN: This was a single-center, observational cohort study of elective colorectal surgical patients. SETTING: A tertiary care and academic teaching hospital in Canada. PATIENTS: Prospective data was collected from 495 consecutive major colorectal surgical patients following the ERAS launch. Retrospective data was also collected from a pre-ERAS cohort of 99. MEASUREMENTS: Adherence to 12 ERAS components were measured, along with American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) defined patient complications and hospital length of stay (LOS). Post-ERAS patients were divided in to two groups: high compliance (≥75% process adherence) and low compliance (<75% adherence). Outcomes were compared between groups. MAIN RESULTS: There was a significant reduction in both complication rate (31.5% vs 14.6%; p ≤0.05) and hospital mean LOS (10.1 vs 6.9 days; p ≤0.05) following introduction of the ERAS pathway. The high adherence group had a shorter mean LOS (5.7 vs 8.6 days; p ≤0.01) and lower rate of complications (11.2% vs 19.6%; p = 0.02) compared with the low compliance group. CONCLUSIONS: Higher adherence to the standardized ERAS protocol was associated with improved patient outcomes, including reduced pulmonary complications. The cause-effect relationship is complex and likely influenced by confounding factors. Our data provides feedback to aid ongoing innovation of our pathway locally and adds to the growing body of evidence supporting the value of ERAS in general.


Assuntos
Procedimentos Cirúrgicos Eletivos/efeitos adversos , Fidelidade a Diretrizes/estatística & dados numéricos , Assistência Perioperatória/normas , Complicações Pós-Operatórias/epidemiologia , Idoso , Anestesiologia/normas , Anestesiologia/estatística & dados numéricos , Canadá , Protocolos Clínicos/normas , Colo/cirurgia , Feminino , Hospitais de Ensino/normas , Hospitais de Ensino/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Readmissão do Paciente/estatística & dados numéricos , Assistência Perioperatória/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Reto/cirurgia , Estudos Retrospectivos , Fatores de Tempo
12.
Dis Colon Rectum ; 62(3): 318-326, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30451756

RESUMO

BACKGROUND: The perioperative behavior of fecal calprotectin and whether it predicts early postoperative endoscopic recurrence of Crohn's disease are unknown. OBJECTIVE: We aimed to compare the perioperative profiles of fecal calprotectin between patients with Crohn's disease and patients without Crohn's disease undergoing intestinal resection and to identify the association between consecutive fecal calprotectin levels and endoscopic recurrence 3 months after surgery in patients with Crohn's disease. DESIGN: This was a prospective observational study. SETTINGS: This study was conducted in a tertiary referral hospital. PATIENTS: One hundred fourteen consecutive patients (90 Crohn's disease, 24 non-Crohn's disease) who underwent resection were recruited. MAIN OUTCOME MEASURES: Univariate and multivariate analyses were performed to identify variations and risk factors. The predictive accuracy of the possible predictors was assessed by using receiver operating characteristic curves. RESULTS: The fecal calprotectin levels on preoperative day 14 and postoperative days 14, 21, 28, 60, and 90 were higher in the Crohn's disease group than they were in non-Crohn's disease group (p < 0.05). Twenty patients (22.2%) developed endoscopic recurrence 3 months after resection. The trend for fecal calprotectin change (Δfecal calprotectin) from preoperative day 14 to postoperative day 14 was opposite in the recurrence and nonrecurrence groups. Multivariate analysis showed that this change was a predictive factor of early endoscopic recurrence (p < 0.05). ΔFecal calprotectin was more accurate at predicting early endoscopic recurrence than was fecal calprotectin at single time points with a cutoff value of 240 µg/g. LIMITATIONS: This is a single-center trial with a limited cohort of patients. CONCLUSIONS: The perioperative fecal calprotectin levels were higher in patients with Crohn's disease than they were in the control group. The change in fecal calprotectin levels from preoperative day 14 to postoperative day 14 could serve as a practical predictive index for early postoperative endoscopic recurrence. See Video Abstract at http://links.lww.com/DCR/A796.


Assuntos
Doença de Crohn , Procedimentos Cirúrgicos do Sistema Digestório , Endoscopia Gastrointestinal , Fezes , Complexo Antígeno L1 Leucocitário/análise , Assistência Perioperatória , Adulto , Biomarcadores/análise , China , Doença de Crohn/diagnóstico , Doença de Crohn/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Endoscopia Gastrointestinal/métodos , Endoscopia Gastrointestinal/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória/métodos , Assistência Perioperatória/estatística & dados numéricos , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Recidiva , Fatores de Risco , Índice de Gravidade de Doença
13.
Int Urogynecol J ; 30(2): 313-321, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30374533

RESUMO

INTRODUCTION AND HYPOTHESIS: Enhanced recovery protocols (ERPs) are evidenced-based interventions designed to standardize perioperative care and expedite recovery to baseline functional status after surgery. There remains a paucity of data addressing the effect of ERPs on pelvic reconstructive surgery patients. METHODS: An ERP was implemented at our institution including: patient counseling, carbohydrate loading, avoidance of opioids, goal-directed fluid resuscitation, immediate postoperative feeding and early ambulation. Patients undergoing elective pelvic reconstructive surgery before and after implementation of the ERP were identified in this cohort study. RESULTS: One hundred eighteen patients underwent pelvic reconstructive surgery within the ERP compared with 76 historic controls. Reductions were seen in length of hospital stay (29.9 vs. 27.9 h, p = 0.04), total morphine equivalents (37.4 vs. 19.4 mg, p < 0.01) and total intravenous fluids administered (2.7 l vs. 1.5 l, p < 0.0001). Hospital discharges before noon doubled (32.9 vs. 60.2%, p < 0.01). More patients in the ERP group ambulated on the day of surgery (17.1 vs. 73.7%, p < 0.01) and ambulated at least two times the day following surgery (34.2 vs. 72.9%, p < 0.01). No differences were seen in average pain scores (highest pain score 7.39 vs. 7.37, p = 0.95), hospital readmissions (3.9 vs. 3.4%, p = 0.84), or postoperative complications (6.58 vs. 8.47%, p = 0.79). Patient satisfaction significantly improved. ERP was not associated with an increase in 30-day total hospital costs. CONCLUSIONS: Implementation of ERP for pelvic reconstructive surgery patients was associated with a reduced length of hospital stay, improved patient satisfaction, and decreased administration of intravenous fluids and opioids without an increase in complications, readmissions, or hospital costs.


Assuntos
Procedimentos Cirúrgicos em Ginecologia/reabilitação , Pelve/cirurgia , Assistência Perioperatória/estatística & dados numéricos , Procedimentos Cirúrgicos Reconstrutivos/reabilitação , Procedimentos Cirúrgicos Urológicos/reabilitação , Adulto , Idoso , Analgésicos Opioides/uso terapêutico , Estudos de Coortes , Feminino , Procedimentos Cirúrgicos em Ginecologia/métodos , Custos Hospitalares/estatística & dados numéricos , Humanos , Tempo de Internação , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/reabilitação , Satisfação do Paciente/estatística & dados numéricos , Assistência Perioperatória/métodos , Período Pós-Operatório , Procedimentos Cirúrgicos Reconstrutivos/métodos , Resultado do Tratamento
14.
Acta Obstet Gynecol Scand ; 98(1): 61-67, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30187912

RESUMO

INTRODUCTION: The risk of perioperative cardiovascular complications following operations for urinary incontinence and pelvic organ prolapse (POP) must be taken into consideration during surgical planning. The literature on the cardiovascular risk following urinary incontinence and POP operations shows conflicting results. Our aims were to provide an estimate of the mortality and the risk of cardiovascular complications following urinary incontinence and POP operations considering women's preoperative cardiovascular comorbidity. MATERIAL AND METHODS: This nationwide register-based study includes a total of 13 992 operations for urinary incontinence and 35 765 for POP from 2007 to 2017. The risk was estimated as an incidence/rate ratio for women with and without former cardiovascular comorbidity adjusted for relevant confounders by using a case-crossover study design. RESULTS: A total of 7677 patients were at high risk, with a cardiovascular comorbidity prior to the operation, and 42 076 patients were at low risk, with no cardiovascular comorbidity. Overall, 11 patients died within 30 days following an operation, of whom five were in the high-risk group and six in the low-risk group. Of the women at high risk, 0.59% had cardiovascular complications from 0 to 6 days following an operation, corresponding to an incidence/rate ratio of 3.64 (95% CI; 2.67-4.97), compared with women at low risk where no complications were registered in the first week. CONCLUSIONS: We found an increased risk of cardiovascular complications following urogynecological operations in women with preoperative cardiovascular comorbidity, and no increased risk in women without prior cardiovascular comorbidity. In general, the risk of cardiovascular complications was lower than that found in previous studies.


Assuntos
Prolapso de Órgão Pélvico/cirurgia , Assistência Perioperatória/estatística & dados numéricos , Incontinência Urinária por Estresse/cirurgia , Incontinência Urinária/cirurgia , Adulto , Comorbidade , Estudos Cross-Over , Dinamarca/epidemiologia , Feminino , Humanos , Pessoa de Meia-Idade , Prolapso de Órgão Pélvico/mortalidade , Assistência Perioperatória/mortalidade , Período Pós-Operatório , Fatores de Risco , Incontinência Urinária/mortalidade , Incontinência Urinária por Estresse/mortalidade
15.
Eur Urol Focus ; 4(5): 641-642, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30415922

RESUMO

While feasible, it is unclear whether robotic inferior vena cava thrombectomy affords significant benefits. Outcomes are acceptable in carefully selected patients, but the approach is not applicable to all-comers. Higher costs are a challenge for health care systems and the value proposition for this approach is undefined.


Assuntos
Procedimentos Cirúrgicos Robóticos/métodos , Trombectomia/métodos , Veia Cava Inferior/cirurgia , Competência Clínica , Hemorragia/complicações , Humanos , Complicações Intraoperatórias , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Células Neoplásicas Circulantes , Assistência Perioperatória/mortalidade , Assistência Perioperatória/estatística & dados numéricos , Cirurgiões , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Veia Cava Inferior/patologia
16.
Colorectal Dis ; 20(12): 1097-1108, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30307103

RESUMO

AIM: The present database study aimed to identify patients with a longer postoperative length of stay (LOS) or patients readmitted and to characterize both groups based on perioperative factors. METHOD: A retrospective review of the Danish Colorectal Cancer Group database and a local database was performed of all patients undergoing elective resection for colorectal cancer in a 25-month period. The primary outcome was the number of patients with a prolonged hospital stay (LOS ≥ 10 days after the primary operation) and readmissions within 30 days after discharge. RESULTS: A total of 372 patients with colon resection and 215 patients with rectal resection were included. Patients undergoing colonic resection had a rate of prolonged hospital stay of 10.6% and a readmission rate of 13.7%; prolonged hospital stay was significantly associated with age ≥ 76 years and those who underwent a conversion from a laparoscopic procedure. Patients undergoing rectal cancer resection had a rate of prolonged hospital stay of 17.7% and a readmission rate of 14.0%; Charlson comorbidity score (CCS) ≥ 2, total mesorectal excision (TME) and laparoscopic conversion were significantly associated with prolonged hospital stay, and American Society of Anesthesiologists (ASA) score ≥ 3, TME and a duration of surgery ≥ 300 min were significantly associated with readmission. CONCLUSION: In patients with colon cancer, older age and conversion to open surgery were associated with prolonged hospital stay. In patients with rectal cancer, CCS ≥ 2, TME and conversion were associated with prolonged hospital stay, and a preoperative ASA score ≥ 3, TME and a duration of surgery ≥ 300 min were associated with readmission.


Assuntos
Colectomia/estatística & dados numéricos , Neoplasias Colorretais/cirurgia , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Colectomia/métodos , Conversão para Cirurgia Aberta/estatística & dados numéricos , Bases de Dados Factuais , Dinamarca , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória/estatística & dados numéricos , Período Pós-Operatório , Protectomia/estatística & dados numéricos , Estudos Prospectivos , Estudos Retrospectivos , Resultado do Tratamento
17.
PLoS One ; 13(10): e0205712, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30347001

RESUMO

OBJECTIVES: To evaluate the impact of preoperative anemia and perioperative blood transfusion (PBT) on disease free (DFS) and overall survival (OS) of patients with head and neck squamous cell carcinoma (HNSCC). METHODS: Retrospective study of 354 patients primarily treated with surgery between 2006 and 2016. Cases were selected according to completeness and accuracy of available clinical data. Thus, a selection bias cannot be excluded. Patients who received PBT were identified by our controlling department and verified by our blood bank data base. RESULTS: Both, preoperative anemia and PBT significantly decreased OS in univariate analysis. Although PBT was needed more frequently by older patients in worse physical conditions with more advanced HNSCC, subgroup analysis also demonstrate a profoundly negative effect of PBT on OS in younger patients and early stage HNSCC. According to a restrictive transfusion policy at our hospital the transfusion rate was comparably low. We could not verify increasing effects of PBT on cancer recurrence rates as it was previously shown. DISCUSSION: Preoperative anemia is the most common paraneoplastic syndrome in HNSCC. Despite its devastating prognostic effect we suggest a restrictive transfusion policy whenever possible. Our data also show that anemia as an independent prognostic factor in head and neck surgical oncology is defined not only by low hemoglobin concentrations but low red blood cell counts as well.


Assuntos
Anemia/epidemiologia , Transfusão de Sangue/estatística & dados numéricos , Neoplasias de Cabeça e Pescoço/mortalidade , Recidiva Local de Neoplasia/epidemiologia , Assistência Perioperatória/estatística & dados numéricos , Carcinoma de Células Escamosas de Cabeça e Pescoço/mortalidade , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Anemia/sangue , Anemia/terapia , Intervalo Livre de Doença , Contagem de Eritrócitos , Feminino , Seguimentos , Neoplasias de Cabeça e Pescoço/sangue , Neoplasias de Cabeça e Pescoço/patologia , Neoplasias de Cabeça e Pescoço/cirurgia , Hemoglobinas/análise , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Assistência Perioperatória/métodos , Período Pré-Operatório , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Carcinoma de Células Escamosas de Cabeça e Pescoço/sangue , Carcinoma de Células Escamosas de Cabeça e Pescoço/patologia , Carcinoma de Células Escamosas de Cabeça e Pescoço/cirurgia
18.
Curr Opin Anaesthesiol ; 31(6): 723-731, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30169341

RESUMO

PURPOSE OF REVIEW: This narrative review will discuss what value Big Data has to offer anesthesiology and aims to highlight recently published articles of large databases exploring factors influencing perioperative outcome. Additionally, the future perspectives of Big Data and its major pitfalls will be discussed. RECENT FINDINGS: The potential of Big Data has given an incentive to create nationwide and anesthesia-initiated registries like the MPOG and NACOR. These large databases have contributed in elucidating some of the rare perioperative complications, such as declined cognition after exposure to general anesthesia and epidural hematomas in parturients. Additionally, they are useful in finding patterns such as similar outcome in subtypes of beta-blockers and lower incidence of pneumonia in preoperative influenza vaccinations in the elderly. SUMMARY: Big Data is becoming increasingly popular with the collaborative collection of registries offering anesthesia a way to explore rare perioperative complications and outcome to encourage further hypotheses testing. Although Big Data has its flaws in security, lack of expertise and methodological concerns, the future potential of analytics combined with genomics, machine learning and real-time decision support looks promising.


Assuntos
Big Data , Período Perioperatório/estatística & dados numéricos , Resultado do Tratamento , Anestesiologia , Humanos , Assistência Perioperatória/estatística & dados numéricos , Período Perioperatório/tendências , Sistema de Registros
19.
J Arthroplasty ; 33(10): 3138-3142, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30077468

RESUMO

BACKGROUND: Institutional pathways in total joint arthroplasty (TJA) have been shown to reduce costs and improve patient care, but questions remain regarding their efficacy in certain populations. We sought to evaluate the comprehensive effect of a rapid recovery perioperative TJA protocol in the Veterans Health Administration (VA) setting. METHODS: In a VA hospital, a rapid recovery protocol was implemented for all patients undergoing primary total hip or knee arthroplasty. A retrospective chart review was performed comparing pre-protocol (n = 174) and protocol (n = 78) cohorts. Measured outcomes included length of stay (LOS), discharge destination, unplanned readmissions, overall complications, and total cost of healthcare during admission and at 30 and 90 days postoperatively. RESULTS: After implementation of the protocol, the average LOS decreased from 3.2 to 1.7 days (P < .0001). In the protocol group, there was a 12.3% increase in patients discharging directly home (85.1% vs 97.4%, P = .005). There were lower unplanned readmissions (6.3% vs 3.8%, P = .56) and overall complications (7.5% vs 3.8%, P = .40), but these were not statistically significant. The summative cost of all perioperative healthcare was lower after implementation of the protocol during the inpatient stay ($19,015 vs $21,719, P = .002) and out to 30 days postoperatively ($21,083 vs $23,420, P = .03) and 90 days postoperatively ($24,189 vs $26,514, P = .07). CONCLUSION: In the VA setting, implementation of a rapid recovery TJA protocol led to decreased LOS, decreased cost of perioperative healthcare, and an increase in patients discharging directly home without increased readmission or complication rates. Such protocols are essential as we transition into an era of value-based arthroplasty.


Assuntos
Artroplastia de Quadril/normas , Artroplastia do Joelho/normas , Protocolos Clínicos/normas , Hospitais de Veteranos/estatística & dados numéricos , Assistência Perioperatória/normas , Idoso , Artroplastia de Quadril/efeitos adversos , Artroplastia de Quadril/economia , Artroplastia de Quadril/estatística & dados numéricos , Artroplastia do Joelho/efeitos adversos , Artroplastia do Joelho/economia , Artroplastia do Joelho/estatística & dados numéricos , Análise Custo-Benefício , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Hospitais de Veteranos/economia , Hospitais de Veteranos/normas , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Assistência Perioperatória/economia , Assistência Perioperatória/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos/epidemiologia
20.
J Arthroplasty ; 33(10): 3125-3129, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30029928

RESUMO

BACKGROUND: With the recent implementation of a bundled payment model for total joint arthroplasty, healthcare providers are financially responsible for management of complications throughout the 90-day perioperative period. Our aim was to assess the effectiveness of a surveillance system that was implemented to enhance communication during this period. METHODS: A retrospective study was conducted using a prospectively collected database of patients who underwent primary total joint arthroplasty from January 2015 to April 2016. Surveillance was performed using electronic messages and telephone calls. The use of this system in response to several clinical scenarios was measured by the total number of messages and calls exchanged. RESULTS: Communication was greater among patients who experienced a complication (median 8), went to the emergency department (ED; median 9), and were readmitted to the hospital (median 8), relative to patients who had an uncomplicated course (median 5). Additionally, communication was greater among patients who presented to outside facilities for ED visits (median 11) and readmissions (median 9) relative to those who returned to the index hospital for ED visits (median 7) and readmissions (median 6). More distant patients had decreased follow-up attendance but did not have a compensatory increase in use of the surveillance system. CONCLUSION: Patients used the surveillance system to relay information about clinically significant events when such events arose. Additionally, patients who returned to outside facilities used the surveillance system to remain engaged with their original provider. However, more distant patients did not appear to use the surveillance system to compensate for decreased follow-up attendance.


Assuntos
Artroplastia de Substituição/efeitos adversos , Readmissão do Paciente/estatística & dados numéricos , Assistência Perioperatória/estatística & dados numéricos , Vigilância da População , Idoso , Artroplastia de Substituição/economia , Comunicação , Bases de Dados Factuais , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Pacotes de Assistência ao Paciente/economia , Pacotes de Assistência ao Paciente/estatística & dados numéricos , Assistência Perioperatória/economia , Relações Médico-Paciente , Estudos Retrospectivos
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