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1.
Surg Clin North Am ; 100(2): 337-360, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32169183

RESUMO

The role of robotics in colon and rectal surgery has been established as an important and effective tool for the surgeon. Its inherent technologies have provided for increased visualization and ease of dissection in the minimally invasive approach to surgery. The value of the robot is apparent in the more challenging aspects of colon and rectal procedures, including the intracorporeal anastomosis for right colectomies and the low pelvic dissection for benign and malignant diseases.


Assuntos
Doenças do Colo/cirurgia , Cirurgia Colorretal/métodos , Doenças Retais/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Colectomia/métodos , Humanos , Laparoscopia/métodos
2.
Ann R Coll Surg Engl ; 102(2): 141-143, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31660754

RESUMO

INTRODUCTION: Colonic stent insertion has been shown to be an effective treatment for patients with acute large bowel obstruction, either as a bridge to surgery or as definitive treatment. However, little is known of the role of secondary stent insertion following primary stent failure in patients considered inappropriate or high risk for emergency surgery. METHODS: Fourteen patients presenting with acute large bowel obstruction who had previously been treated with colonic stent insertion were studied. All underwent attempted placement of a secondary stent. RESULTS: Technical deployment of the stent was accomplished in 12 patients (86%) but only 9 (64%) achieved clinical decompression. Successful deployment and clinical decompression of a secondary stent was associated with older age (p=0.038). Sex, pathology, site of obstruction, duration of efficacy of initial stent and cause of primary failure were unrelated to outcome. No procedure related morbidity or mortality was noted following repeated intervention. CONCLUSIONS: Secondary colonic stent insertion appears an effective, safe treatment in the majority of patients presenting with acute large bowel obstruction following failure of a primary stent.


Assuntos
Doenças do Colo/cirurgia , Descompressão Cirúrgica/instrumentação , Obstrução Intestinal/cirurgia , Complicações Pós-Operatórias/epidemiologia , Stents , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Descompressão Cirúrgica/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Retratamento/instrumentação , Falha de Tratamento , Resultado do Tratamento
3.
Ann R Coll Surg Engl ; 102(2): 133-140, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31508999

RESUMO

INTRODUCTION: Surgical site infections cause considerable postoperative morbidity and mortality. The aim of this study was to determine the effect on surgical site infection rates following introduction of a departmental oral antibiotic bowel preparation protocol. METHODS: A prospective single-centre study was performed for elective colorectal resections between May 2016-April 2018; with a control group with mechanical bowel preparation and treatment group with oral antibiotic bowel preparation (neomycin and metronidazole) and mechanical bowel preparation. The primary outcome of surgical site infection and secondary outcomes of anastomotic leak, length of stay and mortality rate were analysed using Fisher's exact test and independent samples t-tests. A cost-effectiveness analysis was also performed. RESULTS: A total of 311 patients were included; 156 in the mechanical bowel preparation group and 155 in the mechanical bowel preparation plus oral antibiotic bowel preparation group. The study included 180 (57.9%) men and 131 (42.1%) women with a mean age of 68 years. There was a significant reduction in surgical site infection rates (mechanical bowel preparation 16.0% vs mechanical bowel preparation plus oral antibiotic bowel preparation 4.5%; P = 0.001) and mean length of stay (mechanical bowel preparation 10.2 days vs mechanical bowel preparation plus oral antibiotic bowel preparation 8.2 days; P = 0.012). There was also a reduction in anastomotic leak and mortality rates. Subgroup analyses demonstrated significantly reduced surgical site infection rates in laparoscopic resections (P = 0.008). There was an estimated cost saving of £239.13 per patient and £37,065 for our institution over a one-year period. CONCLUSION: Oral antibiotic bowel preparation is a feasible and cost-effective intervention shown to significantly reduce the rates of surgical site infection and length of stay in elective colorectal surgery.


Assuntos
Antibacterianos/administração & dosagem , Antibioticoprofilaxia/métodos , Doenças do Colo/cirurgia , Doenças Retais/cirurgia , Infecção da Ferida Cirúrgica/prevenção & controle , Administração Oral , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibioticoprofilaxia/economia , Doenças do Colo/economia , Análise Custo-Benefício , Procedimentos Cirúrgicos Eletivos/economia , Inglaterra , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Doenças Retais/economia , Infecção da Ferida Cirúrgica/economia , Adulto Jovem
4.
Ann R Coll Surg Engl ; 102(1): 28-35, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31232611

RESUMO

INTRODUCTION: Enhanced recovery programmes are established as an essential part of laparoscopic colorectal surgery. Optimal pain management is central to the success of an enhanced recovery programme and is acknowledged to be an important patient reported outcome measure. A variety of analgesia strategies are employed in elective laparoscopic colorectal surgery ranging from patient-controlled analgesia to local anaesthetic wound infiltration catheters. However, there is little evidence regarding the optimal analgesia strategy in this cohort of patients. The LapCoGesic study aimed to explore differences in analgesia strategies employed for patients undergoing elective laparoscopic colorectal surgery and to assess whether this variation in practice has an impact on patient-reported and clinical outcomes. MATERIALS AND METHODS: A prospective, multicentre, observational cohort study of consecutive patients undergoing elective laparoscopic colorectal resection was undertaken over a two-month period. The primary outcome measure was postoperative pain scores at 24 hours. Data analysis was conducted using SPSS version 22. RESULTS: A total of 103 patients undergoing elective laparoscopic colorectal surgery were included in the study. Thoracic epidural was used in 4 (3.9%) patients, spinal diamorphine in 56 (54.4%) patients and patient-controlled analgesia in 77 (74.8%) patients. The use of thoracic epidural and spinal diamorphine were associated with lower pain scores on day 1 postoperatively (P < 0.05). The use of patient-controlled analgesia was associated with significantly higher postoperative pain scores and pain severity. DISCUSSION: Postoperative pain is managed in a variable manner in patients undergoing elective colorectal surgery, which has an impact on patient reported outcomes of pain scores and pain severity.


Assuntos
Analgesia/métodos , Doenças do Colo/cirurgia , Laparoscopia/métodos , Padrões de Prática Médica/estatística & dados numéricos , Doenças Retais/cirurgia , Idoso , Analgesia/estatística & dados numéricos , Analgesia Controlada pelo Paciente/estatística & dados numéricos , Analgésicos Opioides/uso terapêutico , Conversão para Cirurgia Aberta/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Feminino , Humanos , Cuidados Intraoperatórios/métodos , Cuidados Intraoperatórios/estatística & dados numéricos , Laparoscopia/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Medição da Dor , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/prevenção & controle , Cuidados Pós-Operatórios/métodos , Cuidados Pós-Operatórios/estatística & dados numéricos , Estudos Prospectivos , Reoperação/estatística & dados numéricos , Resultado do Tratamento
5.
Ann R Coll Surg Engl ; 102(3): 180-184, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31841027

RESUMO

INTRODUCTION: Stoma formation following colorectal resection is often anticipated prior to surgery. Becoming independent with stoma handling can sometimes delay discharge beyond achievement of discharge criteria. The aim of this study was to assess the impact of preoperative stoma training on length of stay. METHODS: Patients undergoing colorectal resection within an enhanced recovery after surgery (ERAS) programme were prospectively entered into a database. Retrospective analysis was performed of those who received a stoma as part of their operation. Patients who underwent preoperative stoma training were compared with those who had conventional postoperative training. The primary outcome measure was length of hospital stay. Secondary outcome measures included overall morbidity, stoma related morbidity, ERAS milestone achievement and readmission rates. RESULTS: The median length of stay was improved in the patients receiving preoperative stoma training (8 days [interquartile range: 6-10] vs 9 days [interquartile range: 7-19.5], p=0.025). No statistically significant difference was observed in overall morbidity rates, stoma specific morbidity, ERAS milestones or readmission rates. CONCLUSIONS: Preoperative stoma training can reduce length of stay and could be employed routinely for patients who are planned to have colorectal surgery. Such training can be incorporated within ERAS pathways.


Assuntos
Colostomia , Ileostomia , Tempo de Internação , Educação de Pacientes como Assunto , Idoso , Idoso de 80 Anos ou mais , Doenças do Colo/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Período Pré-Operatório , Doenças Retais/cirurgia
6.
Gastroenterology ; 158(1): 168-175.e6, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31563627

RESUMO

BACKGROUND & AIMS: We performed a large, multicenter, randomized controlled trial to determine the efficacy and safety of early colonoscopy on outcomes of patients with acute lower gastrointestinal bleeding (ALGIB). METHODS: We performed an open-label study at 15 hospitals in Japan of 170 patients with ALGIB randomly assigned (1:1) to groups that underwent early colonoscopy (within 24 hours of initial visit to the hospital) or elective colonoscopy (24-96 hours after hospital admission). The primary outcome was identification of stigmata of recent hemorrhage (SRH). Secondary outcomes were rebleeding within 30 days, endoscopic treatment success, need for transfusion, length of stay, thrombotic events within 30 days, death within 30 days, and adverse events. RESULTS: SRH were identified in 17 of 79 patients (21.5%) in the early colonoscopy group vs 17 of 80 patients (21.3%) in the elective colonoscopy group (difference, 0.3; 95% confidence interval, -12.5 to 13.0; P = .967). Rebleeding within 30 days of hospital admission occurred in 15.3% of patients in the early colonoscopy group and 6.7% of patients in the elective colonoscopy group (difference, 8.6; 95% confidence interval, -1.4 to 18.7); there were no significant differences between groups in successful endoscopic treatment rate, transfusion rate, length of stay, thrombotic events, or death within 30 days. The adverse event of hemorrhagic shock occurred during bowel preparation in no patient in the early group vs 2 patients (2.5%) in the elective colonoscopy group. CONCLUSIONS: In a randomized controlled study, we found that colonoscopy within 24 hours after hospital admission did not increase SRH or reduce rebleeding compared with colonoscopy at 24-96 hours in patients with ALGIB. ClinicalTrials.gov, Numbers: UMIN000021129 and NCT03098173.


Assuntos
Doenças do Colo/cirurgia , Colonoscopia/efeitos adversos , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Hemorragia Gastrointestinal/cirurgia , Tempo para o Tratamento , Doença Aguda/mortalidade , Doença Aguda/terapia , Idoso , Idoso de 80 Anos ou mais , Transfusão de Sangue/estatística & dados numéricos , Doenças do Colo/mortalidade , Feminino , Hemorragia Gastrointestinal/mortalidade , Mortalidade Hospitalar , Humanos , Japão , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Recidiva , Resultado do Tratamento
9.
J Ayub Med Coll Abbottabad ; 31(3): 464-465, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31535530

RESUMO

Tuberculosis continues to be a fatal infectious disease in developing countries. Despite the advances in medical sciences and introduction of potent therapeutic regimes tuberculosis has still managed to survive and prevail worldwide. It can affect many organs of body. Isolated splenic tuberculosis is uncommon in immunocompetent host and only some cases are reported internationally. Extrapulmonary tuberculosis with splenic involvement is also rare and only comes after lungs and liver. We present a case of patient presented with complaints of prolonged fever, cough and insidious onset of abdominal pain and sepsis. Exploratory laparotomy revealed spleenic abscess as incidental finding associated with tuberculous perforation of colon. She underwent double barrel colostomy and spleenectomy followed by intensive care unit admission. Measures such as awareness about the disease, early medical assistance and good compliance regarding treatment can produce positive results in combating tuberculosis and its complications.


Assuntos
Abscesso/microbiologia , Doenças do Colo/complicações , Perfuração Intestinal/microbiologia , Esplenopatias/microbiologia , Tuberculose/complicações , Abscesso/cirurgia , Idoso de 80 Anos ou mais , Doenças do Colo/cirurgia , Colostomia , Feminino , Humanos , Perfuração Intestinal/cirurgia , Esplenectomia , Esplenopatias/cirurgia , Tuberculose/cirurgia
10.
Acta Med Port ; 32(9): 614-617, 2019 Sep 02.
Artigo em Inglês | MEDLINE | ID: mdl-31493366

RESUMO

Intramural hematoma of the colon is very rare, particularly when associated with the development of autoantibodies against factor VIII.We report a case of a 66-year-old man with abdominal pain, hematochezia and clots in the left colon, without any radiologic signs of active bleeding or bowel occlusion or analytical changes in routine coagulation screening, but with positive autoantibodies against factor VIII. The clinical instability prompted surgical exploration. An intramural hematoma of the left colon was found, and a left colectomy was performed. The patient was treated with hemoderivatives and corticosteroids with clinical improvement. The diagnosis of spontaneous intramural hematoma might be a challenge, particularly in the absence of clinical suspicion. An early recognition is essential for a positive outcome. This case highlights a rare cause of bleeding and intestinal obstruction, but also the difficulty and relevance of establishing a clinical diagnosis when diagnostic tests are not completely informative.


Assuntos
Dor Abdominal/etiologia , Autoanticorpos/análise , Doenças do Colo/etiologia , Fator VIII/imunologia , Hematoma/etiologia , Hemofilia A/complicações , Idoso , Doenças do Colo/diagnóstico , Doenças do Colo/cirurgia , Colonoscopia , Fator VIII/análise , Hemorragia Gastrointestinal/etiologia , Hematoma/diagnóstico , Hematoma/cirurgia , Hemofilia A/diagnóstico , Humanos , Obstrução Intestinal/etiologia , Masculino
11.
JSLS ; 23(3)2019.
Artigo em Inglês | MEDLINE | ID: mdl-31488941

RESUMO

Background: Laparoscopic surgery has become the standard of care for the most common surgical procedures performed. However, laparoscopic techniques have not reached this same penetrance in colorectal surgery. We wanted to determine the percentage of colon operations performed in Texas that were done via laparoscopic, robotic and open techniques. Methods: The Texas Inpatient Public Use Data File (PUDF) was queried using ICD-9-CM diagnostic and procedure codes to determine overall utilization of laparoscopic colectomies (LC) in Texas between 2013-14 for reporting facilities. We specifically looked at cost and the length of stay for LC, open colectomy (OC) and robotic assisted colectomy (RAC). Results: In the state of Texas between 2013-14 there were 20,454 colectomies performed. Of these 12,328 (60.3%) were OC, 7,536 (36.8%) were LC, and 590 (3.9%) were RAC. Average total cost was $117,113 for OC, $75,741.9 for LC, and $81,996.2 for RAC. Average length of stay for each technique was 10.6 days for OC, 6.1 days for LC, and 5.1 days for RAC. The risk of a postoperative complication occurring was higher in the open procedure than a laparoscopic procedure. Conclusions: LC accounted for only 36.8% of all colectomies performed in Texas between 2013-14. OC costs twice as much as LC and increased the length of stay by nearly 4 d. LC and RAC are both associated with significantly less cost and length of stay for patients undergoing surgery, while lowering perioperative complications. Disclosures: None of the authors have any relevant disclosures.


Assuntos
Colectomia/tendências , Doenças do Colo/cirurgia , Armazenamento e Recuperação da Informação/estatística & dados numéricos , Pacientes Internados/estatística & dados numéricos , Laparoscopia/estatística & dados numéricos , Laparoscopia/tendências , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Adolescente , Adulto , Idoso , Colectomia/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Texas , Adulto Jovem
12.
Urology ; 134: 90-96, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31560917

RESUMO

OBJECTIVE: To describe a rare complication in 5 women who had vaginal prolapse, dehiscence, and/or evisceration after having undergone robotic-assisted radical cystectomy with creation of ileal conduit urinary diversion. Radical cystectomy is the standard of care in the extirpative treatment for muscle invasive urothelial carcinoma. Anterior exenteration in the female patient requires removal of the anterior vaginal wall, urethra, uterus, and adnexa which results in significant changes to the pelvic floor. METHODS: Retrospective identification of all women having undergone robotic-assisted radical cystectomy for urothelial carcinoma who ultimately represented with vaginal prolapse, dehiscence, and/or evisceration between January 2012 and April 2019. We identified patient characteristics detailing their presentation. A review of the available literature highlighted the lack of available information in this uncommon cohort. RESULTS: Five women with vaginal dehiscence and/or evisceration who had previously undergone robotic-assisted radical cystectomy, anterior vaginectomy with urethrectomy, pelvic lymph node dissection, and creation of ileal conduit by 4 surgeons were identified. Mean interval time to initial presentation of prolapse or dehiscence was 44.4 weeks (range 11-120). In the 2 patients that eviscerated prior to repair, this occurred at 5 and 25 weeks after initial outpatient consultation. All reconstructive efforts were approached transvaginally. Two patients underwent 2 or more repairs. Management options included expectant management, pessary, and immediate vs delayed transvaginal surgical repair. CONCLUSION: Our case series describes the unique and potentially devastating complication of vaginal dehiscence and bowel evisceration in women with history of robotic-assisted radical cystectomy.


Assuntos
Carcinoma/cirurgia , Doenças do Colo , Cistectomia , Herniorrafia/métodos , Distúrbios do Assoalho Pélvico , Complicações Pós-Operatórias/cirurgia , Deiscência da Ferida Operatória , Neoplasias da Bexiga Urinária/cirurgia , Prolapso Uterino , Idoso , Carcinoma/patologia , Doenças do Colo/etiologia , Doenças do Colo/cirurgia , Cistectomia/efeitos adversos , Cistectomia/métodos , Feminino , Humanos , Pessoa de Meia-Idade , Invasividade Neoplásica , Distúrbios do Assoalho Pélvico/diagnóstico , Distúrbios do Assoalho Pélvico/etiologia , Distúrbios do Assoalho Pélvico/cirurgia , Reoperação/métodos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/métodos , Deiscência da Ferida Operatória/etiologia , Deiscência da Ferida Operatória/cirurgia , Resultado do Tratamento , Neoplasias da Bexiga Urinária/patologia , Derivação Urinária/efeitos adversos , Derivação Urinária/métodos , Prolapso Uterino/etiologia , Prolapso Uterino/cirurgia
13.
Cir Pediatr ; 32(3): 150-153, 2019 Jul 29.
Artigo em Espanhol | MEDLINE | ID: mdl-31486308

RESUMO

INTRODUCTION: Colopericardial fistula is a rare complication of colonic replacement surgery whose incidence is unknown. Therefore, we present the following case and perform a literature review. CLINICAL CASE: 17-year-old female patient of age consults for respiratory distress and precordial pain of 5 days of evolution. Background: Long gap esophageal atresia (esophagostoma and feeding gastrostomy, subsequent colonic graft). Bilateral pneumonia is initially diagnosed. It rapidly evolves to a state of sepsis. On chest x-ray, pneumopericardium is observed. Water-soluble contrasted study confirms diagnosis of colopericardial fistula. Surgical treatment is established, despite this the patient dies due to respiratory distress. COMMENT: Colopericardial fistula is a very serious entity with a high mortality rate. The clinical presentation and the complementary methods of diagnostic confirmation must be known in order to carry out the appropriate treatment.


Assuntos
Doenças do Colo/diagnóstico , Esôfago/cirurgia , Fístula/diagnóstico , Adolescente , Doenças do Colo/etiologia , Doenças do Colo/cirurgia , Atresia Esofágica/cirurgia , Evolução Fatal , Feminino , Fístula/etiologia , Fístula/cirurgia , Gastrostomia/métodos , Humanos , Pneumopericárdio/diagnóstico por imagem , Complicações Pós-Operatórias/diagnóstico
14.
S Afr J Surg ; 57(3): 50-53, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31392865

RESUMO

BACKGROUND: Colorectal surgery has developed into an established surgical subspecialty in South Africa, however there is a paucity of data regarding the epidemiology and surgical outcomes of patients with colorectal disease in this country. The objective is to present the findings of a one-year audit of the Wits Donald Gordon Medical Centre (WDGMC) Colorectal Unit with specific reference to indications, surgical procedures and patient outcomes. METHOD: Patient files from December 2016 to November 2017 were included in a retrospective analysis. The Mann-Whitney U test was used to analyse continuous variables and the Chi-squared test was used to compare categorical variables. RESULTS: During the audit period, 1264 patients were admitted to the Colorectal Unit and a further 564 outpatient endoscopic procedures were performed. There were 306 emergency admissions. 139 elective colorectal resections took place, with a 16% major complication rate, a 12% anastomotic leak rate and no deaths. Rectal resections constituted 66% of the operations and 34% were colonic resections. The median length of stay for all patients undergoing resection was 9 days and there was no statistically significant difference in length of stay between open and laparoscopic cases. CONCLUSION: The WDGMC Colorectal Unit manages a high volume of patients presenting with the full spectrum of colorectal disease.


Assuntos
Colectomia/estatística & dados numéricos , Doenças do Colo/cirurgia , Complicações Pós-Operatórias/etiologia , Protectomia/estatística & dados numéricos , Doenças Retais/cirurgia , Centros Médicos Acadêmicos/estatística & dados numéricos , Fístula Anastomótica/etiologia , Colectomia/efeitos adversos , Endoscopia Gastrointestinal/efeitos adversos , Endoscopia Gastrointestinal/estatística & dados numéricos , Unidades Hospitalares/estatística & dados numéricos , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/estatística & dados numéricos , Tempo de Internação , Auditoria Médica , Readmissão do Paciente/estatística & dados numéricos , Protectomia/efeitos adversos , Estudos Retrospectivos
15.
Ann Saudi Med ; 39(4): 251-257, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31381364

RESUMO

BACKGROUND: Colon surgery can cause systemic inflammatory response syndrome (SIRS). There is a recent trend towards the use of antioxidant agents in the prevention or alleviation of the severity of postoperative SIRS, but its use is controversial as studies have shown conflicting results. OBJECTIVES: Investigate the efficacy and tolerability of perioperative intravenous administration of N-acetylcysteine (NAC) as an antioxidant and anti-inflammatory agent in patients undergoing colon surgery. DESIGN: Randomized, double-blinded, and controlled clinical trial. SETTING: Surgical critical care unit in Egypt. PATIENTS AND METHODS: Sixty patients who required admission to the ICU following colon surgery were enrolled in the study between July 2015 and October 2016. Eligibility included the need for parenteral nutrition for at least 5 days due to failure of or contraindication to enteral nutrition. Patients were randomly allocated using a computer-generated list to a loading dose of NAC followed by continuous infusion started one hour prior to induction, and continued over 48 hours, or to the control group, who received the same volume of dextrose 5%. Allocation was concealed using opaque, sealed envelopes under pharmacy control. The researcher, the anesthesiologist, the surgeon, and patients were blinded to the treatment allocation. MAIN OUTCOME MEASURES: Clinical and laboratory evaluation for manifestations of SIRS, serum levels of tumor necrosis factor alpha and malondialdehyde, and occurrence of side effects in the study group. SAMPLE SIZE: 60 patients with mean (SD) ages of 56 (15.1) years in the study group (n=30) and 57.7 (12.3) years in the control group (n=30). RESULTS: There was a significant difference in the mean serum level of ALT (22.6 (9.9) U/L in the study group vs. 31.1 (17.8) U/L in the control group, P=.028) after treatment with NAC, but differences between the groups in the serum level of tumor necrosis factor alpha and malondialdehyde after treatment were not significant. Serum levels of malondialdehyde increased in both groups after treatment P<.001. There was no statistically significant difference from baseline or between the groups after treatment in other clinical data and laboratory parameters following NAC administration, and only 6.6% of the patients in the study group experienced mild side effects. CONCLUSIONS: Preoperative administration of NAC is safe, but its efficacy as an antioxidant and anti-inflammatory agent was not statistically significant and requires further investigation in a larger sample. LIMITATIONS: Single-center study, small sample size, and short duration of NAC administration. CLINICAL TRIALS REGISTRY: NCT03589495. CONFLICT OF INTEREST: None.


Assuntos
Acetilcisteína/administração & dosagem , Antioxidantes/administração & dosagem , Doenças do Colo/cirurgia , Dipeptídeos/administração & dosagem , Síndrome de Resposta Inflamatória Sistêmica/prevenção & controle , Acetilcisteína/efeitos adversos , Administração Intravenosa , Adulto , Idoso , Antioxidantes/efeitos adversos , Dipeptídeos/efeitos adversos , Método Duplo-Cego , Egito , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Cuidados Pré-Operatórios/métodos , Estudos Prospectivos , Síndrome de Resposta Inflamatória Sistêmica/epidemiologia
16.
Dis Colon Rectum ; 62(9): 1028-1030, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31397752

RESUMO

CASE SUMMARY: An otherwise healthy 59-year-old man presented to the emergency department with 2 weeks of narrowed stools, 5 days of obstipation, and 1 day of abdominal pain, nausea, and vomiting. Computed tomography revealed an obstructing sigmoid mass without evidence of metastatic disease, and the CEA was 1.2 ng/mL. Flexible sigmoidoscopy confirmed a circumferentially obstructing distal sigmoid neoplasm. Endoscopic stent placement was immediately followed by a firm distended abdomen. An upright radiograph obtained following the procedure demonstrated free intraperitoneal air. An emergent Hartmann procedure was performed for iatrogenic colon perforation in a patient with malignant obstruction and chronic dilation of the proximal colon.


Assuntos
Doenças do Colo/cirurgia , Ileostomia/métodos , Obstrução Intestinal/cirurgia , Laparoscopia/métodos , Neoplasias do Colo Sigmoide/complicações , Sigmoidoscopia/métodos , Tomografia Computadorizada por Raios X/métodos , Doenças do Colo/diagnóstico , Doenças do Colo/etiologia , Humanos , Obstrução Intestinal/diagnóstico , Obstrução Intestinal/etiologia , Masculino , Pessoa de Meia-Idade , Neoplasias do Colo Sigmoide/diagnóstico , Neoplasias do Colo Sigmoide/cirurgia
17.
Surg Today ; 49(12): 1003-1012, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31256255

RESUMO

PURPOSE: Our animal studies have demonstrated the safety and feasibility of end-to-end intestinal anastomosis using a stent for laparoscopic colonic surgery. Therefore, we designed a non-inferiority trial to investigate the outcomes of stent anastomosis (SA) vs. those of conventional hand-sewn anastomosis (CA). METHODS: A multicenter randomized controlled trial was conducted between December, 2016 and April, 2018. The primary outcome was the healing condition of the anastomoses, evaluated by endoscopy 6 months postoperatively. The secondary outcomes were the anastomotic completion time, anastomotic leak, intestinal obstruction, peritoneal effusion, and bleeding. Quality of life (QOL) was evaluated by questionnaires. RESULTS: The subjects of this study were 60 patients, randomly divided into a SA group (n = 30) and a CA group (n = 30). There were no differences in anastomotic healing conditions (P = 1.00). The stent procedure was associated with a significantly shorter anastomosis time than the hand-sewn anastomosis (13.517 ± 4.281 vs. 20.333 ± 2.998 min, respectively; P < 0.001). There were no significant differences in anastomotic leakage, intestinal obstruction, peritoneal effusion, or bleeding between the groups. Questionnaires revealed almost no discrepancy between baseline QOL scores and those assessed 2, 4, 8, 12, and 24 weeks postoperatively in either group. CONCLUSIONS: Intestinal anastomosis with a stent is a non-inferior strategy for laparoscopic colonic surgery, which requires less time for the anastomosis.


Assuntos
Implantes Absorvíveis , Anastomose Cirúrgica/métodos , Colo/cirurgia , Doenças do Colo/cirurgia , Endoscopia Gastrointestinal/métodos , Laparoscopia/métodos , Stents , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Estudos Prospectivos , Qualidade de Vida , Inquéritos e Questionários , Resultado do Tratamento , Adulto Jovem
18.
Dis Colon Rectum ; 62(9): 1105-1116, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31318772

RESUMO

BACKGROUND: Enhanced recovery program is a multimodal, multidisciplinary-team, evidence-based care approach to reduce perioperative surgical stress, decrease morbidity and hospital stay, and improve recovery after surgery. This program may be most beneficial for elderly (≥70 y), but sparse series have investigated this question. OBJECTIVE: Feasibility and efficiency of a dedicated enhanced recovery program in the elderly as compared with standard care were studied. DESIGN: This was a nonblinded, randomized controlled study. SETTINGS: This study was conducted in a single high-volume university hospital. PATIENTS: A total of 150 eligible elderly patients undergoing elective colorectal surgery were included. INTERVENTIONS: Enhanced recovery after colorectal elective surgery in elderly patients was studied. MAIN OUTCOME MEASURES: The primary outcome was 30-day postoperative morbidity. Additional outcomes included hospital stay, readmission, postoperative pain, opioid consumption, independence preservation, and protocol compliance. RESULTS: An enhanced recovery program reduces postoperative morbidity according to Clavien-Dindo classification by 47% as compared with standard care (35% vs 65%; p = 0.0003), total number of complications (54 vs 118; p = 0.0003), and infectious complications (13 vs 29; p = 0.001). No anastomotic leak was recorded in the enhanced recovery group versus 5 for the standard group (p = 0.01). The enhanced recovery program resulted in shorter hospital stay (7 vs 12 d; p = 0.003) and better independence preservation (home discharge, 87% vs 67%; p = 0.005). A high protocol compliance of 77.2% could be achieved in this population. According to multivariate analysis, enhanced recovery program was strongly associated with reduced morbidity (OR = 0.23 (95% CI, 0.09-0.57); p = 0.001), less severe complications (OR = 0.36 (95% CI, 0.15-0.84); p = 0.02), and shorter hospital stay (OR = 2.07 (95% CI, 1.33-3.22); p = 0.001). LIMITATIONS: Limitations were a single-center recruitment and the impossibility of subject or healthcare professional blinding attributed to the nature of this multimodal program. CONCLUSIONS: Enhanced recovery program is safe and improves postoperative recovery in elderly patients with decreased morbidity, shorter hospital stay, and better maintenance of independence. It should therefore be considered as a standard of care for elective colorectal surgery in elderly patients. See Video Abstract at http://links.lww.com/DCR/A981. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT01646190. ENSAYO CONTROLADO ALEATORIZADO DE UN PROGRAMA DE RECUPERACIÓN INTENSIFICADA DEDICADO A PACIENTES DE EDAD AVANZADA DESPUÉS DE CIRUGÍA COLORECTAL: El Programa de Recuperación Intensificada es un enfoque de atención multimodal, multidisciplinaria y basada en evidencia para reducir el estrés quirúrgico perioperatorio, disminuir la morbilidad y la estancia hospitalaria, y mejorar la recuperación después de la cirugía. Este programa puede ser más beneficioso para las personas mayores (≥70 años), pero pocas series han investigado esta pregunta. OBJETIVO: Viabilidad y eficiencia del Programa de Recuperación Intensificada dedicado en personas de edad avanzada en comparación con la atención estándar. DISEÑO:: Este fue un estudio controlado, aleatorizado, sin método ciego. ESCENARIO: Este estudio se realizó en un único hospital universitario de alto volumen. PACIENTES: Un total de 150 pacientes de edad avanzada elegibles sometidos a cirugía colorrectal electiva fueron incluidos. INTERVENCIONES: Recuperación Intensificada después de cirugía electiva colorrectal en pacientes de edad avanzada. PRINCIPALES MEDIDAS DE RESULTADO: El resultado primario fue la morbilidad postoperatoria a 30 días. Los resultados adicionales incluyeron estancia hospitalaria, reingreso, dolor postoperatorio, consumo de opioides, preservación de la independencia y cumplimiento del protocolo. RESULTADOS: El Programa de Recuperación Intensificada reduce la morbilidad postoperatoria según la clasificación de Clavien-Dindo en un 47% en comparación con la atención estándar (35% vs 65%; p = 0.0003), número total de complicaciones (54 vs 118; p = 0.0003) y complicaciones infecciosas (13 vs 29; p = 0.001). No se registró ninguna fuga anastomótica en el grupo de Recuperación Intensificada frente a 5 para el grupo estándar (p = 0.01). El Programa de Recuperación Intensificada dio como resultado una estancia hospitalaria más corta (7 contra 12 días; p = 0.003) y una mejor conservación de la independencia (alta hospitalaria: 87% vs 67%; p = 0.005). Se pudo lograr un alto cumplimiento del protocolo del 77.2% en esta población. De acuerdo con el análisis multivariable, el Programa de Recuperación Intensificada se asoció fuertemente con la reducción de morbilidad (OR = 0.23; IC 95%: 0.09-0.57; p = 0.001), menos complicaciones graves (OR = 0.36; IC 95%: 0.15-0.84; p = 0.02) y estancia hospitalaria más corta (OR = 2.07; IC 95%: 1.33-3.22; p = 0.001). LIMITACIONES: Las limitaciones fueron un centro único de reclutamiento y la imposibilidad de que los pacientes o el profesional de la salud tuvieran cegamiento debido a la naturaleza de este programa multimodal. CONCLUSIONES: El Programa de recuperación Intensificada es seguro y mejora la recuperación postoperatoria en pacientes de edad avanzada, con menor morbilidad, menor estancia hospitalaria y mejor mantenimiento de la independencia. Por lo tanto, debe considerarse como un estándar de atención para la cirugía colorrectal electiva en pacientes de edad avanzada. Vea el Resumen en video en http://links.lww.com/DCR/A981.


Assuntos
Colectomia/reabilitação , Doenças do Colo/reabilitação , Defecação/fisiologia , Procedimentos Cirúrgicos Eletivos/reabilitação , Laparoscopia/reabilitação , Cuidados Pós-Operatórios/métodos , Recuperação de Função Fisiológica , Idoso , Doenças do Colo/fisiopatologia , Doenças do Colo/cirurgia , Estudos de Viabilidade , Feminino , Seguimentos , Humanos , Tempo de Internação , Masculino
19.
Am J Case Rep ; 20: 1057-1062, 2019 Jul 20.
Artigo em Inglês | MEDLINE | ID: mdl-31324749

RESUMO

BACKGROUND Ehlers-Danlos Syndrome (EDS) is a group of connective tissue disorders with heterogeneous clinical features associated with varying genetic mutations. EDS type IV, also known as vascular EDS (vEDS), is the rarest type but has fatal complications, including rupture of major vasculature and intestinal and uterine perforation. Intestinal perforation can be spontaneous or a consequence of long-standing constipation, a common symptom among patients with EDS. CASE REPORT We present a case of a 6-year-old boy with the previous diagnosis of vEDS who presented with colonic perforation from a stercoral ulcer. He underwent diagnostic laparoscopy and loop colostomy, with an uneventful postoperative course. Unfortunately, he developed a second colonic perforation 14 months after the initial episode and underwent total abdominal colectomy with end ileostomy. CONCLUSIONS Intestinal perforation is a well-documented and devastating complication of vEDS. However, spontaneous intestinal perforation is extremely rare in a young child. Therefore, the diagnosis of vEDS should be included in the differential diagnosis if a child presents with intestinal perforation. There is no clear guideline available for surgical management of colonic perforation in patients with vEDS, but total abdominal colectomy appears to provide the best chance of preventing recurrent perforation.


Assuntos
Doenças do Colo/diagnóstico , Doenças do Colo/etiologia , Síndrome de Ehlers-Danlos/complicações , Síndrome de Ehlers-Danlos/diagnóstico , Perfuração Intestinal/diagnóstico , Perfuração Intestinal/etiologia , Criança , Doenças do Colo/cirurgia , Diagnóstico Diferencial , Humanos , Perfuração Intestinal/cirurgia , Masculino
20.
Sao Paulo Med J ; 137(2): 132-136, 2019 Jul 15.
Artigo em Inglês | MEDLINE | ID: mdl-31314873

RESUMO

BACKGROUND: Despite advances in surgical approaches, emergency colorectal surgery has high mortality and morbidity. OBJECTIVE: We aimed to create a simple and distinctive scoring system, for predicting mortality among patients undergoing emergency colorectal surgery. DESIGN AND SETTING: Prediction model development study based on retrospective data-gathering. METHODS: Patients who underwent emergency colorectal surgery between March 2014 and December 2016 at a single tertiary-level referral center were included in our study. Patient demographics, comorbidities, type of surgery, etiology and laboratory and radiological findings were collected retrospectively and analyzed. A new clinical score (named the Numune emergency colorectal resection score) was constructed from the last logistic regression model, in which one point was assigned for the presence of each predictive factor. RESULTS: 138 patients underwent emergency colorectal surgery. These comprised 64 males (46.4%) and 74 females (53.6%), with a mean age of 64 years. Multivariate analysis revealed that blood urea nitrogen level > 65 mg/dl (odds ratio, OR: 8.03; 95% confidence interval, CI: 2.16-15.77), albumin level < 0.7 -mg/-dl (OR: 4.43; 95% CI: 1.96-14.39) and American Society of Anesthesiologists score ≥ 3 (OR: 3.47; 95% CI: 0.81-9.18) were associated with postoperative complications. The Numune score was graded from I to III. The risk of mortality was found to be 63.2% in the group with grade III, which accounted for 35.2% of the subjects. There were 37 postoperative deaths. CONCLUSIONS: Surgeons need scoring systems, especially to predict postoperative mortality. We propose the Numune emergency colorectal resection score for emergency surgical procedures as a practical, usable and effective system for predicting postoperative morbidity.


Assuntos
Doenças do Colo/cirurgia , Cirurgia Colorretal/mortalidade , Tratamento de Emergência/mortalidade , Medição de Risco/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças do Colo/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
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