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1.
Brasília, D.F.; OPAS; 2020-03-31. (OPAS/EOC/Covid-19/20-0004).
em Português | PAHO-IRIS | ID: phr2-52013

RESUMO

[Introdução]: O objetivo deste documento é fornecer recomendações que facilitem o atendimento em situação de pico de demanda por cuidados médicos e a alocação de equipes médicas de emergência, para responder a grandes números de pacientes, que poderiam sobrecarregar a rede integrada de serviços de saúde em comunidades ou áreas de circulação da COVID-19. Com base nos dados de uma grande coorte de pacientes com COVID-19, 40% dos pacientes irão apresentar quadro leve e receber apenas tratamento sintomático, sem necessidade de internação; cerca de 40% irão apresentar quadro moderado e podem ou não precisar de internação; 15% terão quadro grave, com necessidade de oxigenoterapia, entre outras intervenções hospitalares; e cerca de 5% evoluem para um quadro crítico, com necessidade de ventilação mecânica. O monitoramento da trajetória do surto em alguns países também mostra que os casos estão dobrando a cada três dias, com uma proporção maior de casos graves e críticos, o que cria a necessidade urgente de expandir a capacidade dos sistemas de saúde para prevenir a exaustão e o esgotamento dos profissionais da saúde, bem como o esvaziamento dos estoques de materiais biomédicos indispensáveis para a resposta.


Assuntos
Infecções por Coronavirus , Capacidade de Resposta ante Emergências , Sistemas de Saúde , Hospitais com Alto Volume de Atendimentos , Serviços Médicos de Emergência
3.
Ann R Coll Surg Engl ; 102(1): 36-42, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31660752

RESUMO

INTRODUCTION: The temporal patterns and unit-based distributions of trauma patients requiring surgical intervention are poorly described in the UK. We describe the distribution of trauma patients in the UK and assess whether changes in working patterns could provide greater exposure for operative trauma training. METHODS: We searched the Trauma Audit and Research Network database to identify all patients between 1 January 2014 to 31 December 2016. Operative cases were defined as all patients who underwent laparotomy, thoracotomy or open vascular intervention. We assessed time of arrival, correlations between mechanism of injury and surgery, and the effect of changing shift patterns on exposure to trauma patients by reference to a standard 10-hour shift assuming a dedicated trauma rotation or fellowship. RESULTS: There were 159,719 patients from 194 hospitals submitted to the Network between 2014 and 2016. The busiest 20 centres accounted for 57,568 (36.0%) of cases in total. Of these 2147/57,568 patients (3.7%) required a general surgical operation; 43% of penetrating admissions (925 cases) and 2.2% of blunt admissions (1222 cases). The number of operations correlated more closely with the number of penetrating rather than blunt admissions (r = 0.89 vs r = 0.51). A diurnal pattern in trauma admissions enabled significant increases in trauma exposure with later start times. CONCLUSIONS: Centres with high volume and high penetrating rates are likely to require more general surgical input and should be identified as locations for operative trauma training. It is possible to improve the number of trauma patients seen in a shift by optimising shift start time.


Assuntos
Educação de Pós-Graduação em Medicina/métodos , Cirurgia Geral/educação , Admissão do Paciente/estatística & dados numéricos , Traumatologia/educação , Ferimentos e Lesões/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Inglaterra , Feminino , Hospitais com Alto Volume de Atendimentos , Humanos , Irlanda , Masculino , Pessoa de Meia-Idade , Admissão e Escalonamento de Pessoal/organização & administração , Admissão e Escalonamento de Pessoal/estatística & dados numéricos , Estudos Retrospectivos , Jornada de Trabalho em Turnos/estatística & dados numéricos , Fatores de Tempo , Centros de Traumatologia/organização & administração , Centros de Traumatologia/estatística & dados numéricos , País de Gales , Local de Trabalho/organização & administração , Local de Trabalho/estatística & dados numéricos , Ferimentos e Lesões/cirurgia
4.
J Urol ; 203(5): 926-932, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31846391

RESUMO

PURPOSE: Robot-assisted radical prostatectomy has become the predominant surgical modality to manage localized prostate cancer in the U.S. However, there are few studies focusing on the associations between hospital volume and outcomes of robot-assisted radical prostatectomy. MATERIALS AND METHODS: We identified robot-assisted radical prostatectomies for clinically localized (cT1-2N0M0) prostate cancer diagnosed between 2010 and 2014 in the National Cancer Database. We categorized annual average hospital robot-assisted radical prostatectomy volume into very low, low, medium, high and very high by most closely sorting the final included patients into 5 equal-sized groups (quintiles). Outcomes included 30-day mortality, 90-day mortality, conversion (to open), prolonged length of stay (more than 2 days), 30-day (unplanned) readmission, positive surgical margin and lymph node dissection rates. RESULTS: A total of 114,957 patients were included in the study, and hospital volume was categorized into very low (3 to 45 cases per year), low (46 to 72), medium (73 to 113), high (114 to 218) and very high (219 or more). Overall 30-day mortality (0.12%), 90-day mortality (0.16%) and conversion rates (0.65%) were low. Multivariable logistic regressions showed that compared with the very low volume group, higher hospital volume was associated with lower odds of conversion to open surgery (OR 0.23, p <0.001 for very high), prolonged length of stay (OR 0.25, p <0.001 for very high), 30-day readmission (OR 0.53, p <0.001 for very high) and positive surgical margins (OR 0.61, p <0.001 for very high). Higher hospital volume was also associated with higher odds of lymph node dissection in the intermediate/high risk cohort (OR 3.23, p <0.001 for very high). CONCLUSIONS: Patients undergoing robot-assisted radical prostatectomy at higher volume hospitals are likely to have improved perioperative and superior oncologic outcomes compared to lower volume hospitals.


Assuntos
Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Prostatectomia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Seguimentos , Humanos , Incidência , Tempo de Internação/tendências , Masculino , Readmissão do Paciente/tendências , Neoplasias da Próstata/cirurgia , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
5.
Ann Vasc Surg ; 62: 1-7, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31207399

RESUMO

BACKGROUND: Volume-outcome relationships exist for many complex surgical procedures, prompting institutions to adopt surgical volume standards for credentialing. The current Leapfrog Group Hospital volume standard for open abdominal aortic aneurysm repair (OAR) is 15 per year. However, this is primarily based on data from the 1990s and may not be appropriate given the dramatic decline in OAR. We sought to quantify the proportion of hospitals meeting volume standards, the difference in perioperative outcomes between low-volume and high-volume hospitals, and the potential travel burden of volume credentialing on patients. METHODS: We identified Medicare beneficiaries for individuals aged ≥65 years undergoing OAR in 2013-2014. Hospital "all-payer" annual volume was estimated based on the national proportion of patients undergoing OAR covered by Medicare in the Vascular Quality Initiative. Hospital annual OAR volume was characterized as <5/year, 5-9/year, 10-14/year, and ≥15/year (high volume). Adjusted rates of postoperative morbidity, reoperation, failure to rescue, and mortality in 2014 were compared across volume cohorts. Distance between patients' home zip code and high-volume hospitals was calculated. RESULTS: A total of 21,191 OARs were performed at 1,445 hospitals between 2013 and 2014. The average hospital OAR annual volume was 7.8 (standard deviation [SD] ± 9.3) with a median of 4.5. Among the 1,445 hospitals, only 190 (13.1%) performed ≥15 OARs per year whereas 756 hospitals (53.3%) performed <5 per year. Among patients who underwent OAR in 2014, 5,395 (53.3%) received care at a hospital that performed <15 per year. There was no difference in complication, reoperation, or failure to rescue rates between high-volume and low-volume hospitals. Mortality did not significantly differ among OAR volume cohorts. Hospitals performing <5 OARs per year had a mortality rate of 5.7% compared with 5.6% at high-volume hospitals (P = 0.817). One-quarter of patients who received care at a low-volume hospital would have had to travel more than 60 miles to reach a high-volume hospital. CONCLUSIONS: By conservative estimates, only 13% of hospitals performing OAR meet current volume standards. Triaging all patients to high-volume hospitals would require shifting over 5,000 patients annually with no associated improvement in perioperative outcomes. Implementation of the current OAR hospital volume standard may significantly burden patients and hospitals without improving surgical outcomes.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Credenciamento/normas , Hospitais com Alto Volume de Atendimentos/normas , Hospitais com Baixo Volume de Atendimentos/normas , Melhoria de Qualidade/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Procedimentos Cirúrgicos Vasculares/normas , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/mortalidade , Bases de Dados Factuais , Falha da Terapia de Resgate/normas , Feminino , Acesso aos Serviços de Saúde/normas , Humanos , Masculino , Medicare , Encaminhamento e Consulta/normas , Reoperação/normas , Fatores de Tempo , Viagem , Resultado do Tratamento , Estados Unidos , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidade
6.
Ann Vasc Surg ; 62: 248-257, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31449931

RESUMO

BACKGROUND: This study aims to identify potential risk factors for becoming symptomatic in patients with radiographic celiac artery compression (CAC) as well as prognostic factors for patients with median arcuate ligament syndrome (MALS) who underwent surgical ligament release. METHODS: This is a retrospective cohort study of patients with findings of CAC on computed tomography or magnetic resonance angiography (CT/MRA) who were asymptomatic and who were diagnosed with MALS at a single university hospital between January 2001 and 2018. RESULTS: Following a review of 1,330 CT/MRA reports, a total of 109 patients were identified as having radiographically apparent CAC. Among these, 48 (44.0%) patients were symptomatic. Univariate comparison between those with and without symptoms showed that symptomatic patients were more commonly younger than 30 years old [17/48 (35.4%) vs. 8/61 (13.1%), P = 0.006], had a history of prior abdominal surgery [25/48 (52.1%) vs. 18/61 (29.5%), P = 0.017], and had high-grade stenosis [32/43 (74.4%) vs. 25/61 (41.0%), P = 0.001]. Among 41 included patients who underwent surgical release of the median arcuate ligament including open, laparoscopic, and robotic approaches, 82.9% reported overall clinical improvement, 5/41 (12.2%) reported persistent pain, and 13/36 (36.0%) experienced pain recurrence. The only identified risk factor associated with symptom recurrence was American Society of Anesthesiologists class III [7/13 (53.8%) vs. 4/23 (17.4%), P = 0.029]. CONCLUSIONS: The severity of stenosis and prior abdominal surgery both contributed to symptom development in patients with radiographically apparent CAC from the median arcuate ligament.


Assuntos
Artéria Celíaca , Descompressão Cirúrgica , Síndrome do Ligamento Arqueado Mediano/cirurgia , Adulto , Idoso , Artéria Celíaca/diagnóstico por imagem , Artéria Celíaca/fisiopatologia , Angiografia por Tomografia Computadorizada , Descompressão Cirúrgica/efeitos adversos , Feminino , Hospitais com Alto Volume de Atendimentos , Hospitais Universitários , Humanos , Los Angeles , Angiografia por Ressonância Magnética , Masculino , Síndrome do Ligamento Arqueado Mediano/diagnóstico por imagem , Síndrome do Ligamento Arqueado Mediano/fisiopatologia , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular
7.
J Stroke Cerebrovasc Dis ; 28(12): 104455, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31680032

RESUMO

BACKGROUND: Perioperative cerebral infarction is one of the concerning complications after transcatheter aortic valve implantation in patients with aortic stenosis. Several studies have reported on this complication; however, those included only Caucasians and analyzed a small number of cases. Here, we report on the characteristics and risk factors of symptomatic cerebral infarction after transcatheter aortic valve implantation in a single, high-volume center in Japan. METHODS: We included 308 consecutive patients who underwent transcatheter aortic valve implantation in our facility between 2013 and 2016. We retrospectively analyzed the occurrence, characteristics, and prognoses of symptomatic cerebral infarction within 7 days after the procedure and statistically compared the risk factors between patients with or without cerebral infarction. RESULTS: Five patients (1.6%) suffered from symptomatic cerebral infarction, which was usually recognized just after the procedure, with mild symptoms. Long-term prognoses tended to be good unless other factors influenced disability. Comorbidities, such as carotid artery stenosis and peripheral artery disease, were significantly higher in patients with cerebral infarction (P = .036 and .002, respectively); in addition, coronary artery disease and longer anesthesia duration (indicating challenging catheter procedures) tended to be associated with cerebral infarction (P = .080 and .069, respectively). CONCLUSIONS: Symptomatic cerebral infarction occurred in 1.6% of patients after transcatheter aortic valve implantation in a single, high-volume center in Japan; the infarctions were of mild severity tending toward good long-term prognoses. We speculate arterial embolism from atherosclerotic large arteries, especially from the aortic arch, during catheter procedures might be the mechanistic basis of cerebral infarction.


Assuntos
Estenose da Valva Aórtica/cirurgia , Infarto Cerebral/etiologia , Hospitais com Alto Volume de Atendimentos , Substituição da Valva Aórtica Transcateter/efeitos adversos , Idoso de 80 Anos ou mais , Infarto Cerebral/diagnóstico por imagem , Infarto Cerebral/terapia , Comorbidade , Feminino , Humanos , Masculino , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Tóquio , Resultado do Tratamento
8.
J Surg Oncol ; 120(8): 1318-1326, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31701535

RESUMO

BACKGROUND: While better outcomes at high-volume surgical centers have driven regionalization of complex surgical care, access to high-volume centers often requires travel over longer distances. We sought to evaluate travel patterns of patients undergoing pancreaticoduodenectomy (PD) for pancreatic cancer to assess willingness of patients to travel for surgical care. METHODS: The California Office of Statewide Health Planning database was used to identify patients who underwent PD between 2005 and 2016. Total distance traveled, as well as whether a patient bypassed the nearest hospital that performed PD to get to a higher-volume center was assessed. Multivariate analyses were used to identify factors associated with bypassing a local hospital for a higher-volume center. RESULTS: Among 23 014 patients who underwent PD, individuals traveled a median distance of 18.0 miles to get to a hospital that performed PD. The overwhelming majority (84%) of patients bypassed the nearest providing hospital and traveled a median additional 16.6 miles to their destination hospital. Among patients who bypassed the nearest hospital, 13,269 (68.6%) did so for a high-volume destination hospital. Specifically, average annual PD volume at the nearest "bypassed" vs final destination hospital was 29.6 vs 56 cases, respectively. Outcomes at bypassed vs destination hospitals varied (incidence of complications: 39.2% vs 32.4%; failure-to-rescue: 14.5% vs 9.1%). PD at a high-volume center was associated with lower mortality (OR = 0.46 95% CI, 0.22-0.95). High-volume PD ( > 20 cases) was predictive of hospital bypass (OR = 3.8 95% CI, 3.3-4.4). Among patients who had surgery at a low-volume center, nearly 20% bypassed a high-volume hospital in route. Furthermore, among patients who did not bypass a high-volume hospital, one-third would have needed to travel only an additional 30 miles or less to reach the nearest high-volume hospital. CONCLUSION: Most patients undergoing PD bypassed the nearest providing hospital to seek care at a higher-volume hospital. While these data reflect increased regionalization of complex surgical care, nearly 1 in 5 patients still underwent PD at a low-volume center.


Assuntos
Comportamento de Escolha , Hospitais com Alto Volume de Atendimentos , Pancreaticoduodenectomia/estatística & dados numéricos , Viagem , Centros Médicos Acadêmicos , Idoso , California/epidemiologia , Feminino , Acesso aos Serviços de Saúde , Número de Leitos em Hospital , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Análise Multivariada , Recursos Humanos de Enfermagem no Hospital/estatística & dados numéricos , Salas Cirúrgicas/estatística & dados numéricos
9.
Medicine (Baltimore) ; 98(44): e17712, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31689806

RESUMO

Accumulation of the literature has suggested an inverse association between healthcare provider volume and mortality for a wide variety of surgical procedures. This study aimed to perform meta-analysis of meta-analyses (umbrella review) of observational studies and to summarize existing evidence for associations of healthcare provider volume with mortality in major operations.We searched MEDLINE, SCOPUS, and Cochrane Library, and screening of references.Meta-analyses of observational studies examining the association of hospital and surgeon volume with mortality following major operations. The primary outcome is all-cause short-term morality after surgery. Meta-analyses of observational studies of hospital/surgeon volume and mortality were included. Overall level of evidence was classified as convincing (class I), highly suggestive (class II), suggestive (class III), weak (class IV), and non-significant (class V) based on the significance of the random-effects summary odds ratio (OR), number of cases, small-study effects, excess significance bias, prediction intervals, and heterogeneity.Twenty meta-analyses including 4,520,720 patients were included, with 19 types of surgical procedures for hospital volume and 11 types of surgical procedures for surgeon volume. Nominally significant reductions were found in odds ratio in 82% to 84% of surgical procedures in both hospital and surgeon volume-mortality associations. To summarize the overall level of evidence, however, only one surgical procedure (pancreaticoduodenectomy) fulfilled the criteria of class I and II for both hospital and surgeon volume and mortality relationships, with a decrease in OR for hospital (0.42, 95% confidence interval[CI] [0.35-0.51]) and for surgeon (0.38, 95% CI [0.30-0.49]), respectively. In contrast, most of the procedures appeared to be weak or "non-significant."Only a very few surgical procedures such as pancreaticoduodenectomy appeared to have convincing evidence on the inverse surgeon volume-mortality associations, and yet most surgical procedures resulted in having weak or "non-significant" evidence. Therefore, healthcare professionals and policy makers might be required to steer their centralization policy more carefully unless more robust, higher-quality evidence emerges, particularly for procedures considered as having a weak or non-significant evidence level including total knee replacement, thyroidectomy, bariatric surgery, radical cystectomy, and rectal and colorectal cancer resections.


Assuntos
Mortalidade Hospitalar , Hospitais/estatística & dados numéricos , Cirurgiões/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/mortalidade , Feminino , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Humanos , Masculino , Metanálise como Assunto , Estudos Observacionais como Assunto , Razão de Chances
10.
Dis Colon Rectum ; 62(12): 1512-1517, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31569096

RESUMO

BACKGROUND: There has been increasing concern and scrutiny in the use of mesh for certain pelvic organ prolapse procedures. However, mesh erosion was often associated with sites of suture fixation of the mesh to the rectum or vagina. Thus, in response to this finding, we replaced our suture material with absorbable monofilament suture. OBJECTIVE: The purpose of this study was to compare the rates of mesh-related complications after laparoscopic ventral mesh rectopexy, according to the type of suture used in fixation of mesh. DESIGN: This was retrospective cohort study. SETTINGS: This study was performed at a high-volume, tertiary care center. It was conducted using a prospective database including patients who underwent laparoscopic ventral mesh rectopexy over a 7-year period. PATIENTS: A total of 495 cases were included; 296 (60%) laparoscopic ventral mesh rectopexies were performed using a nonabsorbable suture compared with 199 (40%) with an absorbable suture in a case-matched analysis. In addition, 151 cases of laparoscopic ventral mesh rectopexy with nonabsorbable were matched based on age, sex, and time of follow-up, with an equal number of patients using absorbable monofilament suture. MAIN OUTCOMES MEASURES: Primary outcome was symptomatic mesh erosion after rectopexy. Secondary outcomes included other mesh-related complications and/or reoperations. RESULTS: The erosion rate was 2% (6/495) in the nonabsorbable suture group, including 4 erosions into the rectum and 2 into the vagina. There was no erosion in the group with absorbable suture. This difference was maintained after matching: after a median follow-up of 6 (12) months, there was no erosion in the absorbable suture group versus 3.3% erosion (n = 5) in the nonabsorbable suture group (p = 0.03). LIMITATIONS: This study was limited by its retrospective design. CONCLUSIONS: Mesh-related complications are reduced using absorbable sutures compared with nonabsorbable sutures when performing laparoscopic ventral mesh rectopexy with synthetic mesh without an increase in rectopexy failures. See Video Abstract at http://links.lww.com/DCR/B49. IMPACTO DEL TIPO DE SUTURA EN LA TASA DE EROSIóN DESPUéS DE LA RECTOPEXIA VENTRAL LAPAROSCóPICA CON MALLA: UN ESTUDIO DE CASOS EMPAREJADOS: Ha habido una creciente preocupación y escrutinio en el uso de la malla para ciertos procedimientos de prolapso de órganos pélvicos. Sin embargo, la erosión de la malla a menudo se asoció con sitios de fijación de sutura de la malla al recto o la vagina. Por lo tanto, en respuesta a este hallazgo, reemplazamos nuestro material de sutura con sutura de monofilamento absorbible.Comparar las tasas de complicaciones relacionadas con la malla después de la rectopexia laparoscópica de malla ventral, de acuerdo al tipo de sutura utilizada en la fijación de la malla.Este fue un estudio de cohorte retrospectivo.Este estudio se realizó en un centro de atención de tercer nivel de alto volumen. Se realizó utilizando una base de datos prospectiva que incluía pacientes que se sometieron a una rectopexia de malla ventral laparoscópica durante un período de 7 años.Se incluyeron un total de 495 casos; 296 (60%) rectopexias de malla ventral laparoscópica utilizando una sutura no reabsorbible en comparación con 199 (40%) con una sutura absorbible en un análisis de casos emparejados. Además, 151 casos de rectopexia ventral laparoscópica con malla no absorbible se emparejaron según la edad, el sexo y el tiempo de seguimiento con un número igual de pacientes que usaban sutura de monofilamento absorbible.La medida de resultado primaria fue la erosión sintomática de la malla después de la rectopexia. La medida de resultado secundarias incluyeron otras complicaciones y/o reoperaciones relacionadas con la malla.La tasa de erosión fue del 2% (6/495) en el grupo de sutura no absorbible; 4 erosiones en el recto y 2 en la vagina. No hubo erosión en el grupo con sutura absorbible. Esta diferencia se mantuvo después del emparejamiento: después de una mediana de seguimiento de 6 (12) meses, no hubo erosión en el grupo de sutura absorbible versus 3.3% de erosión (n = 5) en el grupo de sutura no absorbible (p = 0.03).Este estudio estuvo limitado por su diseño retrospectivo.Las complicaciones relacionadas con la malla se reducen utilizando suturas absorbibles en comparación con las suturas no absorbibles cuando se realiza la rectopexia de malla ventral laparoscópica con malla sintética, sin un aumento en los fracasos de rectopexia. Vea el Resumen del Video en http://links.lww.com/DCR/B49.


Assuntos
Laparoscopia/instrumentação , Prolapso Retal/cirurgia , Telas Cirúrgicas/efeitos adversos , Suturas/classificação , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Hospitais com Alto Volume de Atendimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Centros de Atenção Terciária , Resultado do Tratamento
11.
Am Surg ; 85(9): 949-955, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31638505

RESUMO

Regionalizing surgical care to high-volume centers has improved outcomes for endocrine surgery. This shift is associated with increased travel time, costs, and morbidity within certain patient populations. We examined travel time-related differences in demographics, health-care utilization, thyroid-specific disease, and cost for patients undergoing thyroid surgery at a single high-volume center. Data were extracted from the 2005 to 2014 ACS-NSQIP and clinical data repository for patients undergoing thyroid surgery. Travel times between patients' home address and the hospital were calculated using Google Earth under assumptions of standard road conditions and speed restrictions. Travel time was divided into <2 hours versus ≥2 hours. Primary outcomes were hospital cost and 30-day morbidity. Factors associated with travel time and primary outcomes were analyzed using appropriate bivariate tests and multivariable regression modeling. A total of 1046 thyroid procedures were included, with median (IQR) travel time of 68.8 (40.1-107.2) minutes. Eight hundred forty-seven (80.9%) patients traveled <2 hours compared with 199 (19.1%) traveled ≥2 hours. Patients traveling ≥2 hours were more likely to have complex thyroid disease (37.7% vs 27.6%, P = 0.005), uninsured status (31.1% vs 11.8%, P < 0.001), lower preoperative morbidity risk (2.3% vs 2.7%, P = 0.02), and longer length of stay (1.21 vs 1.07 days, P = 0.04), but similar median operative times (163 vs 165 minutes, P = 0.89). Average cost was higher for patients traveling ≥2 hours ($7300 vs $6846 [2014 USD], P = 0.05). Despite observed patient differences, hospital costs and postoperative morbidity did not differ after adjustment. Existing management practices and the nature of the disease process may be protective against the potential negative effects of regionalization.


Assuntos
Custos Hospitalares , Hospitais com Alto Volume de Atendimentos , Aceitação pelo Paciente de Cuidados de Saúde , Complicações Pós-Operatórias , Doenças da Glândula Tireoide/economia , Doenças da Glândula Tireoide/cirurgia , Viagem , Adulto , Feminino , Humanos , Tempo de Internação/economia , Masculino , Pessoas sem Cobertura de Seguro de Saúde , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/economia , Centros de Atenção Terciária , Fatores de Tempo , Virginia
12.
Am Surg ; 85(10): 1159-1161, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657315

RESUMO

There are conflicting views regarding techniques for repair of small umbilical hernias (UHs). Here, we compare the recurrence rate in primary repair with that reported for mesh repair by examining a single surgeon's practice at a large medical center with a comprehensive electronic medical record. A six-year retrospective review of primary UH repairs between January 2012 and December 2017 at Kaiser Permanente Los Angeles Medical Center was undertaken. Patients were identified through a database search of the electronic medical record. The primary endpoint of UH recurrence was examined; median follow-up was 3.4 years. Primary, elective UH repair was performed in 244 patients; 71 per cent of hernias were small (<2 cm). The total number of recurrences was seven (3%). The t test analysis showed significant differences in the average size of hernia defects between those with recurrences (2 cm) and those without (1.4 cm), P < 0.05. Primary repair affords low infection and recurrence rates, comparable to those reported for mesh repair. Our single-surgeon/large-volume study contributes to the evidence that primary UH repair is a safe and durable method, with low risk of recurrence. The use of absorbable monofilament suture, and selection for lower BMI and smaller hernia sizes proved to be effective.


Assuntos
Hérnia Umbilical/cirurgia , Herniorrafia/estatística & dados numéricos , Telas Cirúrgicas/estatística & dados numéricos , Adulto , Fatores Etários , Idoso , Índice de Massa Corporal , California , Feminino , Hérnia Umbilical/patologia , Herniorrafia/efeitos adversos , Herniorrafia/métodos , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Fumantes/estatística & dados numéricos , Telas Cirúrgicas/efeitos adversos , Suturas , Técnicas de Fechamento de Ferimentos
13.
Cir. Esp. (Ed. impr.) ; 97(8): 470-476, oct. 2019. tab
Artigo em Espanhol | IBECS | ID: ibc-187622

RESUMO

El tratamiento quirúrgico de los adenocarcinomas de la unión esofagogástrica se basa en gastrectomías totales o esofaguectomías oncológicas, procedimientos de alta complejidad y considerable morbimortalidad. Los datos obtenidos del análisis de registros quirúrgicos poblacionales muestran una elevada variabilidad en el enfoque terapéutico y los resultados entre diferentes centros hospitalarios y zonas geográficas. Una de las principales medidas destinadas a reducir esta variabilidad, mejorando los resultados globales, es la centralización de la enfermedad en centros de referencia, proceso que debe basarse en el cumplimiento de unos estándares de calidad e ir acompañada de la armonización de protocolos terapéuticos. La cirugía mínimamente invasiva puede disminuir la morbilidad postoperatoria sin comprometer la supervivencia, pero es técnicamente más demandante que la cirugía abierta. Los programas de formación quirúrgica tutelada permiten incorporar la cirugía mínimamente invasiva a la práctica de los equipos quirúrgicos sin que la curva de aprendizaje condicione la morbimortalidad ni la radicalidad oncológica


Surgical treatment of oesophagogastric junction adenocarcinomas is based on total gastrectomies or oesophagectomies, which are complex procedures with potentially high morbidity and mortality. Population-based registers show a considerable variability of protocols and outcomes among different hospitals and regions. One of the main strategies to improve global results is centralization at high-volume hospitals, a process that should take into account the benchmarking of processes and outcomes at referral hospitals. Minimally invasive surgery can improve postoperative morbidity while maintaining oncological guaranties, but is technically more demanding than open surgery. This fact underlines the need for structured training and mentorship programs that minimize the impact of surgical teams’ training curves without affecting morbidity, mortality or oncologic radicality


Assuntos
Humanos , Adenocarcinoma/cirurgia , Benchmarking , Neoplasias Esofágicas/cirurgia , Junção Esofagogástrica/cirurgia , Neoplasias Gástricas/cirurgia , Esofagectomia/educação , Esofagectomia/mortalidade , Esofagectomia/normas , Gastrectomia/educação , Gastrectomia/mortalidade , Gastrectomia/normas , Complicações Pós-Operatórias/prevenção & controle , Curva de Aprendizado , Serviços Centralizados no Hospital , Hospitais com Alto Volume de Atendimentos
14.
Dis Colon Rectum ; 62(10): 1186-1194, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31490827

RESUMO

BACKGROUND: Many patients with rectal cancer are treated at small, low-volume hospitals despite evidence that better outcomes are associated with larger, high-volume hospitals. OBJECTIVES: This study aims to examine trends of patients with rectal cancer who are receiving care at large hospitals, to determine the patient characteristics associated with treatment at large hospitals, and to assess the relationships between treatment at large hospitals and guideline-recommended therapy. DESIGN: This study was a retrospective cohort analysis to assess trends in rectal cancer treatment. SETTINGS: Data from the National Cancer Institute's Surveillance, Epidemiology, and End Results Patterns of Care studies were used. PATIENTS: The study population consisted of adults diagnosed with stages II/III rectal cancer in 1990/1991, 1995, 2000, 2005, 2010, and 2015. MAIN OUTCOME MEASURES: The primary outcome was treatment at large hospitals (≥500 beds). The receipt of guideline-recommended preoperative chemoradiation therapy and postoperative chemotherapy was assessed for patients diagnosed in 2005+. RESULTS: Two thousand two hundred thirty-one patients were included. The proportion treated at large hospitals increased from 19% in 1990/1991 to 27% in 2015 (ptrend < 0.0001). Black race was associated with treatment at large hospitals (vs white) (OR, 1.73; 95% CI, 1.30-2.31), as was being 55 to 64 years of age (vs 75+), and diagnosis in 2015 (vs 1990/1991). Treatment in large hospitals was associated with twice the odds of preoperative chemoradiation, as well as younger age and diagnosis in 2010 or 2015 (vs 2005). LIMITATIONS: The study did not account for the change in the number of large hospitals over time. CONCLUSIONS: Results suggest that patients with rectal cancer are increasingly being treated in large hospitals where they receive more guideline-recommended therapy. Although this trend is promising, patients receiving care at larger, higher-volume facilities are still the minority. Initiatives increasing patient and provider awareness of benefits of specialized care, as well as increasing referrals to large centers may improve the use of recommended treatment and ultimately improve outcomes. See Video Abstract at http://links.lww.com/DCR/A994. QUIMIORRADIACIÓN RECOMENDADA EN GUÍAS PARA PACIENTES CON CÁNCER RECTAL EN HOSPITALES DE GRAN TAMAÑO: UNA TENDENCIA EN LA DIRECCIÓN CORRECTA: Muchos pacientes con cáncer rectal se tratan en hospitales pequeños y de bajo volumen a pesar de evidencia de que los mejores resultados se asocian con hospitales más grandes y de gran volumen. OBJETIVOS: Examinar las tendencias en los pacientes con cáncer rectal que reciben atención en hospitales de gran tamaño, determinar las características de los pacientes asociadas con el tratamiento en hospitales grandes y evaluar la relación entre el tratamiento en hospitales grandes y la terapia recomendada en guías. DISEÑO:: Este estudio fue un análisis de cohorte retrospectivo para evaluar las tendencias en el tratamiento del cáncer de recto. ESCENARIO: Se utilizaron datos de los estudios del programa Patrones de Atención, Vigilancia, Epidemiología y Resultados Finales (SEER) del Instituto Nacional de Cáncer (NIH). PACIENTES: La población de estudio consistió en adultos diagnosticados con cáncer rectal en estadio II / III en 1990/1991, 1995, 2000, 2005, 2010 y 2015. PRINCIPALES MEDIDAS DE RESULTADO: El resultado primario fue el tratamiento en hospitales grandes (≥500 camas). La recepción de quimiorradiación preoperatoria recomendada según las guías y la quimioterapia posoperatoria se evaluaron para los pacientes diagnosticados en 2005 y posteriormente. RESULTADOS: Se incluyeron 2,231 pacientes. La proporción tratada en los hospitales grandes aumentó del 19% en 1990/1991 al 27% en 2015 (ptrend < 0.0001). La raza afroamericana se asoció con el tratamiento en hospitales grandes (vs. blanca) (OR, 1.73; IC 95%, 1.30-2.31), al igual que 55-64 años de edad (vs ≥75) y diagnóstico en 2015 (vs 1990/1991). El tratamiento en los hospitales grandes se asoció con el doble de probabilidad de quimiorradiación preoperatoria, así como con una edad más temprana y diagnóstico en 2010 o 2015 (vs 2005). LIMITACIONES: El estudio no tomó en cuenta el cambio en el número de hospitales grandes a lo largo del tiempo. CONCLUSIONES: Los resultados sugieren que los pacientes con cáncer rectal reciben cada vez más tratamiento en hospitales grandes donde reciben terapia recomendada por las guías mas frecuentemente. Aunque esta tendencia es prometedora, los pacientes que reciben atención en hospitales más grandes y de mayor volumen siguen siendo una minoría. Las iniciativas que aumenten la concientización del paciente y del proveedor de servicios médicos sobre los beneficios de la atención especializada, así como el aumento de las referencias a centros grandes podrían mejorar el uso del tratamiento recomendado y, en última instancia, mejorar los resultados. Vea el Resumen en video en http://links.lww.com/DCR/A994.


Assuntos
Antineoplásicos/uso terapêutico , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Estadiamento de Neoplasias , Guias de Prática Clínica como Assunto/normas , Neoplasias Retais/terapia , Programa de SEER , Adolescente , Adulto , Idoso , Quimiorradioterapia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Neoplasias Retais/diagnóstico , Neoplasias Retais/epidemiologia , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologia , Adulto Jovem
15.
Surgery ; 166(6): 1027-1032, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31472971

RESUMO

BACKGROUND: Little is known regarding the impact of minimally invasive approaches to pancreatoduodenectomy on the aggregate costs of care for patients undergoing pancreatoduodenectomy. METHODS: We queried the Healthcare Cost and Utilization Project State Inpatient Database to identify patients undergoing elective laparoscopic or open pancreatoduodenectomy between 2014 and 2016. RESULTS: In this database, 488 (10%) patients underwent elective laparoscopic; 4,544 (90%) underwent open pancreatoduodenectomy. On adjusted analysis, the risk of perioperative morbidity and overall duration of hospitalization for patients undergoing elective laparoscopic were identical to those for patients undergoing open pancreatoduodenectomy. Patients undergoing elective laparoscopic in low (+$10,399, 95% confidence interval [$3,700, $17,098]) and moderate to high (+$4,505, 95% confidence interval [$528, $8,481]) volume centers had greater costs than those undergoing open pancreatoduodenectomy in the same centers. In very high-volume centers (>127 pancreatoduodenectomies/year), aggregate costs of care for patients undergoing elective laparoscopic were essentially identical to those undergoing open pancreatoduodenectomy in the same centers (+$815, 95% confidence interval [-$1,530, $3,160]). CONCLUSION: Rates of morbidity and overall duration of hospitalization for patients undergoing elective laparoscopic are not different than those undergoing open pancreatoduodenectomy. At low to moderate and high-volume centers, elective laparoscopic is associated with greater aggregate costs of care relative to open pancreatoduodenectomy. At very high-volume centers, elective laparoscopic is cost-neutral.


Assuntos
Procedimentos Cirúrgicos Eletivos/economia , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Laparoscopia/economia , Pancreaticoduodenectomia/economia , Complicações Pós-Operatórias/economia , Idoso , Análise Custo-Benefício , Bases de Dados Factuais/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pancreaticoduodenectomia/efeitos adversos , Pancreaticoduodenectomia/métodos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos
16.
Surgery ; 166(6): 1011-1016, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31543321

RESUMO

BACKGROUND: Pancreatic cystic neoplasms remain uncommon. Although data are accumulating on the incidence of pancreatic cystic neoplasms in the published literature, Indian data on these tumors are sparse. MATERIAL AND METHODS: We collated data from prospectively maintained databases of patients operated for cystic tumors of the pancreas from 2007 to 2016 at 7 academic centers across India to gain insights into clinical presentation and outcome of the operative treatment of these tumors. Data were compared with large series across the world to understand the regional differences in this pathology. RESULTS: Of the 423 patients, there were 98 (23.2%) serous cystic neoplasms, 128 (30.2%) mucinous neoplasms, 34(8%) intraductal papillary mucinous neoplasms, and 121 (28.6%) solid pseudopapillary epithelial neoplasms managed in these 7 academic centers. Malignancy (adenocarcinoma, malignant intraductal papillary mucinous neoplasms, and mucinous cystadenocarcinoma) was reported in 39 (9.2%) patients. Median age at presentation was 41 years, and the female-to-male ratio was 3.4:1. At presentation, 81% of patients were symptomatic. A total of 66.7% of lesions were located in body and tail region of the pancreas. Median tumor size was 6 cm. Operative resection with curative intent was performed in 405 of these 423 patients. Major morbidity occurred in 12%, and 30-day perioperative mortality was 0.9%. Laparoscopic resections were performed in 18% and spleen-preserving resections were performed in 3% of patients. CONCLUSION: Female preponderance, young age, and a benign nature of most pancreatic cystic neoplasms were observed. Large size of tumors on presentation, fewer intraductal papillary mucinous neoplasm resections, and a much greater incidence of solid pseudopapillary epithelial neoplasms were distinctive of this study. Although the proportion of laparoscopic resections and splenic preservation was less compared with Western centers, the perioperative morbidity and mortality was on par with established standards.


Assuntos
Cistadenocarcinoma Mucinoso/epidemiologia , Pancreatectomia/efeitos adversos , Cisto Pancreático/epidemiologia , Neoplasias Pancreáticas/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Criança , Cistadenocarcinoma Mucinoso/patologia , Cistadenocarcinoma Mucinoso/cirurgia , Feminino , Mortalidade Hospitalar , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Humanos , Incidência , Índia/epidemiologia , Masculino , Pessoa de Meia-Idade , Pâncreas/patologia , Pâncreas/cirurgia , Cisto Pancreático/cirurgia , Neoplasias Pancreáticas/patologia , Neoplasias Pancreáticas/cirurgia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/patologia , Estudos Prospectivos , Fatores de Risco , Fatores Sexuais , Carga Tumoral , Adulto Jovem
17.
Br J Anaesth ; 123(5): 679-687, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31561883

RESUMO

BACKGROUND: While increased surgical-provider volume has been associated with improved outcomes, research regarding volume-outcome relationships within high-volume institutions and the role of anaesthesiologists is limited. Further, the effect of anaesthesia-care-team composition remains understudied. This analysis aimed to identify the impact of anaesthesiologist and surgeon volume on adverse events after total joint arthroplasties. METHODS: We retrospectively identified 40 437 patients who underwent total joint arthroplasties at a high-volume institution from 2005 to 2014. The main effects of interest were anaesthesiologist and surgeon volume and experience along with anaesthesia-care-team composition. Multivariable logistic regression models were used to evaluate three outcomes: any complication, cardiopulmonary complication, and length of stay (>5 days). Odds ratios (ORs) and 99.75% confidence intervals (CIs) were reported. RESULTS: Across all three models, anaesthesiologist volume and experience, and anaesthesia-care-team composition were not significant predictors. Surgeon annual case volume >50 was associated with significantly reduced odds of any complication (annual case volume: 50-149; OR: 0.80; CI: 0.66-0.98) and prolonged length of stay (OR: 0.69; CI: 0.60-0.80). Surgeon experience >20 yr was associated with significantly reduced odds of prolonged length of stay (OR: 0.85; CI: 0.75-0.95). CONCLUSIONS: Anaesthesiologist volume and experience, and anaesthesia-care-team composition did not impact the odds of an adverse outcome, although a higher surgeon volume was associated with decreased odds of complications and prolonged length of stay. Further study is necessary to determine if these findings can be extrapolated to less specialised, lower volume surgical settings.


Assuntos
Anestesiologia/estatística & dados numéricos , Artroplastia de Quadril/normas , Artroplastia do Joelho/normas , Competência Clínica/estatística & dados numéricos , Carga de Trabalho/estatística & dados numéricos , Idoso , Anestesia/métodos , Anestesia/normas , Anestesia/estatística & dados numéricos , Anestesiologia/organização & administração , Anestesiologia/normas , Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Comorbidade , Feminino , Hospitais com Alto Volume de Atendimentos/normas , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , New York/epidemiologia , Equipe de Assistência ao Paciente/organização & administração , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Resultado do Tratamento
18.
Surgery ; 166(4): 540-546, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31416603

RESUMO

BACKGROUND: Fundoplication is performed routinely during laparoscopic repairs of a paraesophageal hernia, but the degree of fundoplication remains controversial. The purpose of this study is to assess postoperative dysphagia and reflux after a Dor versus a Nissen fundoplication in patients undergoing laparoscopic repair of giant paraesophageal hernias. METHODS: We performed a retrospective cohort study of all patients undergoing laparoscopic repair of giant paraesophageal hernias with Nissen or Dor fundoplication between January 2012 and December 2017 at a high-volume center, excluding revisional and emergency cases. Primary outcomes were reflux and dysphagia at 1 and 6 months. Severe dysphagia was defined as intolerance to liquids. Balanced cohorts were created using coarsened exact matching. RESULTS: A total of 106 patients were included, and 87 were matched (Dor = 48, Nissen = 58). Baseline characteristics were well balanced between matched groups. Mean follow-up duration was 17.7 months (standard deviation 16.4). The incidence of severe dysphagia at 1 month was less in the Dor group (0 of 48 vs 8 of 58, P = .02) with similar reflux symptoms. There was no difference in severe dysphagia and reflux symptoms at 6 months and at the latest visit. CONCLUSION: Dor fundoplication is associated with less severe, early postoperative dysphagia. Future studies assessing the relative importance of dysphagia and reflux on quality of life should be conducted to tailor the operative technique and optimize patient satisfaction.


Assuntos
Fundoplicatura/métodos , Refluxo Gastroesofágico/cirurgia , Hérnia Hiatal/cirurgia , Herniorrafia/métodos , Laparoscopia/métodos , Canadá , Estudos de Coortes , Transtornos de Deglutição/etiologia , Transtornos de Deglutição/cirurgia , Feminino , Fundoplicatura/efeitos adversos , Refluxo Gastroesofágico/etiologia , Hérnia Hiatal/diagnóstico por imagem , Herniorrafia/efeitos adversos , Hospitais com Alto Volume de Atendimentos , Humanos , Laparoscopia/efeitos adversos , Masculino , Qualidade de Vida , Recuperação de Função Fisiológica , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Estatísticas não Paramétricas , Centros de Atenção Terciária , Resultado do Tratamento
19.
Iowa Orthop J ; 39(1): 29-35, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31413671

RESUMO

Background: Overlapping surgery is common in high-volume total knee arthroplasty (TKA) practices and has come under recent scrutiny in the press. The aim of this study was to evaluate differences in 6-week clinical and radiographic outcomes for primary TKA patients between single and overlapping operating room (OR) days. Methods: We retrospectively reviewed individual patient records of a consecutive series of primary TKAs with complete 6-week follow-up performed by a single academic surgeon between 2008-2016 (N= 452). Patients were stratified by single vs. overlapping OR days. 177 patients (39%) had an overlapping surgery. Age, body mass index (BMI), Charlson Comorbidity Index (CCI) and American Society of Anesthesiologists (ASA) class were recorded to assess for confounding variables. Outcomes included anesthesia time, 6-week readmission, unplanned return to OR, medical and surgical complication, and 6-week radiographic alignment. Results: There were no significant differences in anesthesiology time (165.5 vs 164.5 min, p=0.85), medical or surgical complication rates (10.5% vs 6.2%, p=0.11), 6-week readmissions (4.4% vs 1.7%, p=0.12), or return to OR (1.8% vs 1.7%, p=1.00) before or after adjusting for age, BMI, gender, ASA and CCI. There was no difference between overlapping and single OR cohorts in rate of neutral coronal alignment (2°-8° valgus) (98.3% vs 98.9%, respectively, p=0.68) or presence of periprosthetic lucency (p=0.43). Conclusions: This study demonstrates no differences in 6-week clinical or radiographic outcomes between patients undergoing primary TKA on single versus overlapping OR days. These results support the safe practice of overlapping surgical scheduling in high-volume primary TKA centers.Level of Evidence: III.


Assuntos
Agendamento de Consultas , Artroplastia do Joelho/efeitos adversos , Salas Cirúrgicas/organização & administração , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Centros Médicos Acadêmicos , Idoso , Artroplastia do Joelho/métodos , Bases de Dados Factuais , Feminino , Hospitais com Alto Volume de Atendimentos , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Segurança do Paciente , Complicações Pós-Operatórias/fisiopatologia , Prognóstico , Estudos Retrospectivos , Fatores de Tempo
20.
J Bone Joint Surg Am ; 101(16): 1479-1484, 2019 Aug 21.
Artigo em Inglês | MEDLINE | ID: mdl-31436656

RESUMO

BACKGROUND: Reports in the literature indicate that implant placement is more accurate with robotic-assisted unicompartmental knee arthroplasty (UKA); however, these studies have not always accounted for surgeon experience. The purpose of the present study was to compare the accuracy of tibial component alignment in UKA between an experienced high-volume surgeon and the published data on robotic-assisted surgery. METHODS: The radiographs made before and after 128 consecutive medial UKAs performed manually by a single surgeon using a cemented fixed-bearing implant were reviewed. Native tibial and tibial implant slope and varus alignment of the tibial implant were measured on preoperative and postoperative lateral and anteroposterior radiographs, respectively. The percentages of knees in which the postoperative measurements were within preoperative targets and the root mean square (RMS) error rates between the planned and achieved targets were compared with published robotic-assisted-UKA data. RESULTS: In the present study, the proportion of manual UKAs in which the tibial component alignment was within the preoperative target was 66% (85 of 128), which exceeded published values in a study comparing robotic (58%) with manual (41%) UKA. The RMS error for tibial component alignment in the present study (1.48°) was less than published RMS error rates for robotic UKAs (range, 1.8° to 5°). Fifty-eight percent (74) of the 128 study UKAs were within the surgeon's preoperative goal for tibial slope, which was closer to the published value of 80% for robotic UKAs than is the published rate of 22% for manual UKAs. The RMS error for tibial slope in the study UKAs (1.50°) was smaller than the published RMS error rates for tibial slope in robotic UKAs (range, 1.6° to 1.9°). CONCLUSIONS: Accurate implant alignment is important in UKA. In this study, an experienced surgeon achieved or exceeded robotic accuracy of tibial implant alignment in UKA. However, the relationship between implant position and patient outcomes is unknown, and a consensus on ideal surgical targets for optimal implant survivorship has yet to be established. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.


Assuntos
Artroplastia do Joelho/métodos , Competência Clínica , Prótese do Joelho , Osteoartrite do Joelho/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Idoso , Estudos de Coortes , Bases de Dados Factuais , Feminino , Seguimentos , Hospitais com Alto Volume de Atendimentos , Humanos , Masculino , Pessoa de Meia-Idade , Osteoartrite do Joelho/diagnóstico por imagem , Cuidados Pré-Operatórios/métodos , Desenho de Prótese , Falha de Prótese , Radiografia/métodos , Estudos Retrospectivos , Estatísticas não Paramétricas , Cirurgiões/estatística & dados numéricos , Resultado do Tratamento
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