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1.
BMC Surg ; 21(1): 63, 2021 Jan 28.
Artigo em Inglês | MEDLINE | ID: mdl-33509187

RESUMO

BACKGROUND: Small bowel obstruction (SBO) is observed in around 10% of patients with prior open abdominal surgery. Rectal resection causes the highest readmission rates. The aim of this study was to investigate risk factors for readmission for SBO and causes for SBO in patients who needed surgery following rectal cancer surgery. METHODS: A population-based registry with prospectively gathered data on 752 consecutive patients with rectal cancer who underwent open pelvic surgery between January 1996 and January 2017 was used. Univariable and multivariable regression analysis was performed, and the risk of SBO was assessed. RESULTS: In total, 84 patients (11%) developed SBO after a median follow-up time of 48 months. Of these patients, 57% developed SBO during the 1st year after rectal cancer surgery. Surgery for SBO was performed in 32 patients (4.3%), and the cause of SBO was stoma-related in one-fourth of these patients. In the univariable analysis previous RT and re-laparotomy were found as risk factors for readmission for SBO. Re-laparotomy was an independent risk factor for readmission for SBO (OR 2.824, CI 1.129-7.065, P = 0.026) in the multivariable analysis, but not for surgery for SBO. Rectal resection without anastomoses, splenic flexors mobilization, intraoperative bleeding, operative time were not found as risk factors for SBO. CONCLUSIONS: One-tenth of rectal cancer patients who had open surgery developed SBO, most commonly within the 1st postoperative year. The risk of SBO is greatest in patients with complications after rectal cancer resection that result in a re-laparotomy.


Assuntos
Obstrução Intestinal , Protectomia/efeitos adversos , Neoplasias Retais , Idoso , Feminino , Humanos , Obstrução Intestinal/epidemiologia , Obstrução Intestinal/etiologia , Obstrução Intestinal/cirurgia , Intestino Delgado/cirurgia , Laparotomia/efeitos adversos , Laparotomia/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Protectomia/métodos , Protectomia/estatística & dados numéricos , Neoplasias Retais/epidemiologia , Neoplasias Retais/cirurgia , Sistema de Registros/estatística & dados numéricos , Reoperação/efeitos adversos , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco
2.
J Surg Res ; 257: 285-293, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32866669

RESUMO

BACKGROUND: Abdominal injuries historically account for 13% of battlefield surgical procedures. We examined the occurrence of exploratory laparotomies and subsequent abdominal surgical site infections (SSIs) among combat casualties. METHODS: Military personnel injured during deployment (2009-2014) were included if they required a laparotomy for combat-related trauma and were evacuated to Landstuhl Regional Medical Center, Germany, before being transferred to participating US military hospitals. RESULTS: Of 4304 combat casualties, 341 (7.9%) underwent laparotomy. Including re-explorations, 1053 laparotomies (median, 2; interquartile range, 1-3; range, 1-28) were performed with 58% occurring within the combat zone. Forty-nine (14.4%) patients had abdominal SSIs (four with multiple SSIs): 27 (7.9%) with deep space SSIs, 14 (4.1%) with a deep incisional SSI, and 12 (3.5%) a superficial incisional SSI. Patients with abdominal SSIs had larger volume of blood transfusions (median, 24 versus 14 units), more laparotomies (median, 4 versus 2), and more hollow viscus injuries (74% versus 45%) than patients without abdominal SSIs. Abdominal closure occurred after 10 d for 12% of the patients with SSI versus 2% of patients without SSI. Mesh adjuncts were used to achieve fascial closure in 20.4% and 2.1% of patients with and without SSI, respectively. Survival was 98% and 96% in patients with and without SSIs, respectively. CONCLUSIONS: Less than 10% of combat casualties in the modern era required abdominal exploration and most were severely injured with hollow viscus injuries and required massive transfusions. Despite the extensive contamination from battlefield injuries, the SSI proportion is consistent with civilian rates and survival was high.


Assuntos
Traumatismos Abdominais/cirurgia , Laparotomia/efeitos adversos , Infecção da Ferida Cirúrgica/epidemiologia , Lesões Relacionadas à Guerra/cirurgia , Traumatismos Abdominais/complicações , Traumatismos Abdominais/diagnóstico , Traumatismos Abdominais/mortalidade , Adulto , Feminino , Humanos , Escala de Gravidade do Ferimento , Laparotomia/estatística & dados numéricos , Masculino , Militares/estatística & dados numéricos , Fatores de Risco , Infecção da Ferida Cirúrgica/etiologia , Taxa de Sobrevida , Resultado do Tratamento , Lesões Relacionadas à Guerra/complicações , Lesões Relacionadas à Guerra/diagnóstico , Lesões Relacionadas à Guerra/mortalidade , Adulto Jovem
3.
Minerva Chir ; 75(5): 320-327, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33210528

RESUMO

BACKGROUND: During Coronavirus disease (COVID-19) pandemic entire countries rapidly ran out of intensive care beds, occupied by critically ill infected patients. Elective surgery was initially halted and acute non-deferrable surgical care drastically limited. The presence of COVID-19 patients into intensive care units (ICU) is currently decreasing but their congestion have restricted our therapeutic strategies during the last months. METHODS: In the COVID-19 era eighteen patients (8 men, 10 women) with a mean age of 80 years, needing undelayable abdominal surgery underwent awake open surgery at our Department. Prior to surgery, all patients underwent COVID-19 investigation. In all cases locoregional anesthesia (LA) was performed. Intraoperative and postoperative pain has been monitored and regularly assessed. A distinct pathway has been set up to keep patients of uncertain COVID-19 diagnosis separated from all other patients. RESULTS: Mean operative time was 104 minutes. In only one case conversion to general anesthesia was necessary. Postoperative pain was always well controlled. None of them required postoperative intensive care support. Only one perioperative complication occurred. Early readmissions after surgery were never observed. CONCLUSIONS: On the basis of our experience awake laparotomy under LA resulted feasible, safe, painless and, in specific cases, the only viable option. For patients presenting fragile cardiovascular and respiratory, reserves and in whom general anesthesia (GA) would presumably increase morbidity and mortality we encourage LA as an alternative to GA. In the COVID-19 era, it has become part of our ICU-preserving strategy allowing us to carry out undeferrable surgeries.


Assuntos
Betacoronavirus , Infecções por Coronavirus/epidemiologia , Idoso Fragilizado , Laparotomia/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Anestesia Geral , Anestesia Local/métodos , Técnicas de Laboratório Clínico/métodos , Infecções por Coronavirus/diagnóstico , Emergências/epidemiologia , Feminino , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Dor Pós-Operatória/prevenção & controle , Pandemias , Pneumonia Viral/diagnóstico , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos
4.
Obstet Gynecol ; 136(4): 803-810, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32925612

RESUMO

OBJECTIVE: To estimate the incidence and risk factors for bowel injury in women undergoing hysterectomy for benign indications. METHODS: A retrospective cohort study was conducted among women undergoing hysterectomy for benign indications from 2012 to 2016 at institutes participating in the American College of Surgeons National Surgical Quality Improvement Program, including both inpatient and outpatient settings. Bowel injury was identified using Current Procedural Terminology codes as patients who underwent bowel repair at the time of hysterectomy or postoperatively within 30 days. Multivariate logistic regression models were used to control for patient clinical factors and perioperative factors. RESULTS: Bowel injury occurred in 610 of 155,557 (0.39%) included women. After bivariate analysis, factors associated with bowel injury included age, race, body mass index, American Society of Anesthesiologists classification, increased operative time, surgical approach, type of hysterectomy, lysis of adhesions, and operative indication. After adjusting for potential confounders, bowel injury was found associated with older age, surgical indication of endometriosis, and abdominal surgical approach. Compared with the surgical indication of endometriosis (n=63/10,625), the surgical indications of menstrual disorder (odds ratio [OR] 0.33, 95% CI 0.23-0.47; adjusted odds ratio [aOR] 0.33, 95% CI 0.23-0.48; n=67/34,168), uterine leiomyomas (OR 0.80, 95% CI 0.61-1.05; aOR 0.44, 95% CI 0.33-0.59; n=243/51,232), and genital prolapse (OR 0.30, 95% CI 0.20-0.45; aOR 0.41, 95% CI 0.25-0.67; n=36/20,384) were each associated with lower odds of bowel injury. Compared with the vaginal approach to hysterectomy (n=27/27,434), the abdominal approach was found to have significantly increased odds of bowel injury (OR 10.80, 95% CI 7.31-15.95; aOR 10.49 95% CI 6.42-17.12; n=401/38,106); the laparoscopic approach had smaller but significantly increased odds (OR 2.06, 95% CI 1.37-3.08; aOR 2.03 95% CI 1.24-3.34; n=182/90,017) as well. CONCLUSION: Increased risk of bowel injury is associated with endometriosis and the abdominal surgical approach to hysterectomy. These findings have implications for the surgical care of women with benign uterine disease.


Assuntos
Endometriose/cirurgia , Trato Gastrointestinal/lesões , Doenças dos Genitais Femininos/cirurgia , Histerectomia Vaginal/efeitos adversos , Histerectomia , Complicações Intraoperatórias , Laparoscopia/efeitos adversos , Laparotomia/efeitos adversos , Canadá/epidemiologia , Feminino , Humanos , Histerectomia/efeitos adversos , Histerectomia/métodos , Histerectomia Vaginal/métodos , Histerectomia Vaginal/estatística & dados numéricos , Incidência , Complicações Intraoperatórias/epidemiologia , Complicações Intraoperatórias/etiologia , Laparoscopia/métodos , Laparoscopia/estatística & dados numéricos , Laparotomia/métodos , Laparotomia/estatística & dados numéricos , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Estudos Retrospectivos , Medição de Risco , Fatores de Risco
5.
Medicine (Baltimore) ; 99(31): e21448, 2020 Jul 31.
Artigo em Inglês | MEDLINE | ID: mdl-32756164

RESUMO

To investigate the diagnostic performance of ultrasound (US) for pregnant women with previous caesarean section (CS) occurring lower uterine segment (LUS) dehiscence and rupture.107 pregnant women with previous CS and LUS thickness of 1.0 mm or less were recruited, the LUS and myometrium was measured, and US findings suggestive of uterine rupture were compared with findings at laparotomy. The included pregnant women were assigned into 2 groups, including 64 pregnant women had vaginal delivery at full-term and 43 pregnant women underwent repeat CS at preterm.US findings suggestive of uterine rupture and dehiscence occurred in 18 women and 89 women, respectively; ten of them developed uterine rupture, and the incidence of uterine rupture was 9.34% (10/107). The sensitivity, specificity, accuracy, positive, and negative predictive values of US for the evaluation of LUS dehiscence and rupture were 100.0%, 91.8%, 92.5%, 55.6%, and 100.0%, respectively. There was no severe maternal obstetric complication, 1 fetus died, and the other fetuses were born with a 5-minute Apgar score of 7 to 10.US has high sensitivity and specificity for pregnant women with previous CS occurring LUS dehiscence and rupture.


Assuntos
Cesárea/efeitos adversos , Miométrio/diagnóstico por imagem , Ultrassonografia/métodos , Útero/diagnóstico por imagem , Adulto , Estudos de Casos e Controles , Parto Obstétrico/métodos , Parto Obstétrico/tendências , Feminino , Idade Gestacional , Humanos , Incidência , Laparotomia/estatística & dados numéricos , Valor Preditivo dos Testes , Gravidez , Resultado da Gravidez , Gravidez de Alto Risco , Estudos Retrospectivos , Sensibilidade e Especificidade , Deiscência da Ferida Operatória/epidemiologia , Ruptura Uterina/epidemiologia , Útero/patologia
6.
S Afr Med J ; 110(5): 374-376, 2020 Apr 29.
Artigo em Inglês | MEDLINE | ID: mdl-32657720

RESUMO

BACKGROUND: Previous work from KwaZulu-Natal (KZN) Province, South Africa, has suggested that public sector district hospitals are not providing adequate access to surgical care in the form of bellwether operations (caesarean section (CS), open reduction of fractures (ORF) and laparotomy). OBJECTIVES: To review the surgical output of regional and tertiary institutions, to quantify their contribution to providing bellwether procedure coverage for the province. METHODS: Data on bellwether operations conducted at all district, regional, tertiary and central hospitals in the public health sector of KZN for the period 1 July - 31 December 2015 were collected from operating theatre registers. RESULTS: Between 1 July and 31 December 2015, a total of 20 926 CSs, 3 947 laparotomies and 3 098 ORFs were performed in KZN provincial hospitals. This translates to a provincial rate for each bellwether procedure of 192/100 000 (CS), 36/100 000 (laparotomy) and 28/100 000 (ORF). The rate of  bellwether operations across the province during the study period was 256/100 000, with numbers as follows: CSs - 10 542 in district hospitals, 8 712 in regional hospitals, 1 538 in tertiary hospitals and 134 in the central hospital; laparotomies - 235 in district hospitals, 2 314 in regional hospitals, 1 259 in tertiary hospitals and 139 in the central hospital; and ORFs - 196 in district hospitals, 1 660 in regional hospitals, 1 201 in tertiary hospitals and 41 in the central hospital. CONCLUSIONS: Regional and tertiary hospitals are performing the bulk of non-obstetric bellwether operations in KZN. This imbalance has major implications for planning future delivery of surgical care in the province.


Assuntos
Cesárea/estatística & dados numéricos , Laparotomia/estatística & dados numéricos , Redução Aberta/estatística & dados numéricos , Programas Médicos Regionais/estatística & dados numéricos , Centros de Atenção Terciária/estatística & dados numéricos , Feminino , Fraturas Ósseas/terapia , Acesso aos Serviços de Saúde/estatística & dados numéricos , Hospitais de Distrito/estatística & dados numéricos , Humanos , Gravidez , África do Sul
7.
Ann R Coll Surg Engl ; 102(6): 437-441, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32374217

RESUMO

INTRODUCTION: In the UK, general surgeons must demonstrate competency in emergency general surgery before obtaining a certificate of completion of training. Subsequently, many consultants develop focused elective specialist interests which may not mirror the breadth of procedures encountered during emergency practice. Recent National Emergency Laparotomy Audit analysis found that declared surgeon special interest impacted emergency laparotomy outcomes, which has implications for emergency general surgery service configuration. We sought to establish whether local declared surgeon special interest impacts emergency laparotomy outcomes. METHODS: Adult patients having emergency laparotomy were identified from our prospective National Emergency Laparotomy Audit database from May 2016 to May 2019 and categorised as colorectal or oesophagogastric according to operative procedure. Outcomes included 30-day mortality, return to theatre and length of stay. Binomial logistic regression was used to identify any association between declared consultant specialist interest and outcomes. RESULTS: Of 600 laparotomies, 358 (58.6%) were classifiable as specialist procedures: 287 (80%) colorectal and 71 (20%) oesophagogastric. Discordance between declared specialty and operation undertaken occurred in 25% of procedures. For colorectal emergency laparotomy, there was an increased risk of 30-day mortality when performed by a non-colorectal consultant (unadjusted odds ratio 2.34; 95% confidence interval 1.10-5.00; p = 0.003); however, when adjusted for confounders within multivariate analysis declared surgeon specialty had no impact on mortality, return to theatre or length of stay. CONCLUSION: Surgeon-declared specialty does not impact emergency laparotomy outcomes in this cohort of undifferentiated emergency laparotomies. This may reflect the on-call structure at Birmingham Heartlands Hospital, where a colorectal and oesophagogastric consultant are paired on call and provide cross-cover when needed.


Assuntos
Competência Clínica/normas , Tratamento de Emergência/estatística & dados numéricos , Gastroenteropatias/cirurgia , Laparotomia/estatística & dados numéricos , Cirurgiões/estatística & dados numéricos , Idoso , Certificação/normas , Competência Clínica/estatística & dados numéricos , Colo/cirurgia , Consultores/estatística & dados numéricos , Estado Terminal/mortalidade , Estado Terminal/terapia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/efeitos adversos , Esôfago/cirurgia , Feminino , Gastroenteropatias/mortalidade , Cirurgia Geral/organização & administração , Cirurgia Geral/normas , Mortalidade Hospitalar , Humanos , Laparotomia/efeitos adversos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Estudos Prospectivos , Reto/cirurgia , Reoperação/estatística & dados numéricos , Estômago/cirurgia , Cirurgiões/organização & administração , Cirurgiões/normas , Resultado do Tratamento
8.
Am J Obstet Gynecol ; 223(4): 555.e1-555.e7, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32247844

RESUMO

BACKGROUND: Although laparoscopic hysterectomy is well established as a favorable mode of hysterectomy owing to decreased perioperative complications, there is still room for improvement in quality of care. Previous studies have described laparoscopic hysterectomy risk, but there is currently no tool for predicting risk of complication at the time of laparoscopic hysterectomy. OBJECTIVE: This study aimed to create a prediction model for complications at the time of laparoscopic hysterectomy for benign conditions. STUDY DESIGN: This is a retrospective cohort study that included patients who underwent laparoscopic hysterectomy for benign indications between 2014 and 2017 in US hospitals contributing to the American College of Surgeons - National Surgical Quality Improvement Program database. Data about patient baseline characteristics, perioperative complications (intraoperative complications, readmission, reoperation, need for transfusion, operative time greater than 4 hours, or postoperative medical complication), and uterine weight at the time of pathologic examination were collected retrospectively. Postoperative uterine weight was used as a proxy for preoperative uterine weight estimate. The sample was randomly divided into 2 patient populations, one for deriving the model and the other to validate the model. RESULTS: A total of 33,123 women met the inclusion criteria. The rate of composite complication was 14.1%. Complication rates were similar in the derivation and validation cohorts (14.1% [2306 of 14,051] vs 13.9% [2289 of 14,107], P=.7207). The logistic regression risk prediction tool for hysterectomy complication identified 7 variables predictive of complication: history of laparotomy (21% increased odds of complication), age (2% increased odds of complication per year of life), body mass index (0.2% increased odds of complication per each unit increase in body mass index), parity (7% increased odds of complication per delivery), race (when compared with white women, black women had 34% increased odds and women of other races had 18% increased odds of complication), and American Society of Anesthesiologists score (when compared with American Society of Anesthesiologists 1, American Society of Anesthesiologists 2 had 31% increased odds, American Society of Anesthesiologists 3 had 62% increased odds, and American Society of Anesthesiologists 4 had 172% increased odds of complication). Predicted preoperative uterine weight also had a statistically significant nonlinear relationship with odds of complication. The c-statistics for the derivation and validation cohorts were 0.62 and 0.62, respectively. The model is well calibrated for women at all levels of risk. CONCLUSION: The laparoscopic hysterectomy complication predictor model is a tool for predicting complications in patients planning to undergo hysterectomy.


Assuntos
Histerectomia , Laparoscopia , Complicações Pós-Operatórias/epidemiologia , Adulto , Afro-Americanos/estatística & dados numéricos , Fatores Etários , Transfusão de Sangue/estatística & dados numéricos , Índice de Massa Corporal , Regras de Decisão Clínica , Estudos de Coortes , Conversão para Cirurgia Aberta/estatística & dados numéricos , Bases de Dados Factuais , Grupos Étnicos/estatística & dados numéricos , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Humanos , Obstrução Intestinal/epidemiologia , Laparotomia/estatística & dados numéricos , Pessoa de Meia-Idade , Duração da Cirurgia , Tamanho do Órgão , Paridade , Readmissão do Paciente , Complicações Pós-Operatórias/etnologia , Reoperação , Estudos Retrospectivos , Medição de Risco , Deiscência da Ferida Operatória/epidemiologia , Infecção da Ferida Cirúrgica/epidemiologia , Estados Unidos/epidemiologia , Útero/patologia
9.
J Surg Res ; 251: 303-310, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32200321

RESUMO

BACKGROUND: There is minimal evidence evaluating the risks and benefits of laparoscopy use in hemodynamically stable children with suspected abdominal injuries. The objective of this study was to evaluate postoperative outcomes in a large cohort of hemodynamically stable pediatric patients with blunt abdominal injury. METHODS: Using the 2015-2016 National Trauma Data Bank, all patients aged <18 y with injury severity score (ISS) ≤25, Glasgow coma scale ≥13, and normal blood pressure who underwent an abdominal operation for blunt abdominal trauma were included. Patients were grouped into three treatment groups: laparotomy, laparoscopy, and laparoscopy converted to laparotomy. Treatment effect estimation with inverse probability weighting was used to determine the association between treatment group and outcomes of interest. RESULTS: Of 720 patients, 504 underwent laparotomy, 132 underwent laparoscopy, and 84 underwent laparoscopy converted to laparotomy. The median age was 10 (IQR: 7-15) y, and the median ISS was 9 (IQR: 5-14). Mean hospital length of stay was 2.1 d shorter (95% confidence interval [CI]: 0.9-3.2 d) and mean intensive care unit length of stay was 1.1 d shorter (95% CI: 0.6-1.5 d) for the laparoscopy group compared with the laparotomy group. The laparoscopy group had a 2.0% lower mean probability of surgical site infection than the laparotomy group (95% CI: 1.0%-3.0%). CONCLUSIONS: In this cohort of hemodynamically stable pediatric patients with blunt abdominal injury, laparoscopy may have improved outcomes over laparotomy.


Assuntos
Traumatismos Abdominais/cirurgia , Laparoscopia/estatística & dados numéricos , Laparotomia/estatística & dados numéricos , Ferimentos não Penetrantes/cirurgia , Traumatismos Abdominais/epidemiologia , Adolescente , Criança , Feminino , Humanos , Masculino , Estudos Retrospectivos , Estados Unidos/epidemiologia , Ferimentos não Penetrantes/epidemiologia
10.
Scand J Public Health ; 48(3): 243-249, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-31973622

RESUMO

Aim: Emergency exploratory laparotomy is a high-risk procedure, but most studies are based on small sample sizes, and no nationwide studies have reported the number of patients and the mortality risk. This descriptive study reports the prevalence, incidence and 30- and 365-day mortality of all patients undergoing emergency exploratory laparotomies in Denmark from 2003 to 2014. Methods: The study population is based on the Danish National Patient Register, which includes all patient contacts with Danish hospitals, including patients undergoing emergency surgery. All patients were followed in registers on mortality. Rates and proportions were estimated using Poisson and logistic regression models. Results: The number of prevalent patients was 15,330 through the period (2003-2014) of whom 13,795 were incident patients. Prevalence increased with age and peaked at 1% for the 80- to 84-year-old age group. The overall incidence was 27 per 100,000 person-years, which strongly increased with age (87 per 100,000 person-years among men and 85 per 100,000 person-years among women). The 30-day mortality was 16.5% and the 365-day mortality was 23.1%. Both increased strongly with age and did not improve over the study period. Both 30- and 365-day mortality were higher among unmarried patients compared to married patients. Conclusions: Emergency exploratory laparotomies are common high-risk procedures especially for the elderly population. These results can be used to focus on better postoperative care to reduce the mortality.


Assuntos
Emergências , Laparotomia/mortalidade , Laparotomia/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Dinamarca/epidemiologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prevalência , Sistema de Registros , Fatores de Risco , Adulto Jovem
11.
J Surg Res ; 245: 587-592, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31499364

RESUMO

BACKGROUND: Surgical disease increasingly contributes to global mortality and morbidity. The Lancet Commission on Global Surgery found that global cost-effectiveness data are lacking for a wide range of essential surgical procedures. This study helps to address this gap by defining the cost-effectiveness of exploratory laparotomies in a regional referral hospital in Uganda. MATERIALS AND METHODS: A time-and-motion analysis was utilized to calculate operating theater personnel costs per case. Ward personnel, administrative, medication, and supply costs were recorded and calculated using a microcosting approach. The cost in 2018 US Dollars (USD, $) per disability-adjusted life year (DALY) averted was calculated based on age-specific life expectancies for otherwise fatal cases. RESULTS: Data for 103 surgical patients requiring exploratory laparotomy at the Soroti Regional Referral Hospital were collected over 8 mo. The most common cause for laparotomy was small bowel obstruction (32% of total cases). The average cost per patient was $75.50. The postoperative mortality was 11.7%, and 7.8% of patients had complications. The average number of DALYs averted per patient was 18.51. The cost in USD per DALY averted was $4.08. CONCLUSIONS: This investigation provides evidence that exploratory laparotomy is cost-effective compared with other public health interventions. Relative cost-effectiveness includes a comparison with bed nets for malaria prevention ($6.48-22.04/DALY averted), tuberculosis, tetanus, measles, and polio vaccines ($12.96-25.93/DALY averted), and HIV treatment with multidrug antiretroviral therapy ($453.74-648.20/DALY averted). Given that the total burden of surgically treatable conditions in DALYs is more than that of malaria, tuberculosis, and HIV combined, our findings strengthen the argument for greater investment in primary surgical capacity in low- and middle-income countries.


Assuntos
Análise Custo-Benefício , Países em Desenvolvimento/economia , Laparotomia/economia , Centros de Atenção Terciária/economia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Países em Desenvolvimento/estatística & dados numéricos , Equipamentos e Provisões Hospitalares/economia , Feminino , Mão de Obra em Saúde/economia , Mão de Obra em Saúde/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Laparotomia/estatística & dados numéricos , Expectativa de Vida , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Anos de Vida Ajustados por Qualidade de Vida , Regionalização/economia , Centros de Atenção Terciária/estatística & dados numéricos , Uganda , Adulto Jovem
12.
J Matern Fetal Neonatal Med ; 33(3): 464-470, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31619101

RESUMO

Aim: This study aimed to examine the risk factors for relaparotomy after cesarean section (RLACS) due to bleeding.Material and methods: In this retrospective descriptive case-control study, women who underwent RLACS only for bleeding between 2008 and 2019 at a single tertiary center were examined (the center oversees approximately 25,000 deliveries per year). Maternal characteristics, postoperative findings, and surgical features were compared with a control group that included non-complicated cesarean sections (CS). Multivariable logistic regression analysis was used to identify the risk factors for relaparotomy.Results: Relaparotomy complicated 0.07% (n = 40) of CS during the study period (n = 58,095). When compared with the control group, age, parity, estimated blood loss (EBL), postoperative pulse, blood replacement, and length of hospital stay were statistically higher in patients undergoing relaparotomy, whereas their postoperative systolic and diastolic blood pressure were found to be low. A history of pelvic surgery, the need for intensive care, and complications were more frequent in patients undergoing relaparotomy. When CSs were grouped according to 8-h periods of the day, it emerged that relaparotomies were mostly performed on the patients who underwent CS after working hours. Time interval during the day of the CS [OR: 2.59 (1.10-6.12)] and high postoperative pulse rate [OR: 1.58 (1.28-1.96)] were found to be independent risk indicators for RLACS (AUC: 0.97).Conclusions: Monitoring vital signs in the postoperative period and increasing the number of physicians and nurses during off-hours in hospitals working with on-call duty procedures as determined by the Ministry of Health will reduce the incidence rate of relaparotomy, maternal morbidity, and mortality due to hemorrhage.


Assuntos
Cesárea/efeitos adversos , Laparotomia/estatística & dados numéricos , Complicações Pós-Operatórias/cirurgia , Hemorragia Pós-Parto/cirurgia , Adulto , Cesárea/estatística & dados numéricos , Feminino , Humanos , Complicações Pós-Operatórias/etiologia , Hemorragia Pós-Parto/etiologia , Gravidez , Estudos Retrospectivos , Centros de Atenção Terciária/estatística & dados numéricos
13.
J Minim Invasive Gynecol ; 27(1): 65-73.e1, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-30928611

RESUMO

STUDY OBJECTIVE: To investigate the surgical trends among different types of hysterectomy (abdominal, vaginal, laparoscopic, and subtotal) over a 15-year period in Taiwan. DESIGN: A retrospective cohort study. SETTING: A population-based National Health Insurance Research Database. PATIENTS: Women undergoing various types of hysterectomy for noncancerous lesions. INTERVENTIONS: Data for this study were extracted from the inpatient expenditures by admissions files of Taiwan's National Health Insurance Research Database from 1998 through 2012 and divided into three 5-year time frames: first (1998-2002), second (2003-2007), and third (2008-2012). The variables included types of hysterectomy, patient age, gynecologist age and sex, hospital accreditation level, and surgical volume. Chi-square and trend tests were used to examine the association between the variables. MEASUREMENTS AND MAIN RESULTS: A total of 329 438 patients who underwent various types of hysterectomy were identified; 306 257 were included in the study. During the 15-year period, 45% underwent total abdominal hysterectomy, 41% underwent laparoscopic hysterectomy (LH), 9.8% underwent vaginal hysterectomy, and 4.2% underwent subtotal abdominal hysterectomy. The frequency of LHs increased from 35.9% in the first period to 43.9% in the second period and remained at 44.2% in the third period. During the same time period, there was a decrease in the frequency of total abdominal hysterectomies. Typically, younger patients underwent LHs by gynecologists with large volume surgical practices and medical centers. CONCLUSION: This 15-year study describes an increase of LHs and subtotal abdominal hysterectomies over time and provides evidence of surgical trends and a paradigm shift of hysterectomies. Surgical skills and performance extended from high- to low-surgical volume gynecologists and from medical centers to regional and local hospitals. This shift may have a great influence on patient and health care provider choice of treatment.


Assuntos
Histerectomia/métodos , Histerectomia/tendências , Doenças Uterinas/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , História do Século XX , História do Século XXI , Humanos , Histerectomia/história , Histerectomia/estatística & dados numéricos , Histerectomia Vaginal/história , Histerectomia Vaginal/métodos , Histerectomia Vaginal/estatística & dados numéricos , Histerectomia Vaginal/tendências , Laparoscopia/história , Laparoscopia/métodos , Laparoscopia/estatística & dados numéricos , Laparoscopia/tendências , Laparotomia/história , Laparotomia/métodos , Laparotomia/estatística & dados numéricos , Laparotomia/tendências , Pessoa de Meia-Idade , Prevalência , Estudos Retrospectivos , Taiwan/epidemiologia , Doenças Uterinas/epidemiologia , Adulto Jovem
14.
J Minim Invasive Gynecol ; 27(1): 178-185.e1, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-30936031

RESUMO

STUDY OBJECTIVE: To investigate whether the rate of increase in the performance of abdominal myomectomy over a laparoscopic approach after the US Food and Drug Administration (FDA) safety communication regarding morcellator use for myomectomy differs among races. DESIGN: Retrospective cohort study. SETTING: The American College of Surgeons National Surgical Quality Improvement data. PATIENTS: Patients aged 18 to 55 years who underwent either laparoscopic or abdominal myomectomy, excluding malignant cases, emergency cases, operations performed by nongynecologic specialists, and cases in which myomectomy was performed during cesarean section. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The odds ratios of abdominal myomectomy over laparoscopic myomectomy before and after the release of the FDA communication were calculated in 3 race categories: white, African American, and other races. In a logistic regression analysis adjusted for possible confounders, including all races, the odds ratio of abdominal myomectomy before and after the FDA communication was 1.30 (95% confidence interval [CI], 1.20-1.41; p <.001). In a logistic regression analysis with a product term of FDA communication exposure and race as a possible effect modifier, the African American population showed a significantly greater change in the odds of abdominal myomectomy over laparoscopic myomectomy in comparison with the white population (1.22; 95% CI, 1.02-1.47; p = .03). In contrast, other races showed no significant change (.83; 95% CI, .64-1.08; p = .17). CONCLUSION: After the FDA communication, the odds ratio of abdominal myomectomy was disproportionately increased in the African American population.


Assuntos
Disparidades em Assistência à Saúde/etnologia , Laparoscopia , Laparotomia , Leiomioma/cirurgia , Morcelação/métodos , Miomectomia Uterina/métodos , Neoplasias Uterinas/cirurgia , Adolescente , Adulto , Afro-Americanos/estatística & dados numéricos , Comunicação , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Fidelidade a Diretrizes/normas , Fidelidade a Diretrizes/estatística & dados numéricos , Disparidades em Assistência à Saúde/normas , Disparidades em Assistência à Saúde/estatística & dados numéricos , Humanos , Histerectomia/métodos , Histerectomia/estatística & dados numéricos , Laparoscopia/métodos , Laparoscopia/estatística & dados numéricos , Laparotomia/métodos , Laparotomia/estatística & dados numéricos , Leiomioma/etnologia , Pessoa de Meia-Idade , Morcelação/efeitos adversos , Morcelação/estatística & dados numéricos , Segurança do Paciente/normas , Segurança do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos/epidemiologia , United States Food and Drug Administration/normas , Miomectomia Uterina/efeitos adversos , Miomectomia Uterina/estatística & dados numéricos , Neoplasias Uterinas/etnologia , Adulto Jovem
15.
Scand J Public Health ; 48(3): 250-258, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-31296134

RESUMO

Aims: Socio-economic disparities in health and access to care are well documented, but socio-economic disparities in surgical care and outcomes have received less attention. The aim of the study was to determine if there are socio-economic disparities in the risk of undergoing emergency laparotomy and postoperative mortality in a universal health-care system with free and equal access to care. Methods: This was a nationwide case-control study including patients undergoing non-malignant emergency laparotomy involving resection, ostomy or open drainage between 2003 and 2014 and population references matched 1:1 on age and sex. Socio-economic disparities in one-year postoperative mortality were explored through a cohort study including all patients. Exposure measures were register-based household disposable income, educational level and employment status. Analyses were adjusted by age, sex, country of origin, marital status and co-morbidity. Results: A total of 11,962 cases and 11,962 population references were included. The highest odds ratios (OR) for undergoing surgery were found among those with the lowest income (OR=1.51; 95% confidence interval (CI) 1.39-1.63), those with elementary school education (OR=1.33; 95% CI 1.22-1.46) and those on early-retirement pension (OR=3.49; 95% CI 3.07-3.98). One-year postoperative mortality was highest among those with lowest income (hazard ratio (HR)=1.51; 95% CI 1.35-1.69), those with elementary school education (HR=1.39; 95% CI 1.22-1.59) and those on early-retirement pension (HR=2.12; 95% CI 1.73-2.61). Conclusions: Socio-economic disparities in health exist in relation to non-malignant emergency laparotomies and still exist after adjustment for confounders, including co-morbidity, indicating that mechanisms other than differences in disease burden are involved. There is a substantial need for exploration of mechanisms and preventive measures.


Assuntos
Emergências , Disparidades nos Níveis de Saúde , Laparotomia/mortalidade , Laparotomia/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Estudos de Coortes , Dinamarca/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Fatores Socioeconômicos , Adulto Jovem
16.
Ann Surg ; 271(2): 317-324, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-30080737

RESUMO

OBJECTIVE: To identify preoperative characteristics to help in selecting laparoscopy or laparotomy in Crohn disease (CD). SUMMARY BACKGROUND: Laparoscopy in CD is associated with high rates of conversion. METHODS: All patients undergoing abdominal surgery for CD in 2004 to 2016 by the senior author. Patients operated by laparoscopy, laparotomy, and converted to open were compared. RESULTS: Four hundred fifty-eight procedures were performed in 427 patients [F:M 1:1; median age = 41 (12-95) yrs], through laparotomy (n = 157, 34%) or laparoscopy (n = 301, 66%). Laparotomy rates decreased over time. Concomitant surgical procedures requiring laparotomy continued to dictate an open approach throughout the study. Sixty-five cases (21.6%) required conversion to laparotomy which occurred within 15' from start of case in 77%. Most common reasons for conversion included dense adhesions (34%), pelvic sepsis with fistulizing disease (26%), large inflammatory mass (18%), and thickened mesentery (9%). After multivariate analysis, predictive factors for conversion included recurrent disease after previous small bowel resection, thickened mesentery, large inflammatory mass, and extensive disease. CONCLUSION: Despite the increasing experience with laparoscopy in CD, one-fifth of selected cases still need conversion. Recurrent disease with dense adhesions, pelvic sepsis with fistulizing disease, large inflammatory mass, and thickened mesentery are all conditions predisposing to a conversion. When the severity of these conditions is known preoperatively or a simultaneous procedure requires a laparotomy, an open approach should be considered; if laparoscopy is selected, conversion to laparotomy can be decided early in the performance of the case.


Assuntos
Doença de Crohn/cirurgia , Laparoscopia/educação , Laparoscopia/estatística & dados numéricos , Curva de Aprendizado , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Conversão para Cirurgia Aberta/estatística & dados numéricos , Tomada de Decisões , Feminino , Humanos , Laparotomia/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade
17.
J Surg Res ; 246: 300-304, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31648068

RESUMO

BACKGROUND: The National Emergency Laparotomy Audit (NELA) highlights the importance of identifying high-risk patients due to the potential for significant morbidity and mortality. The NELA risk prediction calculator (NRPC) was developed from data in England and Wales and is one of several calculators available. We seek to determine the utility of NRPC in the Australian population and compare it with Portsmouth Physiological and Operative Severity Score for the enumeration of mortality and Morbidity (P-POSSUM) and American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) calculators. METHODS: A retrospective review of all emergency laparotomies undertaken at four Australian centers was performed between January 2016 and December 2017. Data extracted from patient records were used to calculate NRPC, ACS-NSQIP, and P-POSSUM scores for 30-day mortality risk. The sensitivity of NRPC was assessed using the NELA high-risk cohort score of ≥10% and this was compared with the other two calculators. RESULTS: There were 562 (M = 261, mean age = 66 [±17] y) patient charts reviewed in the study period. 59 patients died within 30 d (10.5%). NRPC was able to identify 52 (sensitivity = 88.1%) of these as being within the high-risk group. Using the NELA high-risk cutoff, NRPC identified 52 deaths of 205 (25.4%) high-risk patients, P-POSSUM identified 46 of 245 (18.8%), and ACS-NSQIP identified 46 of 201 (22.9%). Using the McNemar test, no significant difference was noted between NRPC and P-POSSUM (P = 0.07) or NRPC and ACS-NSQIP (P = 0.18). CONCLUSIONS: In the Australian context, the NRPC is a highly sensitive and useful tool for predicting 30-day mortality in high-risk emergency laparotomy patients and is comparable with P-POSSUM and ACS-NSQIP calculators.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/efeitos adversos , Laparotomia/efeitos adversos , Auditoria Médica/normas , Complicações Pós-Operatórias/mortalidade , Idoso , Idoso de 80 Anos ou mais , Austrália/epidemiologia , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/normas , Tratamento de Emergência/estatística & dados numéricos , Feminino , Humanos , Laparotomia/estatística & dados numéricos , Masculino , Auditoria Médica/estatística & dados numéricos , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Melhoria de Qualidade , Estudos Retrospectivos , Medição de Risco/métodos , Medição de Risco/normas
18.
J Surg Res ; 248: 45-55, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31863936

RESUMO

BACKGROUND: Although studies have identified published indications that experts and practicing surgeons agree indicate use of damage control (DC) laparotomy, it is unknown whether these indications predict use of the procedure in practice. MATERIALS AND METHODS: We conducted a diagnostic performance study of the accuracy of a set of published appropriateness indications for predicting use of DC laparotomy. We included consecutive adults that underwent emergent laparotomy for trauma (2011-2016) at Memorial Hermann Hospital. RESULTS: We included 1141 injured adults. Two published preoperative appropriateness indications [a systolic blood pressure (BP) persistently <90 mmHg or core body temperature <34°C] produced moderate shifts in the pretest probability of conducting DC instead of definitive laparotomy. Five published intraoperative appropriateness indications produced large and often conclusive changes in the pretest probability of conducting DC during emergent laparotomy. These included the finding of a devascularized or completely disrupted pancreas, duodenum, or pancreaticoduodenal complex; an estimated intraoperative blood loss >4 L; administration of >10 U of packed red blood cells (PRBCs); and a systolic BP persistently <90 mmHg or arterial pH persistently <7.2 during operation. Most indications that produced large changes in the pretest probability of conducting DC laparotomy had an incidence of 2% or less. CONCLUSIONS: This study suggests that published appropriateness indications accurately predict use of DC laparotomy in practice. Intraoperative variables exert greater influence on the decision to conduct DC laparotomy than preoperative variables, and those indications that produce large shifts in the pretest probability of conducting DC laparotomy are uncommonly encountered.


Assuntos
Laparotomia/estatística & dados numéricos , Ferimentos e Lesões/cirurgia , Adulto , Serviços Médicos de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Adulto Jovem
19.
Anaesthesia ; 75(1): 54-62, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31531978

RESUMO

Patients eligible for emergency laparotomy who do not proceed to surgery are not as well characterised as patients who do proceed to surgery. We studied patients eligible for laparotomy, as defined by National Emergency Laparotomy Audit criteria, from August 2015 to October 2016. We analysed the association of individual variables with survival and two composite scores: P-POSSUM and a general survival model. Out of 314 patients, 214 (68%) underwent laparotomy and 100 (32%) did not. Median (IQR [range]) follow-up was 1.3 (0.1-1.8 [0.0-2.5]) years for the cohort, 1.5 (1.1-2.0 [0.0-2.6]) years after laparotomy and 0.0 (0.0-1.1 [0.0-2.2]) years without laparotomy. There were 126/314 (40%) deaths in the follow-up period, 52/214 (24%) deaths after laparotomy and 74/100 (74%) deaths without surgery. Ninety out of 126 deaths (71%) were within one month of hospital admission. Patient variables were different for the two groups, which when combined in the general survival model generated background median (IQR [range]) life expectancies of 12 (6-21 [0-49]) and 4 (2-6 [0-36]) years, respectively, p < 0.0001. 'Poor fitness' precluded laparotomy in 74/100 (74%) patients. The decision to not operate involved a consultant less often than the decision to operate: 66/100 (66%) vs. 178/214 (83%), p = 0.001. Our study supports the contention that survival beyond 30 postoperative days could be predicted reasonably accurately. Survival in patients who did not have laparotomy was shorter than expected. Emergency laparotomy might have prolonged survival in some patients.


Assuntos
Laparotomia/estatística & dados numéricos , Recusa do Paciente ao Tratamento/estatística & dados numéricos , Idoso , Estudos de Coortes , Emergências , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Análise de Sobrevida , Reino Unido
20.
J Minim Invasive Gynecol ; 27(2): 464-472, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-30965116

RESUMO

STUDY OBJECTIVE: To analyze the interaction between the route of hysterectomy for benign disease and postoperative morbidity among patients stratified by body mass index (BMI) and to test for a dose-dependent relationship between obesity severity and postoperative morbidity. DESIGN: A retrospective cohort study. PATIENTS: Benign hysterectomy cases were abstracted from the American College of Surgeons National Safety and Quality Improvement Program from 2005 to 2016. Cancer and prolapse surgeries were excluded by corresponding International Classification of Diseases and Current Procedural Terminology codes. INTERVENTIONS: Laparoscopic hysterectomy. MEASUREMENTS AND MAIN RESULTS: Associations between BMI, route of surgery, and categoric patient variables were examined using the chi-square test. Associations of BMI, route of surgery, and continuous patient variables were examined using 1-way analysis of variance. Associations of the route of surgery with binary outcomes were examined within BMI categories using the chi-square or Fisher exact test. Logistic regression and interaction tests were used for final outcomes of interest. There were 159 025 patients in the collected sample. Patients who underwent an abdominal hysterectomy had higher odds of composite morbidity if they were obese; the adjusted odds were 17% higher for class 1 obesity, 55% higher for class 2 obesity, and 163% higher for class 3 obesity. An abdominal hysterectomy was associated with worse postoperative outcomes when compared with a laparoscopic hysterectomy (p <.001). The risk of increased composite postoperative morbidity for patients undergoing a laparoscopic hysterectomy was not significantly different from the reference group until women had class 3 obesity; the odds of composite morbidity for class 3 obesity women become 31% higher than for nonobese patients. CONCLUSION: BMI directly impacts postoperative morbidity for both abdominal and laparoscopic hysterectomies although the effect is more pronounced after an abdominal hysterectomy. Roughly 40% of women undergoing a hysterectomy in the United States are obese. These data should motivate surgeons to consider ways to medically and surgically optimize patients, including weight reduction before hysterectomy and choosing a laparoscopic approach whenever possible to lower the risk of postoperative morbidity.


Assuntos
Histerectomia/efeitos adversos , Laparoscopia/efeitos adversos , Laparotomia/efeitos adversos , Obesidade/complicações , Obesidade/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Adolescente , Adulto , Idoso , Índice de Massa Corporal , Estudos de Coortes , Feminino , Humanos , Histerectomia/métodos , Histerectomia/estatística & dados numéricos , Laparoscopia/métodos , Laparoscopia/estatística & dados numéricos , Laparotomia/métodos , Laparotomia/estatística & dados numéricos , Pessoa de Meia-Idade , Morbidade , Obesidade/cirurgia , Obesidade Mórbida/complicações , Obesidade Mórbida/epidemiologia , Obesidade Mórbida/cirurgia , Complicações Pós-Operatórias/etiologia , Período Pós-Operatório , Estudos Retrospectivos , Estados Unidos/epidemiologia , Doenças Uterinas/complicações , Doenças Uterinas/epidemiologia , Doenças Uterinas/cirurgia , Adulto Jovem
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