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1.
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
2.
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
4.
Chirurgia (Bucur) ; 114(4): 487-493, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31511135

RESUMO

Introduction: Crohn disease (CD) has seen a steady increase in incidence over the years in Romania. Laparoscopy had a slow evolution as a feasible therapeutic option for patients with CD. Material and Method: The study is retrospective. The period on which the data was gathered spread over 8 years (01.01.2011-01.01.2019). Data was retrieved from three Clinical Hospitals in Bucharest, Romania Results: the preoperative diagnosis of an intestinal fistula (p = 0,02), sepsis (p = 0.01 ) or increased age should be regarded as a limitation for a laparoscopic approach in CD complications. Also in emergency settings an open approach should be the mainstay treatment (approach p = 0.000001). Conclusion: Laparoscopy is a feasible surgical option in the treatment of surgical complication in CD. In order to increase the safety of the intervention, correct selection of patients is important.


Assuntos
Doença de Crohn/epidemiologia , Doença de Crohn/cirurgia , Fatores Etários , Doença de Crohn/complicações , Humanos , Fístula Intestinal/epidemiologia , Fístula Intestinal/cirurgia , Laparoscopia/estatística & dados numéricos , Laparotomia/estatística & dados numéricos , Seleção de Pacientes , Estudos Retrospectivos , Romênia/epidemiologia , Sepse/epidemiologia , Sepse/etiologia , Sepse/cirurgia , Resultado do Tratamento
5.
Pediatr Surg Int ; 35(11): 1223-1229, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31535197

RESUMO

PURPOSE: Kasai portoenterostomy (KP) is the primary procedure for biliary atresia (BA). However, due to reports of poor outcomes of KP, primary liver transplantation (LT) is preferred in selected cases. In Japan, primary LT is limited with no study reports details, particularly regarding the indications. We conducted the first nationwide survey to assess the status of primary LT in Japan. METHODS: Questionnaires were sent to institutions where procedures other than KP were performed as the initial procedure for BA and registered to the Japan Biliary Atresia Registry. Parameters related to procedure selection were analyzed. RESULTS: Of 2895 patients registered (1989-2013), primary LT (n = 15) or exploratory laparotomy (EL) followed by LT (n = 9) without KP was performed in 24 cases (0.8%). The main reason for primary LT was late diagnosis, and for EL followed by LT, lack of fibrous tissue at the porta hepatis (ο-type). The prognoses of LT without KP was good. CONCLUSION: Non-KP initial procedures were limited. Clear criteria regarding the timing of diagnosis or patient condition could not be determined. Reasons for not initially selecting KP varied, but late diagnosis was predominant. Further study is needed to create guidelines for the initial treatment of BA patients.


Assuntos
Atresia Biliar/cirurgia , Transplante de Fígado/estatística & dados numéricos , Bilirrubina/sangue , Feminino , Humanos , Lactente , Japão , Laparotomia/estatística & dados numéricos , Masculino , Portoenterostomia Hepática , Sistema de Registros , Índice de Gravidade de Doença , Inquéritos e Questionários
6.
J Laparoendosc Adv Surg Tech A ; 29(10): 1281-1284, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31397620

RESUMO

Background: Recently, several series have reported the use of laparoscopy in pediatric trauma, most commonly for bowel and pancreatic injury within the first 12 or 24 hours. During a multicenter trial at 10 Level 1 pediatric trauma centers, selective use of laparoscopy in children with blunt liver or spleen injury (BLSI) was noted. A secondary analysis was performed to describe the frequency and application of these procedures to pediatric BLSI. Patients and Methods: Prospective data were collected on all children age ≤18 years with BLSI presenting to 1 of 10 pediatric trauma centers. An unplanned secondary analysis of children who underwent laparoscopy was done. Results: Of 1008 children with BLSI, 59 initially underwent a laparotomy, but 11 underwent a laparoscopic procedure during their index admission; 1 of these was 22 hours postlaparotomy and 2 others were laparoscopy-assisted and converted to laparotomy. Median age of patients undergoing a laparoscopic procedure was 11.5 years (interquartile range [IQR]: 5.8-16.4). Laparoscopy was performed at 7 of the 10 centers. Median time to surgery was 42 hours (IQR: 8-96). Most patients had a liver (n = 6) injury; 4 had spleen and 1 had both. One of the laparoscopies was for pancreatic surgery, and 2 were for bowel injury (but converted to open). Conclusions: Laparoscopy was utilized in 16% of children requiring abdominal surgery after BLSI, with a median time of 42 hours postinjury. Uses included diagnostic laparoscopy, drain placement, laparoscopic pancreatectomy, and washout of hematoma.


Assuntos
Traumatismos Abdominais/cirurgia , Hemorragia/terapia , Laparoscopia/estatística & dados numéricos , Laparotomia/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Baço/lesões , Ferimentos não Penetrantes/cirurgia , Traumatismos Abdominais/complicações , Adolescente , Criança , Pré-Escolar , Feminino , Seguimentos , Hemorragia/etiologia , Humanos , Lactente , Recém-Nascido , Fígado/lesões , Fígado/cirurgia , Masculino , Estudos Retrospectivos , Baço/cirurgia , Centros de Traumatologia , Estados Unidos , Ferimentos não Penetrantes/complicações
7.
Ethiop J Health Sci ; 29(4): 503-512, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31447524

RESUMO

Background: Abdominal injury is among the major causes of trauma admissions. The aim was to determine etiology, commonly injured organs, indication and outcome of patients with abdominal injuries requiring laparotomy. Methods: A retrospective study of all adult patients who underwent laparotomy for abdominal injury at St. Paul's Hospital Millennium Medical College was conducted from January 2014 to December 2016. The factors associated with outcome were identified with bivariate and multivariate logistic regressions. Results: Laparotomy for abdominal injury was performed for 145 patients. Of these, 129 (89%) case records were retrieved. The male to female ratio was 6.2:1. The mean age was 29 years, and most of them were unemployed. Penetrating trauma was the commonest injury, stab (46, 35.7%) and Road Traffic Accidents (RTA) (27, 20.9%) being the leading causes. Extra-abdominal injuries were seen in 33.3% (46) of the cases. Hollow organs were commonly injured than solid organs. Small intestine (35, 43.8%) and Spleen (17, 34.7%) were the leading injured organs in penetrating and blunt respectively. The main procedure performed was repair of hollow and solid organ laceration/perforation (70,54.3%). The negative laparotomy rate was 4.6% (6). Complications were seen in 23(17.8%) patients, the commonest being irreversible shock (7,30.4%). The mortality rate was 8.5 % (11), and it was significantly associated with blunt abdominal injury (AOR=7.25; 95% CI 1.09-48.37; p=0.041) and systolic blood pressure<90mmHg (AOR=8.66; 95% CI 1.1-68.41; p=0.041). Conclusion: Stab and RTA were the commonest indications of laparotomy. The mortality was significantly associated with blunt abdominal injury and hypotension (SBP<90mmHg).


Assuntos
Traumatismos Abdominais/cirurgia , Hospitais de Ensino/estatística & dados numéricos , Laparotomia/estatística & dados numéricos , Traumatismos Abdominais/epidemiologia , Traumatismos Abdominais/mortalidade , Traumatismos Abdominais/patologia , Adulto , Etiópia/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Ferimentos não Penetrantes/epidemiologia , Ferimentos não Penetrantes/patologia , Ferimentos não Penetrantes/cirurgia , Ferimentos Penetrantes/epidemiologia , Ferimentos Penetrantes/patologia , Ferimentos Penetrantes/cirurgia , Adulto Jovem
8.
J Trauma Acute Care Surg ; 87(1): 27-34, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31260424

RESUMO

BACKGROUND: Rates of damage control laparotomy (DCL) vary widely and consensus on appropriate indications does not exist. The purposes of this multicenter quality improvement (QI) project were to decrease the use of DCL and to identify indications where consensus exists. METHODS: In 2016, six US Level I trauma centers performed a yearlong, QI project utilizing a single QI tool: audit and feedback. Each emergent trauma laparotomy was prospectively reviewed. Damage control laparotomy cases were adjudicated based on the majority vote of faculty members as being appropriate or potentially, in retrospect, safe for definitive laparotomy. The rate of DCL for 2 years prior (2014 and 2015) was retrospectively collected and used as a control. To account for secular trends of DCL, interrupted time series was used to effectiveness of the QI interventions. RESULTS: Eight hundred seventy-two emergent laparotomies were performed: 73% definitive laparotomies, 24% DCLs, and 3% intraoperative deaths. Of the 209 DCLs, 162 (78%) were voted appropriate, and 47 (22%) were voted to have been potentially safe for definitive laparotomy. Rates of DCL ranged from 16% to 34%. Common indications for DCL for which consensus existed were packing (103/115 [90%] appropriate) and hemodynamic instability (33/40 [83%] appropriate). The only common indication for which primary closure at the initial laparotomy could have been safely performed was avoiding a planned second look (16/32 [50%] appropriate). CONCLUSION: A single faceted QI intervention failed to decrease the rate of DCL at six US Level I trauma centers. However, opportunities for improvement in safely decreasing the rate of DCL were present. Second look laparotomy appears to lack consensus as an indication for DCL and may represent a target to decrease the rate of DCL after injury. LEVEL OF EVIDENCE: Epidemiological study with one negative criterion, level III.


Assuntos
Traumatismos Abdominais/cirurgia , Laparotomia/métodos , Melhoria de Qualidade , Centros de Traumatologia/estatística & dados numéricos , Traumatismos Abdominais/diagnóstico , Traumatismos Abdominais/terapia , Adulto , Feminino , Humanos , Laparotomia/estatística & dados numéricos , Masculino , Estudos Retrospectivos , Cirurgia de Second-Look/métodos , Cirurgia de Second-Look/estatística & dados numéricos
9.
J Laparoendosc Adv Surg Tech A ; 29(8): 1052-1059, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31237470

RESUMO

Purpose: To characterize injury patterns and institutional trends associated with the utilization of laparoscopy in the management of pediatric abdominal trauma. Methods: The National Trauma Data Bank (2010-2014) was queried for encounters involving patients ≤14 years who underwent an open or laparoscopic abdominal operation within 48 hours of emergency department arrival. Patient, injury, and hospital characteristics associated with each approach were identified. Multivariate logistic regression was used to evaluate the influence of patient and hospital characteristics on operative approach. Results: Laparoscopy comprised 7.8% (n = 355) of all abdominal trauma operations. Patients undergoing laparoscopy had lower injury severity scores and higher Glasgow Coma Scale scores on arrival compared with laparotomy subjects (P < .001). Laparoscopic patients also had a shorter length of hospital stay (5.0 versus 8.6 days, P < .001), but longer time to the operating room (9.2 versus 6.3 hours, P < .001) compared with their open counterparts. The proportion of cases managed laparoscopically increased from 6.2% in 2010 to 10.1% in 2014 (P = .013), with increase in utilization primarily driven by university hospitals (P = .026) and level I pediatric trauma centers (P = .043). Conversion to laparotomy was uncommon (18.6%), and mortality in the laparoscopic cohort was low (0.4%). Conclusions: Use of laparoscopy has increased in the pediatric abdominal trauma population, typically in a less injured cohort of patients. As familiarity with and availability of minimally invasive techniques increase, this trend will likely continue.


Assuntos
Traumatismos Abdominais/cirurgia , Laparoscopia/estatística & dados numéricos , Laparotomia/estatística & dados numéricos , Procedimentos Cirúrgicos Minimamente Invasivos/estatística & dados numéricos , Ferimentos e Lesões/cirurgia , Traumatismos Abdominais/epidemiologia , Adolescente , Criança , Pré-Escolar , Bases de Dados Factuais , Feminino , Humanos , Tempo de Internação , Modelos Logísticos , Masculino , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos , Ferimentos e Lesões/epidemiologia
10.
Tidsskr Nor Laegeforen ; 139(10)2019 06 25.
Artigo em Norueguês | MEDLINE | ID: mdl-31238674

RESUMO

BACKGROUND: Bariatric surgery has been performed at Oslo University Hospital since 2004. We wished to describe patient characteristics, use of surgical methods and perioperative complications in the period 2004-14. MATERIAL AND METHOD: We performed a retrospective analysis of prospective data collected for the period 2004-14. Complications include events during hospitalisation and up to 6-8 weeks postoperatively. RESULTS: Altogether 2 127 patients underwent surgery for morbid obesity, whereof 1 468 were women. Average age and body mass index were 42 years (range 17-73) and 46.2 kg/m2 (range 26-92). A total of 512 had a body mass index ≥ 50 kg/m2. Obesity-related sequelae were registered in 1 196 patients before surgery. Gastric bypass was performed in 1 966 patients, gastric sleeve resection in 122 (17 of these later underwent duodenal switch) and duodenal switch in 56 patients. All patients were operated laparoscopically, and four procedures were converted to laparotomy. Median hospitalisation time was two days (range 1-78). Complications were registered in 209 patients, 75 of whom had severe complications (grade ≥ IIIb on the Clavien-Dindo classification system). Patients with a body mass index ≥ 50 kg/m2 had a higher incidence of complications (12.5 % vs 8.9 %). Altogether 67 patients underwent further surgery. Six patients died, two of whom more than 30 days after the operation. The incidence of complications was reduced during the period. INTERPRETATION: Bariatric surgery may be performed laparoscopically with a low incidence of complications and short hospitalisation times. A large proportion of the patients who underwent surgery had obesity-related sequalae.


Assuntos
Cirurgia Bariátrica , Obesidade Mórbida/cirurgia , Adolescente , Adulto , Idoso , Cirurgia Bariátrica/efeitos adversos , Cirurgia Bariátrica/métodos , Cirurgia Bariátrica/estatística & dados numéricos , Índice de Massa Corporal , Feminino , Gastrectomia/estatística & dados numéricos , Derivação Gástrica/estatística & dados numéricos , Hospitais Universitários/estatística & dados numéricos , Humanos , Laparoscopia/estatística & dados numéricos , Laparotomia/estatística & dados numéricos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Noruega , Obesidade Mórbida/complicações , Complicações Pós-Operatórias/epidemiologia , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Adulto Jovem
11.
J Surg Res ; 243: 309-315, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31254904

RESUMO

BACKGROUND: Recent advances in anesthetic and laparoscopic surgical management have improved perioperative outcomes in patients with pheochromocytoma. However, patients converted to laparotomy during laparoscopic adrenalectomy for pheochromocytoma have never been evaluated specifically in terms of intraoperative hemodynamic instability and postoperative complications. METHODS: Retrospective analysis of prospectively maintained databases in five medical centers from 2002 to 2013. Inclusion criteria were consecutive patients who underwent laparoscopic unilateral total adrenalectomy for pheochromocytoma. RESULTS: Two hundred forty-four patients were included. Mean tumor size was 43.9 ± 20 mm with 92 patients (38%) having a tumor diameter > 50 mm. During adrenalectomy, 19 of 244 patients (7.7%) had to be converted to laparotomy. In multivariable analysis, the need for preoperative hospitalization (3.379, 1.209-9.445; P = 0.020), tumor size > 6 cm (2.97, 0.996-8.868; P = 0.050), and ratio of intraoperative systolic blood pressure >200 mmHg duration to anesthesia duration (1.060, 1.007-1.117; P = 0.027) remained significantly associated with conversion. Conversion was significantly associated with postoperative grade II-V Clavien morbidity rate (4.259, 1.471-12.326; P = 0.007) and duration of hospitalization (12.92, 2.90-58.82; P < 0.001). CONCLUSIONS: This study shows that preoperative hospitalization and larger tumor were more frequent in patients undergoing conversion to laparotomy during laparoscopic adrenalectomy for pheochromocytoma. Conversion is associated with increased intraoperative hypertensive episodes and postoperative complications rate. Clinicians should be cognizant of these risks and prepare patients appropriately for conversion when deemed necessary.


Assuntos
Neoplasias das Glândulas Suprarrenais/cirurgia , Adrenalectomia/estatística & dados numéricos , Feocromocitoma/cirurgia , Adrenalectomia/métodos , Adulto , Idoso , Feminino , Humanos , Laparoscopia/estatística & dados numéricos , Laparotomia/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
12.
Isr Med Assoc J ; 5(21): 330-332, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31140225

RESUMO

BACKGROUND: Selective management of stable patients with anterior abdomen stab wounds (AASWs) has become a gold standard management approach throughout the world. Evidenced-based options for supporting selective management include clinical follow-up, local wound exploration with or without diagnostic peritoneal lavage, diagnostic laparoscopy, and abdominal computerized tomography. The presence of multiple AASWs might signify a more aggressive attack and limit the safety of a selective management approach. OBJECTIVES: To evaluate whether multiple AASWs are associated with an increased risk of intra-abdominal injury requiring emergency surgery. METHODS: We retrospectively reviewed all AASW patients admitted to Assaf Harofeh Medical Center, Zerifin, Israel, and Hillel Yaffe Medical Center in Hadera, Israel, from 2007 to 2015. Patients were divided into two groups based on the number of stab wounds: single or multiple. Data were coded for demographics, severity of injury, presence of intra-abdominal injury, laparotomy rate, length of hospital stay (LOS), length of stay in the intensive care unit (LICU), and survival. RESULTS: The study included 169 patients. Of these, 143 patients had a single AASW and 26 had multiple AASWs. There were no differences between the groups regarding demographics, severity of injury, intra-abdominal penetration, specific organ injury, LOS, or LICU. There was no difference in the percentage of patients requiring laparotomy. The overall mortality was 2.36% (4/169). There was no significant difference in the mortality rate between the groups (P = 0.11). CONCLUSIONS: The presence of multiple AASWs is not a risk factor for increased frequency and severity of intra-abdominal injury.


Assuntos
Traumatismos Abdominais , Ferimentos Perfurantes , Traumatismos Abdominais/diagnóstico , Traumatismos Abdominais/mortalidade , Traumatismos Abdominais/terapia , Adulto , Feminino , Humanos , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva/estatística & dados numéricos , Israel/epidemiologia , Laparoscopia/métodos , Laparotomia/métodos , Laparotomia/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Mortalidade , Administração dos Cuidados ao Paciente/métodos , Administração dos Cuidados ao Paciente/normas , Lavagem Peritoneal/métodos , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de Risco , Tomografia Computadorizada por Raios X/métodos , Ferimentos Perfurantes/diagnóstico , Ferimentos Perfurantes/mortalidade , Ferimentos Perfurantes/terapia
13.
J Pediatr Surg ; 54(9): 1736-1739, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31103272

RESUMO

PURPOSE: The risks of laparotomy during extracorporeal life support (ECLS) are poorly defined. We examined risk factors associated with bleeding and mortality after laparotomy on ECLS. METHODS: The Extracorporeal Life Support Organization (ELSO) database was queried for all pediatric patients [0-17 years] with a procedure code for laparotomy. Outcome data were analyzed to define factors contributing to laparotomy complications and mortality while on ECLS. Univariate and multivariate analyses were applied to determine independent risk factors. RESULTS: 196 patients who met inclusion criteria were identified. The mortality rate in the entire cohort was 67.3%. In both univariate and multivariate analyses, surgical site bleeding did not significantly increase the risk of mortality (OR 0.8; 95% CI 0.4-1.7). Logistic regression analysis revealed that lower gestational age, infectious complications and nonsurgical site hemorrhagic complications were independently increased mortality risk (all p < 0.05). CONCLUSION: Mortality following laparotomy on ECLS is not independently associated with surgical site bleeding, but is associated with lower gestational age, infectious and nonsurgical site hemorrhagic complications. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: Level III.


Assuntos
Perda Sanguínea Cirúrgica , Oxigenação por Membrana Extracorpórea , Laparotomia , Adolescente , Perda Sanguínea Cirúrgica/mortalidade , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Criança , Pré-Escolar , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/mortalidade , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Laparotomia/efeitos adversos , Laparotomia/mortalidade , Laparotomia/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco
14.
Updates Surg ; 71(3): 561-567, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31011998

RESUMO

Previous studies have had conflicting results when comparing risk of mortality in patients with gunshot wounds (GSWs) treated at Level-I and II trauma centers. However, the populations studied were restricted geographically. We hypothesized that patients presenting after a GSW to the torso at Level-I centers would have a shorter time to surgical intervention (exploratory laparotomy or thoracotomy) and a lower risk of mortality, compared to Level-IIs in a national database. The Trauma Quality Improvement Program (2010-2016) was queried for patients presenting to Level-I or II trauma center after a GSW to the torso. A multivariable logistic regression analysis was performed. From 17,965 patients with GSWs, 13,812 (76.8%) were treated at Level-Is and 4153 (23.2%) at Level-IIs. There was no difference in the injury severity score (ISS) (p = 0.55). The Level-I cohort had a higher rate of laparotomy (38.9% vs. 36.5%, p < 0.001) with a shorter median time to laparotomy (49 vs. 55 min, p < 0.001) but no difference in rate (p = 0.14) and time to thoracotomy (p = 0.62). After adjusting for covariates, only patients undergoing thoracotomy (OR = 0.66, CI = 0.47-0.95, p = 0.02) or those undergoing non-operative management (NOM) (OR = 0.85, CI = 0.74-0.98, p = 0.03) at a Level-I center had lower risk for death, compared to Level-II. Patients with torso GSWs managed with thoracotomy or NOM at a Level-I center have a lower risk of mortality, compared to a Level-II. Future prospective studies examining variations in practice, resources available and surgeon experience to account for these differences are warranted.


Assuntos
Traumatismos Torácicos/mortalidade , Centros de Traumatologia/estatística & dados numéricos , Ferimentos por Arma de Fogo/mortalidade , Adulto , Feminino , Humanos , Escala de Gravidade do Ferimento , Laparotomia/estatística & dados numéricos , Modelos Logísticos , Masculino , Estudos Retrospectivos , Fatores de Risco , Traumatismos Torácicos/etiologia , Traumatismos Torácicos/terapia , Toracotomia/estatística & dados numéricos , Fatores de Tempo , Estados Unidos/epidemiologia , Ferimentos por Arma de Fogo/terapia , Adulto Jovem
15.
Eur Radiol ; 29(11): 5932-5940, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31025065

RESUMO

OBJECTIVES: To evaluate the performance of an early repeated computed tomography (rCT) in initially non-operated patients with blunt bowel and mesenteric injuries (BBMI). METHODS: This was a monocentric retrospective observational study from 2009 to 2017 of patients with a BBMI on initial CT (iCT). Patients initially non-operated on were scheduled for a rCT within 48 h. Initial CT and rCT diagnostic performance were compared based on a surgical injury prediction score previously described. For statistical analysis, we used the chi-square analyses for paired data (McNemar test). RESULTS: Eighty-four patients (1.9% of trauma) had suspected BBMI on iCT. Among these patients, 22 (26.2%) were initially operated on, 18 (21.4%) were later operated on, and 44 (52.4%) were not operated on. The therapeutic laparotomy rate was 85%. Thirty-four patients initially non-operated on had a rCT. The absolute value of the CT scan score increased for 15 patients (44.1%). The early rCT diagnostic performance, compared with iCT, showed an increase in sensitivity (from 63.6 to 91.7%), in negative predictive value (from 77.4 to 94.7%), and in AUC (from 0.77 to 0.94). CONCLUSION: In initially non-operated patients with BBMI lesions, the performance of an early rCT improved the sensitivity of lesion detection requiring surgical repair and the security of patient selection for non-operative treatment. KEY POINTS: • Selective non-operative treatment for hemodynamically stable patients with blunt bowel and/or mesenteric injuries on CT is developing but remains controversial. • An early repeated CT improved the sensitivity of lesion detection requiring surgical repair and the security of patient selection for conservative treatment.


Assuntos
Intestinos/lesões , Mesentério/lesões , Ferimentos não Penetrantes/diagnóstico por imagem , Traumatismos Abdominais/diagnóstico por imagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Tratamento Conservador/estatística & dados numéricos , Feminino , Humanos , Escala de Gravidade do Ferimento , Intestinos/diagnóstico por imagem , Intestinos/cirurgia , Laparotomia/estatística & dados numéricos , Masculino , Mesentério/diagnóstico por imagem , Pessoa de Meia-Idade , Seleção de Pacientes , Projetos de Pesquisa , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/métodos , Adulto Jovem
16.
Obstet Gynecol ; 133(4): 643-649, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30870280

RESUMO

OBJECTIVE: To characterize long-term national trends in surgical approach for hysterectomy after the U.S. Food and Drug Administration (FDA) warning against power morcellation for laparoscopic specimen removal. METHODS: This was a descriptive study using data from the American College of Surgeons National Surgical Quality Improvement Program from 2012 to 2016. We identified hysterectomies using Current Procedural Terminology codes. We used an interrupted time-series analysis to evaluate abdominal and supracervical hysterectomy trends surrounding The Wall Street Journal article first reporting morcellation safety concerns and the FDA safety communication. We compared categorical and continuous variables using χ, t, and Wilcoxon rank sum tests. RESULTS: We identified 179,950 hysterectomies; laparoscopy was the most common mode of hysterectomy in every quarter. Before The Wall Street Journal article, there was no significant change in proportion of abdominal hysterectomies (0.3% decrease/quarter, P=.14). After The Wall Street Journal article, use of abdominal hysterectomy increased 1.1% per quarter for two quarters through the FDA warning (P<.001), plateaued for three quarters until March 2015 (P=.65), then decreased by 0.8% per quarter through 2016 (P<.001). Supracervical hysterectomy volume continuously decreased after the FDA warning (1.0% decrease per quarter, P<.001) and after three quarters (0.7% decrease per quarter, P=.01), then plateaued from April 2015 through 2016 (0.05% decrease per quarter, P=.40). Mode of supracervical hysterectomy was unchanged from 2012 to 2013 (P=.43), followed by two quarters of significant increase in proportion of supracervical abdominal hysterectomies (11.7%/quarter, P<.001). This change in mode of supracervical hysterectomy then plateaued through 2016 (P=.06). CONCLUSION: Despite early studies suggesting that minimally invasive hysterectomy decreased in response to safety concerns regarding power morcellation, we found that this effect reversed 1 year after the FDA safety communication. However, there was a sustained decline in supracervical hysterectomy, and the remaining supracervical hysterectomies were more likely to be performed using laparotomy.


Assuntos
Histerectomia/métodos , Histerectomia/tendências , Morcelação/efeitos adversos , Morcelação/tendências , Adulto , Feminino , Humanos , Histerectomia/estatística & dados numéricos , Laparoscopia/métodos , Laparoscopia/estatística & dados numéricos , Laparoscopia/tendências , Laparotomia/efeitos adversos , Laparotomia/estatística & dados numéricos , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos , Melhoria de Qualidade , Estados Unidos , United States Food and Drug Administration
17.
Artigo em Inglês | MEDLINE | ID: mdl-30875912

RESUMO

Background: Lymphoceles could represent a detrimental complication after retroperitoneal lymph node dissection. Our aim was to elucidate predictors of lymphoceles. Methods: Between 2011 and 2017, medical records of consecutive women who underwent laparotomic retroperitoneal lymph node dissection for FIGO stage I or II gynecologic cancer were reviewed. Results: A total of 204 women, including those with lymphoceles (n = 31) and symptomatic lymphoceles (n = 7), were reviewed. According to multivariable analysis, parity (odds ratio = 0.59, p = 0.003), adjuvant pelvic radiotherapy (odds ratio = 2.60, p = 0.039), and peritoneal nonclosure without pelvic drainage (odds ratio = 2.31, p = 0.048) were predictors of lymphoceles. In addition, parity (odds ratio = 0.73, p = 0.03), hypertension (odds ratio = 2.62, p = 0.02), and peritoneal partial closure with pelvic drainage (odds ratio = 0.27, p = 0.02) were predictors of complications. Conclusion: Low parity, adjuvant pelvic radiotherapy, and peritoneal nonclosure without pelvic drainage were associated with increased lymphocele formation. In addition, a lower complication rate was found in the peritoneal partial closure with pelvic drainage group; thus, peritoneal partial closure with pelvic drainage might be suggested for women who undergo laparotomic retroperitoneal lymph node dissection.


Assuntos
Neoplasias dos Genitais Femininos/cirurgia , Laparotomia/estatística & dados numéricos , Excisão de Linfonodo/estatística & dados numéricos , Linfocele/epidemiologia , Peritônio/cirurgia , Adulto , Feminino , Humanos , Linfocele/etiologia , Pessoa de Meia-Idade , Razão de Chances , Estudos Retrospectivos , Taiwan/epidemiologia
18.
World J Surg ; 43(7): 1653-1660, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30903247

RESUMO

INTRODUCTION: District hospitals are key to providing universal coverage of essential surgery and for strengthening surgical care in general. This audit set out to quantify the surgical output of all the district hospitals in KwaZulu-Natal Province (KZN) over a 6-month period to see whether district hospitals were delivering the surgical care they are expected to deliver. RESULTS: There were a total of 18,871 operations performed at 37 district hospitals in KwaZulu-Natal from July to December 2015. The number of operations per hospital varied widely between 2150 at a single large district hospital and 68 at a small district hospital, respectively. Surgical operations for obstetrical conditions made up by far the majority of operations at 57%, with gynecological operations making up the second highest at 15%. Only 12% of operations were for general surgical conditions. With regards to the bellwether procedures, 96.1% of these were cesarean sections, 2.1% were laparotomies and 1.8% were ORIFs. For almost all the 37 hospitals, the percentage of laparotomies and ORIFs performed was small to negligible, while the percentage of cesarean sections performed was high. The number of bellwether operations performed per 100,000 population was much higher than the number of general surgical or orthopedic operations performed, primarily because of the preponderance of cesarean sections conducted in each hospital. We observed a strong and significant positive correlation (+0.691, 95% CI +0.538 to +0.800, p < 0.001) between increasing distance to nearest regional referral hospital and rate of laparotomies and ORIF procedures performed. CONCLUSIONS: The surgical output of district hospitals in KZN is heavily skewed toward obstetrics and gynecology. Further work is required to understand the reasons for this, but the current data imply that district hospitals are not delivering surgical and orthopedic care at district hospitals in KwaZulu-Natal.


Assuntos
Cesárea/estatística & dados numéricos , Fixação Interna de Fraturas/estatística & dados numéricos , Hospitais de Distrito/estatística & dados numéricos , Laparotomia/estatística & dados numéricos , Redução Aberta/estatística & dados numéricos , Feminino , Procedimentos Cirúrgicos em Ginecologia/estatística & dados numéricos , Acesso aos Serviços de Saúde , Humanos , Gravidez , África do Sul
19.
Am J Obstet Gynecol ; 220(5): 469.e1-469.e13, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30802438

RESUMO

BACKGROUND: A recent trial demonstrated decreased survival in women with early-stage cervical cancer who underwent radical hysterectomy via minimally invasive surgery compared with laparotomy; however, outcomes following trachelectomy have yet to be studied. OBJECTIVE: To examine trends, characteristics, and survival of reproductive-aged women with early-stage cervical cancer who underwent minimally invasive trachelectomy. STUDY DESIGN: This is a retrospective study examining the National Cancer Database between 2010 and 2015. Women aged <50 years who underwent trachelectomy for stage IA2-IB cervical cancer were grouped by mode of surgery. Clinicopathologic characteristics and outcomes were compared between minimally invasive surgery and laparotomy groups. RESULTS: A total of 246 women were included, 144 (58.5%, 95% confidence interval, 52.4%-64.7%) of whom had trachelectomy with a minimally invasive surgery approach. Median age was similar between the minimally invasive surgery and laparotomy groups (median, 31 vs 29 years, P = .20). There was a significant increase in the use of minimally invasive surgery from 29.3% in 2010 to 75.0% in 2015 (P < .001). Specifically, minimally invasive surgery became the dominant approach for trachelectomy by year 2011 (54.8%). Hospitals registered in the West (75.0% vs 25.0%) were more likely, whereas those registered in the Midwest (46.9% vs 53.1%) were less likely, to perform minimally invasive surgery (P = .02). Median follow-up was 37 months (interquartile range, 23-51) for the minimally invasive surgery group and 40 months (interquartile range, 26-67) for the laparotomy group. During follow-up, there were 11 (5.3%) deaths, 4 (3.5%) in the minimally invasive surgery group and 7 (7.6%) in the laparotomy group (P = .25). CONCLUSION: Minimally invasive surgery has become the dominant modality for trachelectomy in reproductive-aged women with stage IA2-IB cervical cancer after year 2011. Survival of women with stage IA2-IB cervical cancer who underwent trachelectomy is generally good regardless of surgical modality. Although our study showed no difference in survival between the minimally invasive surgery and laparotomy approaches, effects of MIS on survival remain unknown and further study is warranted.


Assuntos
Laparoscopia/estatística & dados numéricos , Laparotomia/estatística & dados numéricos , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Traquelectomia/estatística & dados numéricos , Neoplasias do Colo do Útero/cirurgia , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Adenocarcinoma/cirurgia , Adulto , Carcinoma de Células Escamosas/mortalidade , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/cirurgia , Feminino , Preservação da Fertilidade , Seguimentos , Humanos , Laparoscopia/tendências , Sistema de Registros , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/tendências , Traquelectomia/tendências , Estados Unidos/epidemiologia , Neoplasias do Colo do Útero/mortalidade , Neoplasias do Colo do Útero/patologia
20.
Br J Surg ; 106(2): e103-e112, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30620059

RESUMO

BACKGROUND: The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. METHODS: In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. RESULTS: Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89·6 per cent) compared with that in countries with a middle (753 of 1242, 60·6 per cent; odds ratio (OR) 0·17, 95 per cent c.i. 0·14 to 0·21, P < 0·001) or low (363 of 860, 42·2 per cent; OR 0·08, 0·07 to 0·10, P < 0·001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -9·4 (95 per cent c.i. -11·9 to -6·9) per cent; P < 0·001), but the relationship was reversed in low-HDI countries (+12·1 (+7·0 to +17·3) per cent; P < 0·001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0·60, 0·50 to 0·73; P < 0·001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. CONCLUSION: Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.


Assuntos
Lista de Checagem/estatística & dados numéricos , Tratamento de Emergência/estatística & dados numéricos , Laparotomia/estatística & dados numéricos , Segurança do Paciente/estatística & dados numéricos , Adulto , Idoso , Estudos de Coortes , Procedimentos Cirúrgicos do Sistema Digestório/mortalidade , Procedimentos Cirúrgicos do Sistema Digestório/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/mortalidade , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Tratamento de Emergência/mortalidade , Feminino , Humanos , Laparotomia/mortalidade , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Taxa de Sobrevida , Organização Mundial da Saúde
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