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1.
Ann Surg ; 272(2): 253-265, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32675538

RESUMO

OBJECTIVE: To perform an individual participant data meta-analysis using randomized trials and propensity-score matched (PSM) studies which compared laparoscopic versus open hepatectomy for patients with colorectal liver metastases (CLM). BACKGROUND: Randomized trials and PSM studies constitute the highest level of evidence in addressing the long-term oncologic efficacy of laparoscopic versus open resection for CLM. However, individual studies are limited by the reporting of overall survival in ways not amenable to traditional methods of meta-analysis, and violation of the proportional hazards assumption. METHODS: Survival information of individual patients was reconstructed from the published Kaplan-Meier curves with the aid of a computer vision program. Frequentist and Bayesian survival models (taking into account random-effects and nonproportional hazards) were fitted to compare overall survival of patients who underwent laparoscopic versus open surgery. To handle long plateaus in the tails of survival curves, we also exploited "cure models" to estimate the fraction of patients effectively "cured" of disease. RESULTS: Individual patient data from 2 randomized trials and 13 PSM studies involving 3148 participants were reconstructed. Laparoscopic resection was associated with a lower hazard rate of death (stratified hazard ratio = 0.853, 95% confidence interval: 0.754-0.965, P = 0.0114), and there was evidence of time-varying effects (P = 0.0324) in which the magnitude of hazard ratios increased over time. The fractions of long-term cancer survivors were estimated to be 47.4% and 18.0% in the laparoscopy and open surgery groups, respectively. At 10-year follow-up, the restricted mean survival time was 8.6 months (or 12.1%) longer in the laparoscopy arm (P < 0.0001). In a subgroup analysis, elderly patients (≥65 years old) treated with laparoscopy experienced longer 3-year average life expectancy (+6.2%, P = 0.018), and those who live past the 5-year milestone (46.1%) seem to be cured of disease. CONCLUSIONS: This patient-level meta-analysis of high-quality studies demonstrated an unexpected survival benefit in favor of laparoscopic over open resection for CLM in the long-term. From a conservative viewpoint, these results can be interpreted to indicate that laparoscopy is at least not inferior to the standard open approach.


Assuntos
Neoplasias Colorretais/patologia , Laparoscopia/mortalidade , Laparotomia/mortalidade , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/secundário , Idoso , Teorema de Bayes , Intervalo Livre de Doença , Feminino , Hepatectomia/métodos , Humanos , Estimativa de Kaplan-Meier , Laparoscopia/métodos , Laparotomia/métodos , Neoplasias Hepáticas/cirurgia , Masculino , Pessoa de Meia-Idade , Prognóstico , Pontuação de Propensão , Modelos de Riscos Proporcionais , Ensaios Clínicos Controlados Aleatórios como Assunto , Análise de Sobrevida
2.
Updates Surg ; 72(3): 859-865, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32385794

RESUMO

Emergency laparotomies are often required for life-threatening conditions and consequently are associated with high mortality. This risk should be discussed with patients and ideally their next of kin (NOK). Failure to do so denies patients and their relatives the opportunity to prepare, breaches consent guidance, and may result in complaints and negligent claims. Patients who underwent an emergency laparotomy over 6 months were retrospectively studied. Mortality risk discussion with patients and their NOK as evidenced by documentation on consent forms or clinical notes was recorded. Factors influencing these discussions included patient's age, American Society of Anaesthesiologists' score, pre-operative diagnosis, Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (P-POSSUM); seniority of consenting surgeon was also investigated. Seventy-six consecutive patients underwent an emergency laparotomy. Sixty-nine had capacity to give consent. Mortality risk was discussed with 24 (34.8%). These patients were older (median age 77.5 v 65.5 years; P < 0.05) and had a higher median P-POSSUM score (11.5% v 7%; P = 0.313) compared to patient with whom mortality risk was not discussed. Mortality risk was discussed with 14 (18.4%) NOK. This was not influenced by any factor studied. For patients requiring an emergency laparotomy, mortality risk was infrequently discussed with both patients and their NOK. These patients have a higher mortality risk than any other and this "failure to inform" has the potential for serious ramifications.


Assuntos
Consentimento Livre e Esclarecido/estatística & dados numéricos , Laparotomia/mortalidade , Fatores Etários , Idoso , Emergências , Feminino , Humanos , Masculino , Cuidados Pré-Operatórios , Estudos Retrospectivos , Risco , Índice de Gravidade de Doença , Fatores de Tempo
3.
Anaesthesia ; 75(10): 1321-1330, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32395823

RESUMO

Emergency laparotomy is associated with high mortality. Implementation of an evidence-based care bundle has been shown to improve patient outcomes. A quality improvement project to implement a six-component care bundle was undertaken between July 2015 and May 2018. As part of this project, we worked with 27 hospitals in the Emergency Laparotomy Collaborative. Previous pilot implementation of the same bundle in our hospital between December 2012 and July 2013 had shown marked improvement, maintained until April 2014, but then deterioration. Understanding the reasons for this deterioration informed our work to re-implement the bundle and sustain improvement. A cohort of 930 consecutive patients requiring emergency laparotomy between October 2014 and April 2019 were included. Baseline data were collected between October 2014 and June 2015, and the bundle was re-implemented in July 2015. Thirty-day mortality decreased from 11% in the baseline group to 7.3% after bundle implementation. Hospital length of stay decreased from 19.5 to 17.9 days. Full bundle compliance improved from < 60% to > 80% for all patients, with improvement in application of all individual bundle components. This study provides further evidence that outcomes for high-risk surgical patients can be improved with an evidence-based care bundle, but attention must be paid to maintaining bundle compliance. Issues around sustaining improvement must be considered from project initiation.


Assuntos
Serviços Médicos de Emergência/normas , Laparotomia/normas , Assistência ao Paciente/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Medicina Baseada em Evidências , Feminino , Fidelidade a Diretrizes , Humanos , Laparotomia/mortalidade , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Pacotes de Assistência ao Paciente , Melhoria de Qualidade , Risco , Resultado do Tratamento
4.
Int J Surg ; 77: 154-162, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32234579

RESUMO

BACKGROUND: Emergency laparotomy is associated with high morbidity and mortality. Current trends suggest improvements have been made in recent years, with increased survival and shorter lengths of stay in hospital. The National Emergency Laparotomy Audit (NELA) has evaluated participating hospitals in England and Wales and their individual outcomes since 2013. This study aims to establish temporal trends for patients undergoing emergency laparotomy and evaluate the influence of NELA. METHODS: Data for emergency laparotomies admitted to NHS hospitals in the Northern Deanery between 2001 and 2016 were collected, including demographics, co-morbidities, diagnoses, operations undertaken and outcomes. The primary outcome of interest was in-hospital death within 30 days of admission. Cox-regression analysis was undertaken with adjustment for covariates. RESULTS: There were 2828 in-hospital deaths from 24,291 laparotomies within 30 days of admission (11.6%). Overall 30-day mortality significantly reduced during the 15-year period studied from 16.3% (2001-04), to 8.1% during 2013-16 (p < 0.001). After multivariate adjustment, laparotomies undertaken in more recent years were associated with a lower mortality risk compared to earlier years (2013-16: HR 0.73, p < 0.001). There was a significant improvement in 30-day postoperative mortality year-on-year during the NELA period (from 9.1 to 7.1%, p = 0.039). However, there was no difference in postoperative mortality for patients who underwent laparotomy during NELA (2013-16) compared with the preceding three years (both 8.1%, p = 0.526). DISCUSSION: 30 day postoperative mortality for emergency laparotomy has improved over the past 15-years, with significantly reduced mortality risk in recent years. However, it is unclear if NELA has yet had a measurable effect on 30-day post-operative mortality.


Assuntos
Emergências , Laparotomia/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Auditoria Médica , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto Jovem
5.
J Trauma Acute Care Surg ; 89(2): 382-387, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32301890

RESUMO

PURPOSE: Emergency laparotomy (EL) encompasses a high-risk group of operations, which are increasingly performed on a heterogeneous population of patients, making preoperative risk assessment potentially difficult. The UK National Emergency Laparotomy Audit (NELA) recently produced a risk predictive tool for EL that has not yet been externally validated. We aimed to externally validate and potentially improve the NELA tool for mortality prediction after EL. METHODOLOGY: We reviewed computer and paper records of EL patients from May 2012 to June 2017 at Middlemore Hospital (New Zealand). The inclusion criteria mirrored the UK NELA. We examined the NELA, Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality (P-POSSUM), Acute Physiology and Chronic Health Evaluation II (APACHE-II), and American College of Surgeons National Surgical Quality Improvement Programs risk predictive tools for 30-day mortality. The Hosmer-Lemeshow test was used to assess calibration, and the c statistic, to evaluate discrimination (accuracy) of the tools. We added the modified frailty index (mFI) and nutrition to improve the accuracy of risk predictive tools. RESULTS: A total of 758 patients met the inclusion criteria, with an observed 30-day mortality of 7.9%. The NELA was the only well calibrated tool, with predicted 30-day mortality of 7.4% (p = 0.22). When combined with mFI and nutritional status, the c statistic for NELA improved from 0.83 to 0.88. American College of Surgeons National Surgical Quality Improvement Programs, APACHE-II, and P-POSSUM had lower c statistics, albeit also showing an improvement (0.84, 0.81, and 0.74, respectively). CONCLUSION: We have demonstrated the NELA tool to be most predictive of mortality after EL. The NELA tool would therefore facilitate preoperative risk assessment and operative decision making most precisely in EL. Future research should consider adding mFI and nutritional status to the NELA tool. LEVEL OF EVIDENCE: Level IV; Retrospective observational cohort study.


Assuntos
Serviço Hospitalar de Emergência , Laparotomia , Medição de Risco/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Tomada de Decisão Clínica , Serviço Hospitalar de Emergência/normas , Feminino , Idoso Fragilizado , Mortalidade Hospitalar , Humanos , Laparotomia/mortalidade , Masculino , Pessoa de Meia-Idade , Nova Zelândia , Estado Nutricional , Melhoria de Qualidade , Estudos Retrospectivos , Índice de Gravidade de Doença , Adulto Jovem
6.
J Surg Res ; 251: 211-219, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32171135

RESUMO

BACKGROUND: Although obesity is considered an epidemic in the United States, there is mixed evidence regarding the impact of obesity on outcomes after traumatic injury and major surgery. We hypothesized that obese patients undergoing trauma laparotomy would be at increased risk of failure to rescue (FTR), defined as death after a complication. METHODS: We analyzed trauma registry data for adult patients who underwent abdominal exploration for trauma at all 30 level I and II Pennsylvania trauma centers, 2011-2014. We used competing risks regression to identify significant risk factors for complications. We used multivariable logistic regression to identify significant risk factors for FTR. RESULTS: Of 95,806 admitted patients, 15,253 (15.9%) were categorized as obese. Overall, 3228 (3.4%) underwent laparotomy, including 2681 (83.1%) nonobese and 547 (17.0%) obese patients. Among obese patients, 47.2% had at least one complication and 28.7% had two or more complications, compared with 33.5% and 18.7% of nonobese patients, respectively. The most common complication was pneumonia (15.0% of obese and 10.5% of nonobese patients; P = 0.003), followed by sepsis (8.8% versus 4.2%; P < 0.001) and deep vein thrombosis (8.4% versus 5.9%; P < 0.001). Obesity was independently associated with complications (hazard ratio, 1.4; 95% confidence interval, 1.2-1.6). In multivariable analysis, obesity was not associated with FTR (odds ratio, 1.3; 95% confidence interval, 0.9-2.0). CONCLUSIONS: Obesity is a risk factor for complications after traumatic injury but not for FTR. The increased risk of complications may reflect processes of care that are not attuned to the needs of this population, offering opportunities for improvement in care.


Assuntos
Falha da Terapia de Resgate , Laparotomia/mortalidade , Obesidade/complicações , Complicações Pós-Operatórias/epidemiologia , Ferimentos e Lesões/cirurgia , Adulto , Feminino , Humanos , Laparotomia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Pennsylvania/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Adulto Jovem
7.
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
8.
Dig Dis Sci ; 65(5): 1529-1538, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31559551

RESUMO

BACKGROUND: The causes and management of pyogenic liver abscess (PLA) have undergone multiple changes over the past decades. It is a relatively rare disease in the USA, and its incidence rate in the USA is increasing. The last US community hospital experience of PLA was published in 2005. We performed a retrospective study of patients admitted with PLA to an urban safety net hospital. AIMS: To ascertain risk factors, management approaches, and outcomes of PLA. METHODS: Electronic medical record was queried for diagnosis codes related to PLA during the years 2009-2018. Clinical information was compiled in an electronic database which was later analyzed. Main study outcomes were in-hospital mortality, 30-day readmission rate, and intensive care utilization rate. RESULTS: A total of 77 patients with PLA were admitted in the study period. Most common risk factors were diabetes mellitus (23.4%), previous liver surgery (20.7%), and hepatic malignancy (16.9%). 89% of patients were treated with percutaneous drainage or aspiration, and surgical drainage was reserved for other with other indications for laparotomy. In-hospital mortality, 30-day readmission, and intensive care utilization rates were 2.6%, 7% and 22%, respectively. Median length of stay was 11 days (inter-quartile range 7). Rate of antimicrobial resistance in abscess fluid cultures was 40%; 13 cases of Klebsiella pneumoniae liver abscess were noted in our cohort, most of whom were Hispanic or Asian. CONCLUSIONS: PLA was principally managed by percutaneous drainage or aspiration with good outcomes. Further studies investigating the racial predilection of K. pneumoniae liver abscesses could reveal clues to its pathogenesis.


Assuntos
Hospitalização/estatística & dados numéricos , Abscesso Hepático Piogênico/mortalidade , Abscesso Hepático Piogênico/terapia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Provedores de Redes de Segurança/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Drenagem/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Laparotomia/mortalidade , Abscesso Hepático Piogênico/etiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Estados Unidos/epidemiologia , Adulto Jovem
9.
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
10.
Br J Anaesth ; 124(1): 73-83, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31860444

RESUMO

BACKGROUND: Socioeconomic circumstances can influence access to healthcare, the standard of care provided, and a variety of outcomes. This study aimed to determine the association between crude and risk-adjusted 30-day mortality and socioeconomic group after emergency laparotomy, measure differences in meeting relevant perioperative standards of care, and investigate whether variation in hospital structure or process could explain any difference in mortality between socioeconomic groups. METHODS: This was an observational study of 58 790 patients, with data prospectively collected for the National Emergency Laparotomy Audit in 178 National Health Service hospitals in England between December 1, 2013 and November 31, 2016, linked with national administrative databases. The socioeconomic group was determined according to the Index of Multiple Deprivation quintile of each patient's usual place of residence. RESULTS: Overall, the crude 30-day mortality was 10.3%, with differences between the most-deprived (11.2%) and least-deprived (9.8%) quintiles (P<0.001). The more-deprived patients were more likely to have multiple comorbidities, were more acutely unwell at the time of surgery, and required a more-urgent surgery. After risk adjustment, the patients in the most-deprived quintile were at significantly higher risk of death compared with all other quintiles (adjusted odds ratio [95% confidence interval]: Q1 [most deprived]: reference; Q2: 0.83 [0.76-0.92]; Q3: 0.84 [0.76-0.92]; Q4: 0.87 [0.79-0.96]; Q5 [least deprived]: 0.77 [0.70-0.86]). We found no evidence that differences in hospital-level structure or patient-level performance in standards of care explained this association. CONCLUSIONS: More-deprived patients have higher crude and risk-adjusted 30-day mortality after emergency laparotomy, but this is not explained by differences in the standards of care recorded within the National Emergency Laparotomy Audit.


Assuntos
Serviços Médicos de Emergência , Laparotomia/mortalidade , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/mortalidade , Fatores Socioeconômicos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Inglaterra/epidemiologia , Feminino , Hospitais/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória/economia , Assistência Perioperatória/normas , Pobreza , Risco Ajustado , Medicina Estatal , Adulto Jovem
12.
Rev. argent. coloproctología ; 30(4): 104-113, dic. 2019. ilus, tab, graf
Artigo em Espanhol | LILACS | ID: biblio-1096799

RESUMO

Introducción: Los pacientes que se presentan con cuadros de peritonitis de origen diverticular (estadios Hinchey III o IV) en un contexto de sepsis severa con inestabilidad hemodinámica (shock séptico) la realización de anastomosis primaria presenta una alta tasa de dehiscencia anastomótica y mortalidad operatoria, aconsejándose la realización de una resección y abocamiento a la manera de Hartmann. Sin embargo, la alta tasa de complicaciones relacionadas a la confección del ostoma, la complejidad de la cirugía de restauración del tránsito intestinal, asociado a que entre el 40 % y el 60 % de los Hartmann no se reconstruyen, ha estimulado a que se intenten otras variables de resolución para esta compleja y grave patología. Diversas publicaciones en los últimos años han propuesto la táctica de "cirugía del control del daño" con el objeto de disminuir la morbimortalidad de estos gravísimos cuadros sépticos y a su vez reducir la tasa de ostomías. El objetivo de este trabajo es presentar nuestra experiencia inicial con esta modalidad de manejo de la peritonitis diverticular Hinchey III/IV sepsis severa e inestabilidad hemodinámica (shock séptico) y realizar una revisión bibliográfica del tema. Material y método: Estudio observacional, descriptivo, de series de casos. Entre noviembre de 2015 y diciembre de 2016. Servicio de coloproctología del complejo médico hospitalario Churruca-Visca de la ciudad de Buenos Aires y práctica privada de los autores. Se utilizó la técnica de laparotomía abreviada y cierre temporal del abdomen mediante un sistema de presión negativa. Resultados: En el periodo descripto se operaron 17 pacientes con peritonitis generalizada purulenta o fecal de origen diverticular. Catorce casos fueron Hinchey III (82,36%) y 3 casos Hinchey IV (17,64%). En 3 casos se observó inestabilidad hemodinámica en el preoperatorio o intraoperatorio. Todos ellos correspondientes al estadio IV de Hinchey. Se describen los 3 casos tratados mediante esta táctica quirúrgica. Discusión: La alta tasa de morbimortalidad de este subgrupo de pacientes incentivó a diversos grupos quirúrgicos a implementar la técnica de control del daño, permitiendo de esta manera estabilizar a los pacientes hemodinámicamente y en un segundo tiempo evaluar la reconstrucción del tránsito intestinal. En concordancia con estas publicaciones, dos de nuestros pacientes operados con esta estrategia, pudieron ser anastomosados luego del segundo lavado abdominal. Conclusión: En pacientes con peritonitis diverticular severa asociado a shock séptico el concepto de laparotomía abreviada con control inicial del foco séptico, cierre temporal del abdomen con sistema de presión negativa y posterior evaluación de la reconstrucción del tránsito intestinal, es muy alentador. Permitiendo una disminución de la morbimortalidad como así también del número de ostomías. (AU)


Introduction: Patients presenting with diverticular peritonitis (Hinchey III or IV stages) in a context of severe sepsis with hemodynamic instability (septic shock), performing primary anastomosis has a high rate of dehiscence anastomotic and operative mortality, advising the realization of a resection and ostoma in the manner of Hartmann. However, the high rate of complications related to performing of ostoma, the complexity of intestinal transit restoration surgery, associated with the 40% to 60% of Hartmann reversal not performed, has encouraged other variables to be attempted resolution for this complex and serious pathology. Several publications in recent years have proposed the tactic of "damage control surgery" in order to reduce the morbidity of these serious septic charts while reducing the rate of ostomies. The objective of this study is to present our initial experience with this modality of management of the diverticular peritonitis Hinchey III/IV severe sepsis and hemodynamic instability (septic shock) and to carry out a bibliographic review of the subject. Material and method: Observational, descriptive study of case series. Between November 2015 and December 2016. Coloproctology service of the Churruca-Visca hospital medical complex in the city of Buenos Aires and private practice of the authors. The technique of abbreviated laparotomy and temporary closure of the abdomen was used by a negative pressure system. Results: In the period described, 17 patients with generalized purulent or fecal peritonitis of diverticular origin were operated. Fourteen cases were Hinchey III (82.36%) and 3 cases Hinchey IV (17.64%).In 3 cases, hemodynamic instability was observed in the preoperative or intraoperative period. all of them corresponding to Hinchey's Stage IV. The 3 cases treated using this surgical tactic are described. Discussion: The high morbidity rate of this subgroup of patients encouraged various surgical groups to implement the damage control technique, thus allowing patients to stabilize hemodynamically and in a second time evaluate reconstruction intestinal transit. In line with these publications, two of our patients operated on with this strategy could be anastomosated after the second abdominal wash. Conclusion: In patients with severe diverticular peritonitis associated with septic shock, the concept of abbreviated laparotomy with initial control of the septic focus, temporary closure of the abdomen with negative pressure system and subsequent evaluation of transit reconstruction intestinal, it's encouraging. Allowing a decrease in morbidity as well as the number of ostomies. (AU)


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Peritonite/cirurgia , Choque Séptico , Doença Diverticular do Colo/cirurgia , Tratamento de Ferimentos com Pressão Negativa , Laparotomia/métodos , Peritonite/etiologia , Reoperação , Lavagem Peritoneal , Colostomia/métodos , Colostomia/mortalidade , Doença Aguda , Epidemiologia Descritiva , Sepse , Doença Diverticular do Colo/complicações , Técnicas de Fechamento de Ferimentos Abdominais , Laparotomia/mortalidade
13.
Int J Surg ; 72: 235-240, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31765848

RESUMO

BACKGROUND: The objective of this study was to analyze outcomes and determine independent predictors of subsequent reoperation following emergency laparotomy (EL). MATERIALS AND METHODS: Patients undergoing EL (n = 854) from 2012 to 2018 at our institution were retrospectively assessed. Postoperative complications, in-hospital mortality and predictive factors were assessed. RESULTS: Among the studied patients, 307 (35.9) required subsequent reoperation, and 547 (64.1%) did not. The mean number of surgeries was 2.02 ± 1.54, with a median of 2 (range 1-10). Viscus organ perforation had the highest reoperation rate (25.6%), followed by hemorrhage (16.1%), anastomotic leakage (15.4%), mesenteric ischemia (14.9%), and bowel obstruction (11.9%). The incidence of postoperative complications was higher in reoperated patients (100%) than in non-reoperated patients (58.9%). There were 305 deaths, with an overall in-hospital mortality rate of 35.7%; 175 (57%) occurred in the reoperated group, and 130 (23.8%) occurred in the non-reoperated group. In multivariate regression (N = 854), an American Society of Anesthesiologists (ASA) class of 3 or above (OR, 4.27; 95% CI, 2.54-7.18), coexisting liver cirrhosis of Child grade B or above (OR, 2.50; 95% CI, 1.46-4.29), coexisting cardiac arrhythmia (OR, 1.59; 95% CI, 1.10-2.30), and steroid use (OR, 1.95; 95% CI, 1.01-3.77) strongly predicted reoperation. CONCLUSION: Our data showed notably high mortality due to subsequent reoperation, and there was a steady increase in mortality as the number of reoperations increased. A high ASA class, liver cirrhosis, cardiac arrhythmia and steroid use were independently associated with the risk of subsequent reoperation.


Assuntos
Emergências , Mortalidade Hospitalar , Laparotomia/mortalidade , Complicações Pós-Operatórias/epidemiologia , Reoperação , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reoperação/mortalidade , Estudos Retrospectivos
14.
Clin Med (Lond) ; 19(6): 454-457, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31732584

RESUMO

More than 1.53 million adults undergo inpatient surgery in the UK NHS. Patients undergoing emergency abdominal surgery have a much greater risk of death than patients admitted for elective surgery. Widespread variations in key standards of care between hospitals exist and are associated with differences in mortality rates.Recently there have been three large-scale initiatives to improve quality of care for emergency laparotomy patients: the National Emergency Laparotomy Audit, the enhanced perioperative care for high-risk patients trial and the Emergency Laparotomy Collaborative. Here we provide a critical review of what we currently know about the use of structured methods for improving the quality of healthcare services, with reference to the three initiatives. We find that using structured methods to improve care is the hallmark of quality improvement but attention must too be paid to the context in which these methods are used.


Assuntos
Serviços Médicos de Emergência/normas , Laparotomia , Assistência Perioperatória , Melhoria de Qualidade , Humanos , Laparotomia/mortalidade , Laparotomia/normas , Assistência Perioperatória/mortalidade , Assistência Perioperatória/normas , Reino Unido
15.
Transplant Proc ; 51(9): 2977-2980, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31607626

RESUMO

AIM: We aimed to analyze the risk factors for early surgical complications requiring relaparotomy and the related impact on overall survival (OS) in HIV-infected patients submitted to liver transplantation. METHODS: We performed a retrospective study on a nationwide multicenter cohort of 157 HIV-infected patients submitted to liver transplantation in 6 Italian transplant units between 2004 to 2014. RESULTS: The median preoperative model for end-stage liver disease score was 18 (interquartile range 12-26.5). An early relaparotomy was performed in 24.8% of patients, and the underlying clinical causes were biliary leak (8.2%), bleeding (8.2%), intestinal perforation (4.5%), and suspected vascular complications (3.8%). The OS at 1, 3, and 5 years was 74.3%, 68.0%, and 60.0%, respectively, and an early relaparotomy was not a prognostic factor itself, but an increasing number of relaparotomies was associated with decreased survival (hazard ratio = 1.40, 95% confidence interval [CI] 1.07-1.81, P = .01). In the multivariate analysis, preoperative refractory ascites (odds ratio 3.32, 95% CI 1.18-6.47, P = .02) and Roux-en-Y choledochojejunostomy reconstruction (odds ratio 12.712, 95% CI 2.47-65.38, P ≤ .01) were identified as significant risk factors for early relaparotomy. CONCLUSIONS: In HIV-infected liver transplant recipients, an increasing number of early relaparotomies due to surgical complications did negatively affect the OS. Preoperative refractory ascites reflecting a severe portal hypertension and a difficult biliary tract reconstruction requiring a Roux-en-Y choledochojejunostomy were associated with an increased risk of early relaparotomy.


Assuntos
Infecções por HIV/complicações , Transplante de Fígado , Complicações Pós-Operatórias/cirurgia , Reoperação/mortalidade , Adulto , Feminino , Humanos , Laparotomia/mortalidade , Transplante de Fígado/efeitos adversos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco
18.
Surgery ; 166(4): 623-631, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31326190

RESUMO

BACKGROUND: Previous evaluations of the oncologic efficacy of minimally invasive approaches to total gastrectomy in gastric adenocarcinoma have been limited by sample size and duration of follow-up. METHODS: We queried the National Cancer Database to identify patients undergoing robotic and laparoscopic or open total gastrectomy for gastric adenocarcinoma between 2010 and 2015. Propensity score matching was used to adjust for patient, tumor, and treating facility factors. Kaplan-Meier survival functions were used to compare overall survival. Secondary outcomes included margin status, lymph node sampling, mortality, readmission, and length of stay. RESULTS: In the study, 3,213 (72.2%) patients underwent open total gastrectomy; 1,238 (27.8%) minimally invasive total gastrectomy. Patients undergoing minimally invasive total gastrectomy were more likely to be treated at academic (49.5% vs 57.8%, P < .05) and high-volume centers (21.6% vs 28.4%, P < .05). Propensity score matching yielded 1,238 open and 1,238 minimally invasive well-matched total gastrectomies. Minimally invasive was associated with a decreased median length of stay (10 vs 9 days; P < .01). Rates of positive surgical margins, 30-day readmission, 90-day mortality and overall survival were identical between matched cohorts (P > .1). CONCLUSION: Minimally invasive approaches to total gastrectomy provide perioperative oncologic outcomes and overall survival rates that are identical to those for open total gastrectomy but are associated with reduced length of stay.


Assuntos
Adenocarcinoma/cirurgia , Gastrectomia/métodos , Laparoscopia/métodos , Tempo de Internação/estatística & dados numéricos , Neoplasias Gástricas/cirurgia , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Adulto , Idoso , Estudos de Coortes , Bases de Dados Factuais , Intervalo Livre de Doença , Feminino , Gastrectomia/efeitos adversos , Gastrectomia/mortalidade , Humanos , Estimativa de Kaplan-Meier , Laparoscopia/mortalidade , Laparotomia/métodos , Laparotomia/mortalidade , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/mortalidade , Invasividade Neoplásica/patologia , Estadiamento de Neoplasias , Pontuação de Propensão , Estudos Retrospectivos , Medição de Risco , Procedimentos Cirúrgicos Robóticos/métodos , Procedimentos Cirúrgicos Robóticos/mortalidade , Neoplasias Gástricas/mortalidade , Neoplasias Gástricas/patologia , Análise de Sobrevida
20.
J Crit Care ; 53: 253-257, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31301640

RESUMO

PURPOSE: There is a paucity of literature to support undertaking emergency laparotomy when indicated in patients supported on ECMO. Our study aims to identify the prevalence, outcomes and complications of this high risk surgery at a large ECMO centre. MATERIALS AND METHODS: A single centre, retrospective, observational cohort study of 355 patients admitted to a university teaching hospital Severe Respiratory Failure service between December 2011 and January 2017. RESULTS: The prevalence of emergency laparotomy in patients on ECMO was 3.7%. These patients had significantly higher SOFA and APACHE II scores compared to similar patients not requiring laparotomy. There was no difference in the duration of ECMO or intensive care unit (ICU) stay post decannulation between the two groups. 31% of laparotomy patients survived to hospital discharge. Major haemorrhage was uncommon, however emergency change of ECMO oxygenator was commonly required. CONCLUSION: Survival to hospital discharge is possible following emergency laparotomy on ECMO, however the mortality is higher than for those patients not requiring laparotomy, this likely reflects the severity of underlying organ failure rather than the surgery itself. Our service's collocation with a general surgical service has made this development in care possible. ECMO service planning should consider general surgical provision.


Assuntos
Oxigenação por Membrana Extracorpórea/mortalidade , Laparotomia/mortalidade , Insuficiência Respiratória/mortalidade , Adulto , Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/mortalidade , Feminino , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Alta do Paciente/estatística & dados numéricos , Insuficiência Respiratória/terapia , Estudos Retrospectivos
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