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1.
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
3.
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
5.
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
7.
Br J Hosp Med (Lond) ; 80(6): 343-347, 2019 Jun 02.
Artigo em Inglês | MEDLINE | ID: mdl-31180764

RESUMO

PURPOSE: Predicting perioperative morbidity and mortality can be achieved by several risk predicting algorithms. In the UK, the National Emergency Laparotomy Audit, mandated for all patients undergoing emergency laparotomy, uses pPOSSUM as its risk prediction tool. However, there is no literature reporting the inter-operator variability in calculating the score. Inter-rater variability was assessed based on 10 real general surgical cases that went on to have an emergency laparotomy. METHODS: Forty clinicians, 10 each of registrars and consultants in anaesthetics and general surgery, were asked to calculate the pPOSSUM based on the clinical information typically available at the time of making the decision to proceed to emergency laparotomy for the same 10 National Emergency Laparotomy Audit cases. All participants were surveyed to assess their understanding and use of the pPOSSUM score. RESULTS: More than 80% of respondents stated that they use pPOSSUM in daily clinical practice. There was variability in the calculated scores between the groups analysed. Two subgroups were evident: one in which the calculated mean pPOSSUM was similar between participants but did not reflect the true value, and the other which was accurate, but demonstrated high inter-rater variability. CONCLUSIONS: This is the first study to investigate inter-operator variability in pPOSSUM scores. Previous reports on the validity of the tool fail to account for subjective variation. At a time where pPOSSUM has become a routine part of clinical practice, this variability needs to be accounted for and taken into consideration in the decision-making process.


Assuntos
Mortalidade Hospitalar/tendências , Laparotomia/mortalidade , Período Perioperatório/estatística & dados numéricos , Fatores Etários , Antitrombina III , Pressão Sanguínea , Testes Diagnósticos de Rotina , Humanos , Variações Dependentes do Observador , Reprodutibilidade dos Testes , Medição de Risco , Fatores de Risco , Reino Unido
8.
Ann R Coll Surg Engl ; 101(5): 366-372, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31042429

RESUMO

INTRODUCTION: The 'weekend effect' describes variation in outcomes of patients treated over the weekend compared with those treated during weekdays. This study examines whether a weekend effect exists for patients who undergo emergency laparotomy. MATERIALS AND METHODS: Data entered into the National Emergency Laparotomy Audit between 2014 and 2017 at four NHS trusts in England and Wales were analysed. Patients were grouped into those admitted on weekdays and those on weekends (Friday 5pm to Monday 8am). Patient factors, markers of quality of care and patient outcomes were compared. Secondary analysis was performed according to the day of surgery. RESULTS: After exclusion of patients who underwent laparotomy more than one week after admission to hospital, a total of 1717 patients (1138 patients admitted on weekdays and 579 admitted on weekends) were analysed. Age, preoperative lactate and P-POSSUM scores were not significantly different between the two groups. Time from admission to consultant review, decision to operate, commencement of antibiotics and theatre were not significantly different. Grades of operating surgeon were also similar in both groups. Inpatient 60-day mortality was 12.5% on weekdays and 12.8% on weekends (P = 0.878). Median length of postoperative stay was 12 days in both groups. When analysed according to day of surgery, only number of hours from admission to antibiotics (12.8 weekday vs 9.4 weekend, P = 0.046) and number of hours to theatre (26.5 weekday vs 24.1 hours weekend, P = 0.020) were significantly different. DISCUSSION: Quality of care and clinical outcomes for patients undergoing emergency laparotomy during the weekend are not significantly different to those carried out during weekdays.


Assuntos
Plantão Médico/normas , Mortalidade Hospitalar , Laparotomia/mortalidade , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Plantão Médico/estatística & dados numéricos , Idoso , Auditoria Clínica , Emergências , Inglaterra , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Medicina Estatal/normas , País de Gales
9.
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
10.
Pediatr Int ; 61(6): 601-605, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30958615

RESUMO

BACKGROUND: No data are available on the prevalence of mortality in neonates after major surgery such as laparotomy in China. METHODS: In a tertiary general hospital, 142 newborns who underwent laparotomy for a variety of surgical conditions in the past 6 years were included in this study in Beijing, China. Pre-, intra-, and postoperative variables potentially predictive of postoperative 30 day mortality were collected and compared between the surviving and deceased newborns. RESULTS: Death ≤30 days after laparotomy occurred in 19 of 142 newborns (13.4%) during the study period. Newborns diagnosed with necrotizing enterocolitis (NEC) had the worst outcome (OR, 11.4). Significantly more neonates in the 30 day death group were intubated preoperatively (52.6%) compared with the survival group (19.5%; OR, 10.0). Base excess ≤-10 mmol/L immediately after laparotomy was associated with negative prognosis in the early postoperative period (OR, 11.2). CONCLUSION: The mortality rate of newborns ≤30 days after laparotomy was 13.4% in a Chinese tertiary general hospital in the past 6 years. The factors associated with early death were NEC, preoperative intubation with mechanical ventilation, and postoperative immediate base excess ≤-10 mmol/L.


Assuntos
Doenças do Recém-Nascido/cirurgia , Laparotomia/mortalidade , China , Feminino , Humanos , Recém-Nascido , Doenças do Recém-Nascido/diagnóstico , Doenças do Recém-Nascido/mortalidade , Modelos Logísticos , Masculino , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Centros de Atenção Terciária
11.
Br J Surg ; 106(7): 940-948, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31021420

RESUMO

BACKGROUND: Approximately 30 000 emergency laparotomies are performed each year in England and Wales. Patients with pathology of the gastrointestinal tract requiring emergency laparotomy are managed by general surgeons with an elective special interest focused on either the upper or lower gastrointestinal tract. This study investigated the impact of special interest on mortality after emergency laparotomy. METHODS: Adult patients having emergency laparotomy with either colorectal or gastroduodenal pathology were identified from the National Emergency Laparotomy Audit database and grouped according to operative procedure. Outcomes included all-cause 30-day mortality, length of hospital stay and return to theatre. Logistic and Poisson regression were used to analyse the association between consultant special interest and the three outcomes. RESULTS: A total of 33 819 patients (28 546 colorectal, 5273 upper gastrointestinal (UGI)) were included. Patients who had colorectal procedures performed by a consultant without a special interest in colorectal surgery had an increased adjusted 30-day mortality risk (odds ratio (OR) 1·23, 95 per cent c.i. 1·13 to 1·33). Return to theatre also increased in this group (OR 1·13, 1·05 to 1·20). UGI procedures performed by non-UGI special interest surgeons carried an increased adjusted risk of 30-day mortality (OR 1·24, 1·02 to 1·53). The risk of return to theatre was not increased (OR 0·89, 0·70 to 1·12). CONCLUSION: Emergency laparotomy performed by a surgeon whose special interest is not in the area of the pathology carries an increased risk of death at 30 days. This finding potentially has significant implications for emergency service configuration, training and workforce provision, and should stimulate discussion among all stakeholders.


Assuntos
Competência Clínica/estatística & dados numéricos , Gastroenterologia , Cirurgia Geral , Laparotomia/mortalidade , Especialização , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Emergências , Inglaterra/epidemiologia , Feminino , Humanos , Modelos Logísticos , Masculino , Auditoria Médica , Pessoa de Meia-Idade , Razão de Chances , Distribuição de Poisson , Estudos Prospectivos , Fatores de Risco , País de Gales/epidemiologia , Adulto Jovem
12.
J Trauma Acute Care Surg ; 87(2): 282-288, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30939584

RESUMO

BACKGROUND: In patients for whom surgical equipoise exists for damage control laparotomy (DCL) and definitive laparotomy (DEF), the effect of DCL and its associated resource utilization are unknown. We hypothesized that DEF would be associated with fewer abdominal complications and less resource utilization. METHODS: In 2016, six US Level I trauma centers performed a yearlong, prospective, quality improvement project with the primary aim to safely decrease the use of DCL. From this cohort of patients undergoing emergent trauma laparotomy, those who underwent DCL but were judged by majority faculty vote at each center to have been candidates for potential DEF (pDEF) were prospectively identified. These pDEF patients were matched 1:1 using propensity scoring to the DEF patients. The primary outcome was the incidence of major abdominal complications (MAC). Deaths within 5 days were excluded. Outcomes were assessed using both Bayesian generalized linear modeling and negative binomial regression. RESULTS: Eight hundred seventy-two total patients were enrolled, 639 (73%) DEF and 209 (24%) DCL. Of the 209 DCLs, 44 survived 5 days and were judged to be patients who could have safely been closed at the primary laparotomy. Thirty-nine pDEF patients were matched to 39 DEF patients. There were no differences in demographics, mechanism of injury, Injury Severity Score, prehospital/emergency department/operating room vital signs, laboratory values, resuscitation, or procedures performed during laparotomy. There was no difference in MAC between the two groups (31% DEF vs. 21% pDEF, relative risk 0.99, 95% credible interval 0.60-1.54, posterior probability 56%). Definitive laparotomy was associated with a 72%, 77%, and 72% posterior probability of more hospital-free, intensive care unit-free, and ventilator-free days, respectively. CONCLUSION: In patients for whom surgeons have equipoise for DCL versus definitive surgery, definitive abdominal closure was associated with a similar probability of MAC, but a high probability of fewer hospital-free, intensive care unit-free, and ventilator-free days. LEVEL OF EVIDENCE: Therapeutic/care management, level III.


Assuntos
Laparotomia/métodos , Tempo de Internação/estatística & dados numéricos , Ferimentos e Lesões/cirurgia , Adulto , Teorema de Bayes , Feminino , Humanos , Laparotomia/efeitos adversos , Laparotomia/mortalidade , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Estudos Prospectivos , Ferimentos e Lesões/complicações , Ferimentos e Lesões/mortalidade
13.
Khirurgiia (Mosk) ; (1): 65-69, 2019.
Artigo em Russo | MEDLINE | ID: mdl-30789611

RESUMO

Since the creation of the intensive care unit, active scientific work has been carried out. Pre- and postoperative management of patients undergoing thoracoabdominal surgery was one of the main directions of this work. Diagnostic approaches, preventive measures and standards of treating patients after thoracoabdominal surgery have been developed. The results of this work allowed to reduce significantly contraindications for surgical interventions in these patients, to perform radical operations in patients with severe concomitant diseases, to reduce the incidence of postoperative complications and mortality.


Assuntos
Cuidados Críticos , Laparotomia , Procedimentos Cirúrgicos Torácicos , Cuidados Críticos/métodos , Cuidados Críticos/normas , Humanos , Unidades de Terapia Intensiva , Laparotomia/efeitos adversos , Laparotomia/métodos , Laparotomia/mortalidade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Procedimentos Cirúrgicos Torácicos/efeitos adversos , Procedimentos Cirúrgicos Torácicos/métodos , Procedimentos Cirúrgicos Torácicos/mortalidade
14.
Int J Surg ; 62: 67-73, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30673595

RESUMO

BACKGROUND: General surgeons have become increasingly subspecialised in their elective practice. Emergency laparotomies, however, are performed by a range of subspecialists who may or may not have an interest in the affected area of gastrointestinal tract. This retrospective cohort study evaluates the impact of surgical subspecialisation on patient outcomes following emergency laparotomy. METHODS: Data was collected for patients who underwent an emergency abdominal procedure on the gastrointestinal tract in the North of England from 2001 to 2016. This included demographics, co-morbidities, diagnoses and procedures undertaken. Patients were grouped according to consultants' subspecialist interest. The primary outcome of interest was 30-day postoperative mortality. RESULTS: 24,291 emergency laparotomies were performed with an associated 30-day postoperative mortality of 11.7%. Laparotomies undertaken by upper gastrointestinal (UGI) or colorectal surgeons have significantly lower mortality (10.1%) when compared with other subspecialities (13.5%). More specifically, mortality was decreased for UGI (7.9% vs. 12.9%) and colorectal procedures (10.9% vs. 14.2%) when performed by surgeons with a specialist interest in the relevant area of the gastrointestinal tract (both p < 0.001). The utilisation of laparoscopic surgery is higher, in both UGI (21.8% vs. 9.0%) and colorectal procedures (7.2% vs. 3.5%), when the causative pathology is relevant to the surgeon's subspeciality (both p < 0.001). CONCLUSION: Mortality following emergency laparotomy is improved when performed under the care of gastrointestinal surgeons. Both UGI and colorectal emergency procedures have improved outcomes, with lower mortality and higher rates of laparoscopy, when under the care of a surgeon with a subspecialist interest in the affected area of the gastrointestinal tract.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/normas , Especialização/normas , Adulto , Idoso , Competência Clínica , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Procedimentos Cirúrgicos do Sistema Digestório/mortalidade , Emergências , Inglaterra/epidemiologia , Feminino , Humanos , Laparoscopia/métodos , Laparotomia/métodos , Laparotomia/mortalidade , Laparotomia/normas , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Especialização/estatística & dados numéricos , Especialidades Cirúrgicas/normas , Especialidades Cirúrgicas/estatística & dados numéricos , Cirurgiões/normas , Resultado do Tratamento
15.
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
16.
Asian J Surg ; 42(1): 338-342, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30316666

RESUMO

OBJECTIVE: Emergency surgery is a risk factor for mortality in cirrhotic patients. Portal hypertension is an essential feature of decompensated cirrhosis. This study aimed to assess the value of portal venous pressure (PVP) measurement in prediction of 1-month mortality in cirrhotic patients undergoing emergency laparotomy. METHODS: This prospective study included 121 adults with liver cirrhosis subjected to an emergency laparotomy. Child-Turcotte-Pugh (CTP) score and model for end-stage liver disease (MELD) score were used for preoperative patient evaluation. PVP was measured directly at the beginning of surgery. Portal hypertension (PHT) is diagnosed when PVP is greater than 12 mmHg. The primary outcome measure was the risk of mortality within one month after surgery. RESULTS: PVP ranged from 5 to 27 mmHg; 82 patients (67.8%) had PHT. Fifty-five patients (45.5%) died within 1 month. Mortality was significantly associated with increasing CTP Class, MELD score and PHT (p < 0.001 for all). PHT predicts mortality with a sensitivity of 83.6% and specificity of 92.8%. PHT was the only independent predictor of mortality (OR: 23.0, 95%CI: 8.9-59.4). CONCLUSION: In patients with liver cirrhosis, emergency laparotomy carries a substantial risk of mortality within one month. Portal hypertension is an independent predictor of risk of mortality in these patients.


Assuntos
Determinação da Pressão Arterial , Serviços Médicos de Emergência , Hipertensão Portal/diagnóstico , Hipertensão Portal/mortalidade , Laparotomia/mortalidade , Cirrose Hepática/mortalidade , Cirrose Hepática/cirurgia , Pressão na Veia Porta , Adolescente , Adulto , Idoso , Emergências , Feminino , Humanos , Hipertensão Portal/etiologia , Cirrose Hepática/complicações , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Curva ROC , Fatores de Risco , Sensibilidade e Especificidade , Fatores de Tempo , Adulto Jovem
17.
Surg Oncol ; 27(4): 619-624, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30449481

RESUMO

BACKGROUND: To describe, in patients with resectable pancreatic ductal adenocarcinoma (PDAC), the laparotomy findings, treatments and outcomes before (period 1) and after 2010 (period 2). METHODS: From 2000 to 2015, patients newly diagnosed with resectable PDAC at Paoli-Calmettes Institute, France, were evaluated. Survival was examined using the Kaplan-Meier method, and statistical comparisons were conducted using log rank tests. RESULTS: Among 1175 patients diagnosed with pancreatic mass, 164 underwent laparotomy with an intention of pancreatic resection. Some of them did not undergo pancreatic resection due to peroperative discovery of advanced disease. For those who were finally resected (n = 119), there were fewer pancreaticoduodenectomies (p = 0.045), shorter operation times (p < 0.01), lower mortality rates (p = 0.02), more advanced-stage tumors (T3), more frequent perineural invasion and R1 resection in period 2. This group had a trend of better outcomes after 2010 (51 months vs. 36 months (p = 0.065)). CONCLUSION: Improvement in surgical procedures and postoperative management led to prolonged survival of those who underwent surgery for resectable pancreatic cancer since 2010, despite a higher frequency of advanced tumors at the diagnosis in our institution.


Assuntos
Adenocarcinoma/mortalidade , Carcinoma Ductal Pancreático/mortalidade , Laparotomia/mortalidade , Pancreatectomia/mortalidade , Neoplasias Pancreáticas/mortalidade , Adenocarcinoma/patologia , Adenocarcinoma/cirurgia , Idoso , Carcinoma Ductal Pancreático/patologia , Carcinoma Ductal Pancreático/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Neoplasias Pancreáticas/patologia , Neoplasias Pancreáticas/cirurgia , Prognóstico , Taxa de Sobrevida , Centros de Atenção Terciária
18.
Cochrane Database Syst Rev ; 10: CD006655, 2018 10 31.
Artigo em Inglês | MEDLINE | ID: mdl-30379327

RESUMO

BACKGROUND: This is an update of a previous Cochrane Review published in 2012, Issue 9.Surgery for endometrial cancer (hysterectomy with removal of both fallopian tubes and ovaries) is performed through laparotomy. It has been suggested that the laparoscopic approach is associated with a reduction in operative morbidity. Over the last two decades there has been a steady increase of the use of laparoscopy for endometrial cancer. This review investigated the evidence of benefits and harms of laparoscopic surgery compared with laparotomy for presumed early stage endometrial cancer. OBJECTIVES: To compare overall survival (OS) and disease free survival (DFS) for laparoscopic surgery versus laparotomy in women with presumed early stage endometrial cancer. SEARCH METHODS: For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 5) in the Cochrane Library, MEDLINE via Ovid (April 2012 to June 2018) and Embase via Ovid (April 2012 to June 2018). We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies. The trial registers included NHMRC Clinical Trials Register, UKCCCR Register of Cancer Trials, Meta-Register and Physician Data Query Protocol. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing laparoscopy and laparotomy for early stage endometrial cancer. DATA COLLECTION AND ANALYSIS: We independently abstracted data and assessed risk of bias. We used hazard ratios (HRs) for OS and recurrence free survival (RFS), risk ratios (RR) for severe adverse events and mean differences (MD) for continuous outcomes in women who received laparoscopy or laparotomy with 9% confidence intervals (CI). These were pooled in random-effects meta-analyses. MAIN RESULTS: We identified one new study in this update of the review. The review contains nine RCTs comparing laparoscopy with laparotomy for the surgical management of early stage endometrial cancer.All nine studies met the inclusion criteria and assessed 4389 women at the end of the studies. Six studies assessing 3993 participants with early stage endometrial cancer found no significant difference in the risk of death between women who underwent laparoscopy and women who underwent laparotomy (HR 1.04, 95% 0.86 to 1.25; moderate-certainty evidence) and five studies assessing 3710 participants found no significant difference in the risk of recurrence between the laparoscopy and laparotomy groups (HR 1.14, 95% CI 0.90 to 1.43; moderate-certainty evidence). There was no significant difference in the rate of perioperative death; women requiring a blood transfusion; and bladder, ureteric, bowel and vascular injury. However, one meta-analysis of three studies found that women in the laparoscopy group lost significantly less blood than women in the laparotomy group (MD -106.82 mL, 95% CI -141.59 to -72.06; low-certainty evidence). A further meta-analysis of two studies, which assessed 3344 women and included one very large trial of over 2500 participants, found that there was no clinical difference in the risk of severe postoperative complications in women in the laparoscopy and laparotomy groups (RR 0.78, 95% CI 0.44 to 1.38). Most studies were at moderate risk of bias. All nine studies reported hospital stay and results showed that on average, laparoscopy was associated with a significantly shorter hospital stay. AUTHORS' CONCLUSIONS: This review found low to moderate-certainty evidence to support the role of laparoscopy for the management of early endometrial cancer. For presumed early stage primary endometrioid adenocarcinoma of the endometrium, laparoscopy is associated with similar OS and DFS. Furthermore, laparoscopy is associated with reduced operative morbidity and hospital stay. There is no significant difference in severe postoperative morbidity between the two modalities.The certainty of evidence for OS and RFS was moderate and was downgraded for unclear risk of bias profiles and imprecision in effect estimates. However, most studies used adequate methods of sequence generation and concealment of allocation so studies were not prone to selection bias. Adverse event outcomes were downgraded for the same reasons and additionally for low event rates and low power thus these outcomes provided low-certainty evidence.


Assuntos
Neoplasias do Endométrio/cirurgia , Histerectomia/métodos , Laparoscopia/métodos , Laparotomia/métodos , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Intervalo Livre de Doença , Neoplasias do Endométrio/mortalidade , Neoplasias do Endométrio/patologia , Feminino , Humanos , Histerectomia/efeitos adversos , Histerectomia/mortalidade , Laparoscopia/efeitos adversos , Laparoscopia/mortalidade , Laparotomia/efeitos adversos , Laparotomia/mortalidade , Tempo de Internação , Recidiva Local de Neoplasia , Complicações Pós-Operatórias , Ensaios Clínicos Controlados Aleatórios como Assunto
19.
Implement Sci ; 13(1): 142, 2018 11 13.
Artigo em Inglês | MEDLINE | ID: mdl-30424818

RESUMO

BACKGROUND: Improving the quality and safety of perioperative care is a global priority. The Enhanced Peri-Operative Care for High-risk patients (EPOCH) trial was a stepped-wedge cluster randomised trial of a quality improvement (QI) programme to improve 90-day survival for patients undergoing emergency abdominal surgery in 93 hospitals in the UK National Health Service. METHODS: The aim of this process evaluation is to describe how the EPOCH intervention was planned, delivered and received, at both cluster and local hospital levels. The QI programme comprised of two interventions: a care pathway and a QI intervention to aid pathway implementation, focussed on stakeholder engagement, QI teamwork, data analysis and feedback and applying the model for improvement. Face-to-face training and online resources were provided to support senior clinicians in each hospital (QI leads) to lead improvement. For this evaluation, we collated programme activity data, administered an exit questionnaire to QI leads and collected ethnographic data in six hospitals. Qualitative data were analysed with thematic or comparative analysis; quantitative data were analysed using descriptive statistics. RESULTS: The EPOCH trial did not demonstrate any improvement in survival or length of hospital stay. Whilst the QI programme was delivered as planned at the cluster level, self-assessed intervention fidelity at the hospital level was variable. Seventy-seven of 93 hospitals responded to the exit questionnaire (60 from a single QI lead response on behalf of the team); 33 respondents described following the QI intervention closely (35%) and there were only 11 of 37 care pathway processes that > 50% of respondents reported attempting to improve. Analysis of qualitative data suggests QI leads were often attempting to deliver the intervention in challenging contexts: the social aspects of change such as engaging colleagues were identified as important but often difficult and clinicians frequently attempted to lead change with limited time or organisational resources. CONCLUSIONS: Significant organisational challenges faced by QI leads shaped their choice of pathway components to focus on and implementation approaches taken. Adaptation causing loss of intervention fidelity was therefore due to rational choices made by those implementing change within constrained contexts. Future large-scale QI programmes will need to focus on dedicating local time and resources to improvement as well as on training to develop QI capabilities. EPOCH TRIAL REGISTRATION: ISRCTN80682973 https://doi.org/10.1186/ISRCTN80682973 Registered 27 February 2014 and Lancet protocol 13PRT/7655.


Assuntos
Procedimentos Clínicos/normas , Laparotomia/normas , Assistência Perioperatória/normas , Melhoria de Qualidade/organização & administração , Procedimentos Clínicos/estatística & dados numéricos , Processos Grupais , Humanos , Capacitação em Serviço , Laparotomia/mortalidade , Tempo de Internação/estatística & dados numéricos , Equipe de Assistência ao Paciente , Readmissão do Paciente , Avaliação de Programas e Projetos de Saúde , Medicina Estatal , Reino Unido
20.
Br J Anaesth ; 121(6): 1346-1356, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30442263

RESUMO

BACKGROUND: Studies across healthcare systems have demonstrated between-hospital variation in survival after an emergency laparotomy. We postulate that this variation can be explained by differences in perioperative process delivery, underpinning organisational structures, and associated hospital characteristics. METHODS: We performed this nationwide, registry-based, prospective cohort study using data from the National Emergency Laparotomy Audit organisational and patient audit data sets. Outcome measures were all-cause 30- and 90-day postoperative mortality. We estimated adjusted odds ratios (ORs) for perioperative processes and organisational structures and characteristics by fitting multilevel logistic regression models. RESULTS: The cohort comprised 39 903 patients undergoing surgery at 185 hospitals. Controlling for case mix and clustering, a substantial proportion of between-hospital mortality variation was explained by differences in processes, infrastructure, and hospital characteristics. Perioperative care pathways [OR: 0.86; 95% confidence interval (CI): 0.76-0.96; and OR: 0.89; 95% CI: 0.81-0.99] and emergency surgical units (OR: 0.89; 95% CI: 0.80-0.99; and OR: 0.89; 95% CI: 0.81-0.98) were associated with reduced 30- and 90-day mortality, respectively. In contrast, infrequent consultant-delivered intraoperative care was associated with increased 30- and 90-day mortality (OR: 1.61; 95% CI: 1.01-2.56; and OR: 1.61; 95% CI: 1.08-2.39, respectively). Postoperative geriatric medicine review was associated with substantially lower mortality in older (≥70 yr) patients (OR: 0.35; 95% CI: 0.29-0.42; and OR: 0.64; 95% CI: 0.55-0.73, respectively). CONCLUSIONS: This multicentre study identified low-technology, readily implementable structures and processes that are associated with improved survival after an emergency laparotomy. Key components of pathways, perioperative medicine input, and specialist units require further investigation.


Assuntos
Emergências , Laparotomia/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multinível , Estudos Prospectivos , Adulto Jovem
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