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2.
Am Surg ; 85(9): 973-977, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31638509

RESUMO

Failure to rescue (FTR), defined as death after a major complication in surgical patients, is being used to measure outcomes for quality improvement. Major complications frequently occur in patients undergoing damage control laparotomy (DCL). No previous FTR studies have looked specifically into DCL patients. The aim of this study was to examine risk factors of FTR and identify potential areas for targeted quality improvement in DCL patients. A 10-year retrospective review of all consecutive adult trauma patients who underwent DCL at a Level I trauma center was performed. Demographic and clinical variables were examined for association with FTR. Multivariate regression analysis was performed to identify risk factors of FTR in DCL patients. A total of 199 DCL patients were analyzed. Overall DCL mortality observed was 11.1 per cent (n = 22/199) and overall FTR for the cohort was n = 16/199. FTR represented 72 per cent (n = 16/22) of the total mortality. The significantly increased risk of FTR was associated with older age (P = 0.027), lower initial Glasgow Coma Scale score (P = 0.037), more units of packed red blood cells (P = 0.028), and respiratory complications (P = 0.035). Renal and infectious complications did not significantly increase the risk of FTR in this population. FTR is an important benchmark of quality for trauma patients. This study elucidates potential initial characteristics and complications related to FTR in DCL patients. Efforts in achieving zero death from FTR can potentially improve overall mortality in this subset of patients. Future quality interventions to help minimize FTR should target these specific areas.


Assuntos
Falha da Terapia de Resgate , Laparotomia/efeitos adversos , Laparotomia/normas , Melhoria de Qualidade , Ferimentos e Lesões/cirurgia , Adulto , Fatores Etários , Transfusão de Eritrócitos , Feminino , Escala de Coma de Glasgow , Humanos , Masculino , Complicações Pós-Operatórias , Transtornos Respiratórios , Estudos Retrospectivos , Fatores de Risco , Centros de Traumatologia/normas , Estados Unidos
4.
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
5.
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
7.
World J Emerg Surg ; 13: 43, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30237824

RESUMO

Background: Damage control surgery has revolutionized trauma surgery. Use of damage control surgery allows for resuscitation and reversal of coagulopathy at the risk of loss of abdominal domain and intra-abdominal complications. Temporary abdominal closure is possible with multiple techniques, the choice of which may affect ability to achieve primary fascial closure and further complication. Methods: A retrospective analysis of all trauma patients requiring damage control laparotomy upon admission to an ACS-verified level one trauma center from 2011 to 2016 was performed. Demographic and clinical data including ability and time to attain primary fascial closure, as well as complication rates, were recorded. The primary outcome measure was ability to achieve primary fascial closure during initial hospitalization. Results: Two hundred and thirty-nine patients met criteria for inclusion. Primary skin closure (57.7%), ABThera™ VAC system (ABT) (15.1%), Bogota bag (BB) (25.1%), or a modified Barker's vacuum-packing (BVP) (2.1%) were used in the initial laparotomy. Patients receiving skin-only closure had significantly higher rates of primary fascial closure and lower hospital mortality, but also significantly lower mean lactate, base deficit, and requirement for massive transfusion. Between ABT or BB, use of ABT was associated with increased rates of fascial closure. Multivariate regression revealed primary skin closure to be significantly associated with primary fascial closure while BB was associated with failure to achieve fascial closure. Conclusions: Primary skin closure is a viable option in the initial management of the open abdomen, although these patients demonstrated less injury burden in our study. Use of vacuum-assisted dressings continues to be the preferred method for temporary abdominal closure in damage control surgery for trauma.


Assuntos
Abdome/cirurgia , Laparotomia/métodos , Laparotomia/normas , Resultado do Tratamento , Adulto , Alabama , Análise de Variância , Feminino , Humanos , Escala de Gravidade do Ferimento , Laparotomia/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Centros de Traumatologia/organização & administração , Centros de Traumatologia/estatística & dados numéricos
8.
Crit Care ; 22(1): 179, 2018 07 25.
Artigo em Inglês | MEDLINE | ID: mdl-30045753

RESUMO

BACKGROUND: Decompressive laparotomy has been advised as potential treatment for abdominal compartment syndrome (ACS) when medical management fails; yet, the effect on parameters of organ function differs markedly in the published literature. In this study, we sought to investigate the effect of decompressive laparotomy on intra-abdominal pressure and organ function in critically ill adult and pediatric patients with ACS, specifically focusing on hemodynamic, respiratory, and kidney function and outcome. METHODS: A systematic review and meta-analysis of the literature was performed. Articles reporting data on intra-abdominal pressure (IAP), hemodynamic (mean arterial pressures [MAP], central venous pressure [CVP], cardiac index [CI], heart rate [HR], systemic vascular resistance index [SVRI] and/or pulmonary capillary wedge pressure [PCWP]), respiratory (positive end-expiratory pressure [PEEP], peak inspiratory pressure [PIP] and/or ratio of partial pressure arterial oxygen and fraction of inspired oxygen [P/F ratio]), and/or urinary output (UO) following decompressive laparotomy were analyzed. RESULTS: A total of 15 articles were included; 3 included children only (aged 18 years or younger). Of the 286 patients who were included, 49.7% had primary ACS. The baseline mean IAP in adults decreased with an average of 18.2 ± 6.5 mmHg following decompression, from 31.7 ± 6.4 mmHg to 13.5 ± 3.0 mmHg. There was a decrease in HR (12.2 ± 9.5 beats/min; p = 0.04), CVP (4.6 ± 2.3 mmHg; p = 0.022), PCWP (5.8 ± 2.3 mmHg; p = 0.029), and PIP (10.1 ± 3.9 cmH2O; p < 0.001) and a mean increase in P/F ratio (70.4 ± 49.4; p < 0.001) and UO (95.3 ± 105.3 ml/h; p < 0.001). In children, there was a significant increase in MAP (20.0 ± 2.3 mmHg; p = 0.006), P/F ratio (238.2; p < 0.001), and UO (2.88 ± 0.64 ml/kg/h; p < 0.001) and a decrease in CVP (7 mmHg; p = 0.016) and PIP (9.9 cmH2O; p = 0.002). The overall mortality rate was 49.7% in adults and 60.8% in children following decompressive laparotomy. CONCLUSIONS: Decompressive laparotomy resulted in a significantly lower IAP and had beneficial effects on hemodynamic, respiratory, and renal parameters. Mortality after decompressive laparotomy remains high in both adults and children.


Assuntos
Hipertensão Intra-Abdominal/cirurgia , Laparotomia/métodos , Pressão Negativa da Região Corporal Inferior/métodos , Estado Terminal/terapia , Descompressão Cirúrgica/métodos , Descompressão Cirúrgica/normas , Humanos , Hipertensão Intra-Abdominal/classificação , Laparotomia/normas , Pressão Negativa da Região Corporal Inferior/normas , Escores de Disfunção Orgânica
10.
J Coll Physicians Surg Pak ; 28(2): 150-154, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29394976

RESUMO

OBJECTIVE: To find outcomes of emergency bowel surgery and review the processes involved in the care of these patients on the same template used in National Emergency Laparotomy Audit (NELA). STUDY DESIGN: An audit. PLACE AND DURATION OF STUDY: Surgery Department, The Aga Khan University Hospital, Karachi, from December 2013 to November 2014. METHODOLOGY: Patients undergone emergency bowel surgery during the review period were included. Demographic data, type of admission, ASA grade, urgency of surgery, P-POSSUM score, indication of surgery, length of stay and outcome was recorded. Data was then compared with the data published by NELA team in their first report. P-value for categorical variables was calculated using Chi-square tests. RESULTS: Although the patients were younger with nearly same spectrum of disease, the mortality rate was significantly more than reported in NELA (24% versus 11%, p=0.004). Comparison showed that care at AKUH was significantly lacking in terms of proper preoperative risk assessment and documentation, case booking to operating room timing, intraoperative goal directed fluid therapy using cardiac output monitoring, postoperative intensive care for highest risk patients and review of elderly patients by MCOP specialist. CONCLUSION: This study helped in understanding the deficiencies in the care of patients undergoing emergency bowel surgery and alarmingly poor outcomes in a very systematic manner. In view of results of this study, it is planned to do interventions in the deficient areas to improve care given to these patients and their outcomes with the limited resources of a developing country.


Assuntos
Emergências , Serviços Médicos de Emergência/normas , Intestinos/cirurgia , Laparotomia/mortalidade , Laparotomia/normas , Auditoria Médica , Adulto , Idoso , Serviços Médicos de Emergência/estatística & dados numéricos , Feminino , Humanos , Laparotomia/métodos , Laparotomia/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Padrões de Prática Médica , Estudos Retrospectivos , Medição de Risco , Resultado do Tratamento
11.
Cir Pediatr ; 30(3): 138-141, 2017 Jul 20.
Artigo em Espanhol | MEDLINE | ID: mdl-29043690

RESUMO

INTRODUCTION: Neonatal surgical wound infection occurs in almost 50% of neonatal procedures. It increases the rates of morbimortality in neonatal units. There is no guidelines about prevention of wound infection in neonatal surgery. We present our results after changing our behaviour in neonatal surgery. MATERIALS AND METHODS: Comparative study between 2 groups. In order to decrease wound infection at the end of the procedure gloves, covertures and surgical instruments were changed and saline and antiseptic solutions were used during laparotomy closing. Group P included procedures with these recommendations and Group NP without them. Age, weight, surgery, infection, length of stay, and mortality were analized between groups through a logistic regression model. RESULTS: Group P included 55 procedures in 32 patients, median weight 1,300 g (1,000-2,100), 19 median days of life (6-40), 5 postoperative wound problems (9%). Group NP included 26 procedures in 14 neonates, median weight 1,700 g (700-2,500), 20 median days of life (3-33), 14 wound problems (53.8%). We decrease the wound problems in our patients in 44.8% (p < 0.0001). Additionally, the protection provided by our recommendations was maintained after adjustment by weight, age and type of pathology (0.07) p= 0.000. CONCLUSIONS: Simple changes in during the procedures in neonatal surgery can reduce the appearance of wound infection and morbidity.


Assuntos
Laparotomia/métodos , Instrumentos Cirúrgicos/normas , Infecção da Ferida Cirúrgica/prevenção & controle , Fatores Etários , Luvas Cirúrgicas , Humanos , Lactente , Recém-Nascido , Laparotomia/efeitos adversos , Laparotomia/normas , Tempo de Internação , Modelos Logísticos , Estudos Retrospectivos , Fatores de Risco , Infecção da Ferida Cirúrgica/epidemiologia
12.
Sociol Health Illn ; 39(8): 1314-1329, 2017 11.
Artigo em Inglês | MEDLINE | ID: mdl-28639296

RESUMO

Care pathways are a prominent feature of efforts to improve healthcare quality, outcomes and accountability, but sociological studies of pathways often find professional resistance to standardisation. This qualitative study examined the adoption and adaptation of a novel pathway as part of a randomised controlled trial in an unusually complex, non-linear field - emergency general surgery - by teams of surgeons and physicians in six theoretically sampled sites in the UK. We find near-universal receptivity to the concept of a pathway as a means of improving peri-operative processes and outcomes, but concern about the impact on appropriate professional judgement. However, this concern translated not into resistance and implementation failure, but into a nuancing of the pathways-as-realised in each site, and their use as a means of enhancing professional decision-making and inter-professional collaboration. We discuss our findings in the context of recent literature on the interplay between managerialism and professionalism in healthcare, and highlight practical and theoretical implications.


Assuntos
Competência Clínica/normas , Autonomia Profissional , Profissionalismo/normas , Melhoria de Qualidade , Serviço Hospitalar de Emergência/normas , Cirurgia Geral/métodos , Cirurgia Geral/normas , Pessoal de Saúde/normas , Humanos , Laparotomia/mortalidade , Laparotomia/normas , Pesquisa Qualitativa , Reino Unido
13.
Ostomy Wound Manage ; 63(6): 34-38, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28657898

RESUMO

Necrotizing enterocolitis (NEC) is the most common surgical emergency in neonatal intensive care units, and patients who require surgery have high mortality and morbidity rates. The utility of negative pressure in the management of adults with complicated abdominal wounds has been documented, but there are few reports describing the use of negative pressure wound therapy (NPWT) in children or following neonatal surgery. The case of a 6 day old, 5-weeks premature neonate with NEC is presented. An exploratory midline laparotomy was performed on day 3 of life owing to rectal bleeding and abdominal distension that did not respond to gastric decompression, bowel rest, and intravenous antibiotics. Ten (10) cm of necrosis in the distal ileum were noted and resected; in addition, an ileostomy was performed, and a Penrose drain was left in the surgical site. On postoperative day 5, the laparotomy dehisced. Continuous NPWT (50 mm Hg) was initiated and changed owing to patient tolerance to intermittent therapy (5 minutes on, 30 seconds off) at 80 mm Hg. By postoperative day 11, granulation tissue formation was complete. No surgical procedures were required for the complete closure of the abdominal wall, and no adverse reactions were noted. The baby was discharged from the hospital on postop day 15. In this patient, the use of negative pressure was found to be safe and facilitated management of a complicated abdominal wound in the presence of a stoma and the formation of healthy granulation tissue. Additional research is needed to help clinicians provide optimal, evidence-based care for dehisced wounds in this vulnerable population.


Assuntos
Abdome/cirurgia , Enterocolite Necrosante/terapia , Tratamento de Ferimentos com Pressão Negativa/métodos , Enterocolite Necrosante/etiologia , Feminino , Humanos , Recém-Nascido , Recém-Nascido Prematuro/fisiologia , Laparotomia/métodos , Laparotomia/normas , Masculino , Pneumatose Cistoide Intestinal/complicações , Pneumatose Cistoide Intestinal/cirurgia , Complicações Pós-Operatórias/terapia , Espanha , Deiscência da Ferida Operatória/terapia , Cicatrização
14.
J Trauma Acute Care Surg ; 83(1 Suppl 1): S156-S163, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-28628601

RESUMO

Hemorrhage is the most preventable cause of posttraumatic death. Many cases are potentially anatomically salvageable, yet remain lethal without logistics or trained personnel to deliver diagnosis or resuscitative surgery in austere environments. Revolutions in technology for remote mentoring of ultrasound and surgery may enhance capabilities to utilize the skill sets of non-physicians. Thus, our research collaborative explored remote mentoring to empower non-physicians to address junctional and torso hemorrhage control in austere environments. Major studies involved using remote-telementored ultrasound (RTMUS) to identify torso and junctional exsanguination, remotely mentoring resuscitative surgery for torso hemorrhage control, understanding and mitigating physiological stress during such tasks, and the technical practicalities of conducting damage control surgery (DCS) in austere environments. Iterative projects involved randomized guiding of firefighters to identify torso (RCT) and junctional (pilot) hemorrhage using RTMUS, randomized remote mentoring of MedTechs conducting resuscitative surgery for torso exsanguination in an anatomically realistic surgical trainer ("Cut Suit") including physiological monitoring, and trained surgeons conducting a comparative randomized study for torso hemorrhage control in normal (1g) versus weightlessness (0g). This work demonstrated that firefighters could be remotely mentored to perform just-in-time torso RTMUS on a simulator. Both firefighters and mentors were confident in their abilities, the ultrasounds being 97% accurate. An ultrasound-naive firefighter in Memphis could also be remotely mentored from Hawaii to identify and subsequently tamponade an arterial junctional hemorrhage using RTMUS in a live tissue model. Thereafter, both mentored and unmentored MedTechs and trained surgeons completed resuscitative surgery for hemorrhage control on the Cut-Suit, demonstrating practicality for all involved. While remote mentoring did not decrease blood loss among MedTechs, it increased procedural confidence and decreased physiologic stress. Therefore, remote mentoring may increase the feasibility of non-physicians conducting a psychologically daunting task. Finally, DCS in weightlessness was feasible without fundamental differences from 1g. Overall, the collective evidence suggests that remote mentoring supports diagnosis, noninvasive therapy, and ultimately resuscitative surgery to potentially rescue those exsanguinating in austere environments and should be more rigorously studied.


Assuntos
Serviços Médicos de Emergência/métodos , Meio Ambiente , Exsanguinação/prevenção & controle , Hemorragia/cirurgia , Laparotomia/normas , Consulta Remota/métodos , Telemedicina/métodos , Animais , Canadá , Competência Clínica , Modelos Animais de Doenças , Procedimentos Endovasculares , Exsanguinação/diagnóstico por imagem , Hemorragia/diagnóstico por imagem , Humanos , Militares , Telerradiologia/métodos , Ultrassonografia
15.
Anticancer Res ; 36(10): 5419-5424, 2016 10.
Artigo em Inglês | MEDLINE | ID: mdl-27798909

RESUMO

AIM: To compare the clinical and oncological outcomes of laparoscopic and open approaches in patients with advanced rectal cancer. PATIENTS AND METHODS: In this study, 78 patients who underwent surgery for advanced middle and lower rectal cancer (pStage II - III) were divided into two groups according to type of surgical approach: laparoscopic surgery (LS group; n=40) and open surgery (OS group: n=38). The clinical outcomes and oncological outcomes were compared between the two groups. RESULTS: The operation time was comparable, whereas operative blood loss and complication rates were significantly less in the LS group compared to the OS group. Cancer-specific survival (CSS) and local recurrence-free survival (LRFS) were similar in the two groups. Disease-free survival (DFS) was better in the LS group than in the OS group. CONCLUSION: LS for advanced rectal cancer was safe and not inferior to OS in clinical and oncological outcomes.


Assuntos
Laparoscopia/normas , Laparotomia/normas , Neoplasias Retais/cirurgia , Idoso , Feminino , Humanos , Masculino , Resultado do Tratamento
16.
Anaesthesia ; 71(11): 1291-1295, 2016 11.
Artigo em Inglês | MEDLINE | ID: mdl-27667290

RESUMO

Implementation of a quality improvement bundle for peri-operative management of emergency laparotomy (ELPQuIC) improved mortality in a previous study. We used data from one site that participated in that study to examine whether it was associated with the cost of care. We collected data from 396 patients: 144 before, 144 during and 108 after implementation of the bundle. We estimated costs incurred using previously published methodology based on the time the patient spent in hospital, in the operating theatre and in critical care. Duration of stay in hospital and critical care did not differ between time periods, p = 0.14 and p = 0.28, respectively. The costs per patient and per survivor did not differ between the time periods, p = 0.87 and p = 0.17, respectively. Costs were similar for patients aged < 80 years vs. ≥ 80 years. Implementation of a quality improvement bundle for emergency laparotomy has the capacity to save lives without increasing hospital costs.


Assuntos
Procedimentos Clínicos/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Laparotomia/economia , Laparotomia/normas , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Cuidados Críticos/economia , Procedimentos Clínicos/normas , Emergências , Inglaterra , Pesquisa sobre Serviços de Saúde/métodos , Humanos , Estimativa de Kaplan-Meier , Tempo de Internação/estatística & dados numéricos , Pessoa de Meia-Idade , Assistência Perioperatória/economia , Assistência Perioperatória/normas , Melhoria de Qualidade , Adulto Jovem
17.
Ann R Coll Surg Engl ; 98(8): 554-559, 2016 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-27502336

RESUMO

BACKGROUND Following evidence suggestive of high mortality following emergency laparotomies, the National Emergency Laparotomy Audit (NELA) was set up, highlighting key standards in emergency service provision. Our aim was to compare our NHS trust's adherence to these recommendations immediately prior to, and following, the launch of NELA, and to compare patient outcome. METHODS This was a retrospective study of patients who underwent an emergency laparotomy over the course of 6 months - 3 months either side of the initiation of NELA. RESULTS There were 44 patients before the initiation of NELA (pre-NELA, PN group) and 55 in the first 3 months of NELA (N group). We saw a significant increase in the proportion of patients whose decision to operate was made by the consultant: 75.0% in the PN group vs 100% in N group (subsequent data presented in this order) (P < 0.001). The presence of a consultant surgeon (75.0% vs 83.6%, P = 0.321) and anaesthetist (100.0% vs 90.9%, P = 0.064) in theatres were comparable in both groups. Risk stratification based on Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (P-POSSUM) score showed no difference in high-risk patients in both groups (47.7% vs 36.4%, P = 0.306). With the NELA initiative, however, significantly more patients were admitted directly from theatres to the critical care unit, when compared with the pre-NELA period (9.1% vs 27.3%, P = 0.038). This also reflected a significant reduction in unexpected escalation to a higher level of care during this period (10.0% vs 0%, P = 0.036). Significantly more patients had uneventful recovery in the NELA period (52.3 vs 76.4%, P = 0.018), although there was no difference in 30-day mortality between the groups (2.3% vs 7.3%, P = 0.378). CONCLUSIONS This study demonstrated a greater degree of consultant involvement in the decision to operate during NELA. More high-risk patients have been identified preoperatively with diligent risk assessment and, hence, have been proactively admitted to critical care units following laparotomy, which may account for the significant reduction in unexpected escalation to level 2 or level 3 care and thus in overall better patient outcomes.


Assuntos
Laparotomia/normas , Auditoria Médica , Idoso , Serviços Médicos de Emergência/normas , Serviços Médicos de Emergência/estatística & dados numéricos , Feminino , Humanos , Laparotomia/mortalidade , Laparotomia/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Padrões de Prática Médica/estatística & dados numéricos , Estudos Retrospectivos , Medição de Risco , Resultado do Tratamento , Reino Unido
18.
Chirurg ; 87(9): 731-736, 2016 Sep.
Artigo em Alemão | MEDLINE | ID: mdl-27356925

RESUMO

BACKGROUND: Every abdominal incision can lead to early (e. g. abdominal infection) and late complications (e. g. hernia). The correct incision is often important to have optimal access to the surgical area and to keep complications low. OBJECTIVE: An analysis of the recent literature was carried out to clarify which access routes have advantages over other types of incision. MATERIAL AND METHODS: A literature search was carried out in the following databases: Cochrane database of systematic reviews (CDSR), Cochrane library, Medline and PubMed. Systematic reviews and studies with large numbers of cases were used for the evaluation, whereas studies with small numbers of cases and case reports were not taken into account. RESULTS: Midline incisions are the first choice for acute and elective abdominal surgery because of a good view into and rapid access to the abdominal cavity. For large upper abdominal operations transverse incisions can be considered of equal value due to excellent exploration possibilities, e.g. of the liver and pancreas. 25 years after the introduction of laparoscopy, this technique has become established for cholecystectomy, fundoplication and bariatric surgery. For appendix and colon surgery laparoscopy has the advantage of being less traumatic, whereby postoperative pain and hospitalization are reduced but under circumstances longer operating times must be expected. The single incision laparoscopic surgery (SILS) technique is beneficial in cosmetic outcome; however, incisional hernias, prolonged operating times and higher complication rates are limiting factors for this technique. Natural orifice transluminal endoscopic surgery (NOTES) and atypical incisions are rarely used.


Assuntos
Laparoscopia/métodos , Laparoscopia/normas , Laparotomia/métodos , Laparotomia/normas , Cirurgia Endoscópica por Orifício Natural/métodos , Cirurgia Endoscópica por Orifício Natural/normas , Medicina de Precisão , Humanos , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/prevenção & controle , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Fatores de Risco , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/prevenção & controle
19.
Mil Med ; 181(5 Suppl): 247-52, 2016 05.
Artigo em Inglês | MEDLINE | ID: mdl-27168580

RESUMO

BACKGROUND: Combat casualties have endured an increase in traumatic lower extremity amputations secondary to improvised explosive devices. Often surgical control of the proximal vasculature is required. We evaluate the safety profile of exploratory laparotomy (EXLAP) for proximal control (PC) in combat-injured patients. METHODS: Records of 845 combat casualties from June 2009 to December 2011 were reviewed. Patients undergoing EXLAP were divided by indication into PC and non-PC groups. Demographics, Injury Severity Score, mechanism of injury, transfusion requirements, EXLAP findings, reoperation rates, and abdominal-related complications were recorded. RESULTS: 44 patients were identified as PC and 91 as non-PC. Age was similar (23.7 ± 4.1 vs. 24.0 ± 4.6, p = 0.7138), and all were male. Improvised explosive devices blast was the most common mechanism of injury. Injury Severity Score (25.8 ± 8.2 vs. 21.4 ± 9.1, p = 0.0075), lower extremity amputation (93.1% vs. 28.6%, p = 0.0001), and transfusion requirements were different. Days to fascial closure (1.8 ± 1.9 vs. 1.7 ± 2.8, p = 0.8308) and number of EXLAPs were similar (2.4 ± 1.3 vs. 2.1 ± 1.5, p = 0.2581). PC had higher complications (43.1% vs. 24.2%, p = 0.0292). CONCLUSION: PC demonstrated an increase in abdominal complications. The reason for this remains unclear. Alternative approaches of achieving proximal vascular control may avoid the morbidity associated with laparotomy, and predeployment training of such procedures should be considered for the general surgeon. Further studies are warranted to determine best practices for these patients.


Assuntos
Amputação Traumática/cirurgia , Traumatismos por Explosões/cirurgia , Laparotomia/métodos , Laparotomia/normas , Adulto , Campanha Afegã de 2001- , Amputação Traumática/epidemiologia , Traumatismos por Explosões/epidemiologia , Distribuição de Qui-Quadrado , Estudos de Coortes , Feminino , Hemodinâmica/fisiologia , Humanos , Escala de Gravidade do Ferimento , Guerra do Iraque 2003-2011 , Traumatismos da Perna/epidemiologia , Traumatismos da Perna/cirurgia , Masculino , Militares/estatística & dados numéricos , Razão de Chances , Estudos Retrospectivos , Estados Unidos/epidemiologia
20.
Eur J Surg Oncol ; 42(4): 552-7, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26868165

RESUMO

BACKGROUND: Complete cytoreductive surgery (CCRS) plus Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is the best-known treatment for pseudomyxoma peritonei (PMP). In 30% of the cases, PMP realize a widespread involvement of the peritoneal cavity. In these extreme situations, we developed, devoted strategies to optimize the feasibility and safety of CCRS. This study describes the surgical resections required for CCRS and the consequent approaches that we propose to achieve CCRS. MATERIALS AND METHODS: We defined "huge PMP" by a peritoneal cancer index (PCI) ≥ 28. Surgical procedures of patients operated on between 1994 and 2014 were retrospectively reviewed from a prospective database in a single institution. RESULTS: During this period, 311 patients were operated on and 247 (79%) underwent CCRS + HIPEC. Among them, 100 patients presented "huge" PMP and 54 patients underwent CCRS + HIPEC. In patients with "huge" PMP, the rate of CCRS + HIPEC was 25% before 2002 and reached 71% between 2011 and 2014. We identified 3 conditions for CCRS 1) to guaranty a sufficient length of residual small bowel 2) to preserve the left gastric vessels in order to preserve the superior third of the stomach 3) to ensure that the hepatic pedicle can be entirely cleared from its tumor involvement. None of the other peritonectomy procedures were decisional for CCRS. CONCLUSION: Our learning curve improved the selection and completion rate of CCRS + HIPEC for "huge PMP". Some anatomical and physiological prerequisites guarantee the feasibility and safety of such extensive surgeries.


Assuntos
Procedimentos Cirúrgicos de Citorredução/normas , Estadiamento de Neoplasias , Neoplasias Peritoneais/diagnóstico , Guias de Prática Clínica como Assunto , Pseudomixoma Peritoneal/diagnóstico , Adolescente , Adulto , Idoso , Procedimentos Cirúrgicos de Citorredução/métodos , Feminino , Seguimentos , Humanos , Laparotomia/métodos , Laparotomia/normas , Masculino , Pessoa de Meia-Idade , Neoplasias Peritoneais/cirurgia , Pseudomixoma Peritoneal/cirurgia , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Adulto Jovem
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