Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 2.035
Filtrar
1.
Medicine (Baltimore) ; 98(44): e17712, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31689806

RESUMO

Accumulation of the literature has suggested an inverse association between healthcare provider volume and mortality for a wide variety of surgical procedures. This study aimed to perform meta-analysis of meta-analyses (umbrella review) of observational studies and to summarize existing evidence for associations of healthcare provider volume with mortality in major operations.We searched MEDLINE, SCOPUS, and Cochrane Library, and screening of references.Meta-analyses of observational studies examining the association of hospital and surgeon volume with mortality following major operations. The primary outcome is all-cause short-term morality after surgery. Meta-analyses of observational studies of hospital/surgeon volume and mortality were included. Overall level of evidence was classified as convincing (class I), highly suggestive (class II), suggestive (class III), weak (class IV), and non-significant (class V) based on the significance of the random-effects summary odds ratio (OR), number of cases, small-study effects, excess significance bias, prediction intervals, and heterogeneity.Twenty meta-analyses including 4,520,720 patients were included, with 19 types of surgical procedures for hospital volume and 11 types of surgical procedures for surgeon volume. Nominally significant reductions were found in odds ratio in 82% to 84% of surgical procedures in both hospital and surgeon volume-mortality associations. To summarize the overall level of evidence, however, only one surgical procedure (pancreaticoduodenectomy) fulfilled the criteria of class I and II for both hospital and surgeon volume and mortality relationships, with a decrease in OR for hospital (0.42, 95% confidence interval[CI] [0.35-0.51]) and for surgeon (0.38, 95% CI [0.30-0.49]), respectively. In contrast, most of the procedures appeared to be weak or "non-significant."Only a very few surgical procedures such as pancreaticoduodenectomy appeared to have convincing evidence on the inverse surgeon volume-mortality associations, and yet most surgical procedures resulted in having weak or "non-significant" evidence. Therefore, healthcare professionals and policy makers might be required to steer their centralization policy more carefully unless more robust, higher-quality evidence emerges, particularly for procedures considered as having a weak or non-significant evidence level including total knee replacement, thyroidectomy, bariatric surgery, radical cystectomy, and rectal and colorectal cancer resections.


Assuntos
Mortalidade Hospitalar , Hospitais/estatística & dados numéricos , Cirurgiões/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/mortalidade , Feminino , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Humanos , Masculino , Metanálise como Assunto , Estudos Observacionais como Assunto , Razão de Chances
2.
Prensa méd. argent ; 105(9 especial): 526-531, oct 2019. tab, fig
Artigo em Inglês | LILACS, BINACIS | ID: biblio-1046381

RESUMO

In the case of lung cancer, surgery is the only method of therapy that gives the patient a chance to recover. However, even after radical surgery, up to 50 ­ 60 % of patients die in the subsequent five years from the disease progression. This study was aimed at identifying the technical particularities of surgery, depending on the side of the lung affected by a tumor and the possibility of applying the methods that improve the results of surgical therapy. The study was performed at the Thoracic Department of the Republican Clinical Oncology Dispensary in Ufa and the 1st Surgical Department of the Regional Oncology Center of the Regional Clinical Hospital in Khanty- Mansiysk. The study involved a total of 156 patients (including 148 male and eight female patients). The main result of the study has been the confirmation of the advantages of bronchoplastic surgery, which do not increase post-surgery mortality and improve the post-surgery period, and the relevant principles of preserving surgery.


Assuntos
Humanos , Cirurgia Geral/métodos , Procedimentos Cirúrgicos Operatórios/mortalidade , Mortalidade , Neoplasias Pulmonares/cirurgia
3.
Cochrane Database Syst Rev ; 9: CD013438, 2019 09 26.
Artigo em Inglês | MEDLINE | ID: mdl-31556094

RESUMO

BACKGROUND: Randomized controlled trials (RCTs) have yielded conflicting results regarding the ability of beta-blockers to influence perioperative cardiovascular morbidity and mortality. Thus routine prescription of these drugs in an unselected population remains a controversial issue. A previous version of this review assessing the effectiveness of perioperative beta-blockers in cardiac and non-cardiac surgery was last published in 2018. The previous review has now been split into two reviews according to type of surgery. This is an update, and assesses the evidence in non-cardiac surgery only. OBJECTIVES: To assess the effectiveness of perioperatively administered beta-blockers for the prevention of surgery-related mortality and morbidity in adults undergoing non-cardiac surgery. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, Biosis Previews and Conference Proceedings Citation Index-Science on 28 June 2019. We searched clinical trials registers and grey literature, and conducted backward- and forward-citation searching of relevant articles. SELECTION CRITERIA: We included RCTs and quasi-randomized studies comparing beta-blockers with a control (placebo or standard care) administered during the perioperative period to adults undergoing non-cardiac surgery. If studies included surgery with different types of anaesthesia, we included them if 70% participants, or at least 100 participants, received general anaesthesia. We excluded studies in which all participants in the standard care control group were given a pharmacological agent that was not given to participants in the intervention group, studies in which all participants in the control group were given a beta-blocker, and studies in which beta-blockers were given with an additional agent (e.g. magnesium). We excluded studies that did not measure or report review outcomes. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion, extracted data, and assessed risks of bias. We assessed the certainty of evidence with GRADE. MAIN RESULTS: We included 83 RCTs with 14,967 participants; we found no quasi-randomized studies. All participants were undergoing non-cardiac surgery, and types of surgery ranged from low to high risk. Types of beta-blockers were: propranolol, metoprolol, esmolol, landiolol, nadolol, atenolol, labetalol, oxprenolol, and pindolol. In nine studies, beta-blockers were titrated according to heart rate or blood pressure. Duration of administration varied between studies, as did the time at which drugs were administered; in most studies, it was intraoperatively, but in 18 studies it was before surgery, in six postoperatively, one multi-arm study included groups of different timings, and one study did not report timing of drug administration. Overall, we found that more than half of the studies did not sufficiently report methods used for randomization. All studies in which the control was standard care were at high risk of performance bias because of the open-label study design. Only two studies were prospectively registered with clinical trials registers, which limited the assessment of reporting bias. In six studies, participants in the control group were given beta-blockers as rescue therapy during the study period.The evidence for all-cause mortality at 30 days was uncertain; based on the risk of death in the control group of 25 per 1000, the effect with beta-blockers was between two fewer and 13 more per 1000 (risk ratio (RR) 1.17, 95% confidence interval (CI) 0.89 to 1.54; 16 studies, 11,446 participants; low-certainty evidence). Beta-blockers may reduce the incidence of myocardial infarction by 13 fewer incidences per 1000 (RR 0.72, 95% CI 0.60 to 0.87; 12 studies, 10,520 participants; low-certainty evidence). We found no evidence of a difference in cerebrovascular events (RR 1.65, 95% CI 0.97 to 2.81; 6 studies, 9460 participants; low-certainty evidence), or in ventricular arrhythmias (RR 0.72, 95% CI 0.35 to 1.47; 5 studies, 476 participants; very low-certainty evidence). Beta-blockers may reduce atrial fibrillation or flutter by 26 fewer incidences per 1000 (RR 0.41, 95% CI 0.21 to 0.79; 9 studies, 9080 participants; low-certainty evidence). However, beta-blockers may increase bradycardia by 55 more incidences per 1000 (RR 2.49, 95% CI 1.74 to 3.56; 49 studies, 12,239 participants; low-certainty evidence), and hypotension by 44 more per 1000 (RR 1.40, 95% CI 1.29 to 1.51; 49 studies, 12,304 participants; moderate-certainty evidence).We downgraded the certainty of the evidence owing to study limitations; some studies had high risks of bias, and the effects were sometimes altered when we excluded studies with a standard care control group (including only placebo-controlled trials showed an increase in early mortality and cerebrovascular events with beta-blockers). We also downgraded for inconsistency; one large, well-conducted, international study found a reduction in myocardial infarction, and an increase in cerebrovascular events and all-cause mortality, when beta-blockers were used, but other studies showed no evidence of a difference. We could not explain the reason for the inconsistency in the evidence for ventricular arrhythmias, and we also downgraded this outcome for imprecision because we found few studies with few participants. AUTHORS' CONCLUSIONS: The evidence for early all-cause mortality with perioperative beta-blockers was uncertain. We found no evidence of a difference in cerebrovascular events or ventricular arrhythmias, and the certainty of the evidence for these outcomes was low and very low. We found low-certainty evidence that beta-blockers may reduce atrial fibrillation and myocardial infarctions. However, beta-blockers may increase bradycardia (low-certainty evidence) and probably increase hypotension (moderate-certainty evidence). Further evidence from large placebo-controlled trials is likely to increase the certainty of these findings, and we recommend the assessment of impact on quality of life. We found 18 studies awaiting classification; inclusion of these studies in future updates may also increase the certainty of the evidence.


Assuntos
Antagonistas Adrenérgicos beta/uso terapêutico , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/prevenção & controle , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Anestesia Geral/efeitos adversos , Arritmias Cardíacas/mortalidade , Arritmias Cardíacas/prevenção & controle , Bradicardia/prevenção & controle , Causas de Morte , Humanos , Hipotensão/mortalidade , Hipotensão/prevenção & controle , Morbidade , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/prevenção & controle , Complicações Pós-Operatórias/mortalidade , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Procedimentos Cirúrgicos Operatórios/mortalidade
4.
Br J Anaesth ; 123(5): 688-695, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31558311

RESUMO

BACKGROUND: Postoperative mortality occurs in 1-2% of patients undergoing major inpatient surgery. The currently available prediction tools using summaries of intraoperative data are limited by their inability to reflect shifting risk associated with intraoperative physiological perturbations. We sought to compare similar benchmarks to a deep-learning algorithm predicting postoperative 30-day mortality. METHODS: We constructed a multipath convolutional neural network model using patient characteristics, co-morbid conditions, preoperative laboratory values, and intraoperative numerical data from patients undergoing surgery with tracheal intubation at a single medical centre. Data for 60 min prior to a randomly selected time point were utilised. Model performance was compared with a deep neural network, a random forest, a support vector machine, and a logistic regression using predetermined summary statistics of intraoperative data. RESULTS: Of 95 907 patients, 941 (1%) died within 30 days. The multipath convolutional neural network predicted postoperative 30-day mortality with an area under the receiver operating characteristic curve of 0.867 (95% confidence interval [CI]: 0.835-0.899). This was higher than that for the deep neural network (0.825; 95% CI: 0.790-0.860), random forest (0.848; 95% CI: 0.815-0.882), support vector machine (0.836; 95% CI: 0.802-870), and logistic regression (0.837; 95% CI: 0.803-0.871). CONCLUSIONS: A deep-learning time-series model improves prediction compared with models with simple summaries of intraoperative data. We have created a model that can be used in real time to detect dynamic changes in a patient's risk for postoperative mortality.


Assuntos
Aprendizado Profundo , Complicações Pós-Operatórias/mortalidade , Procedimentos Cirúrgicos Operatórios/mortalidade , Algoritmos , Comorbidade , Humanos , Missouri/epidemiologia , Período Pós-Operatório , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco/métodos , Máquina de Vetores de Suporte
5.
Khirurgiia (Mosk) ; (9): 58-65, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31532168

RESUMO

OBJECTIVE: To define the informative value of qSOFA score in the prediction of outcomes in surgical patients admitted to the Intensive Care Units. STUDY DESIGN: Post hoc analysis of multicenter prospective observational study RISES. The following patient information was analyzed: gender, age, diagnosis, presence of infection, SIRS criteria, qSOFA and SOFA scores, outcomes. RESULTS: The study included data of 331 patients with surgical diseases. Infection was not observed in 174 (52.6%) cases, 157 (47.4%) patients had infection. In the group of patients without infection, area under ROC-curve for SIRS criteria was 0.519 (95% CI 0.429-0.610) and similar to that qSOFA (p=0.535). Area under ROC-curve for SOFA scale was 0.619 (95% CI 0.511-0.726) and did not significantly differ from this value for QSOFA (p=0.241). In the group of surgical patients with infection, area under ROC-curve for SIRS was 0.490 (95% CI 0.419-0.561), that was significantly lower than area under ROC-curve for qSOFA (p=0.016). Area under ROC-curve for SOFA scale was 0.803 (95% CI 0.681-0.924), that significantly exceeded area under ROC-curve for qSOFA (p=0.017). CONCLUSION: qSOFA scale is important in surgical patients with infection admitted to ICUs. Increased qSOFA score is associated with augmentation of mortality rate. qSOFA scale significantly exceeds the SIRS criteria, but is inferior to the SOFA in the prognosis of mortality in these patients.


Assuntos
Unidades de Terapia Intensiva/estatística & dados numéricos , Insuficiência de Múltiplos Órgãos/mortalidade , Escores de Disfunção Orgânica , Procedimentos Cirúrgicos Operatórios/mortalidade , Humanos , Insuficiência de Múltiplos Órgãos/terapia , Prognóstico , Estudos Prospectivos , Federação Russa , Resultado do Tratamento
6.
Radiat Oncol ; 14(1): 116, 2019 Jul 04.
Artigo em Inglês | MEDLINE | ID: mdl-31272506

RESUMO

BACKGROUND: Systemic inflammation plays a critical role in cancer progression and oncologic outcomes in cancer patients. We investigated whether preoperative inflammatory biomarkers, including C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and neutrophil to lymphocyte ratio (NLR), could be surrogate biomarkers for predicting overall survival (OS) in soft tissue sarcoma (STS) patients treated with surgery and postoperative radiotherapy. METHODS: A series of 99 patients who presented with localized extremity STS were retrospectively reviewed. The preoperative CRP levels, ESR, and NLR were evaluated for associations with OS, disease-free survival (DFS), local recurrence-free survival (LRFS), and distant metastasis-free survival (DMFS). Cutoff values for CRP, ESR, and NLR were derived from receiver-operating characteristic curve analysis. RESULTS: Elevated CRP (> 0.14 mg/dL), ESR (> 15 mm/h), and NLR (> 1.95) levels were seen in 33, 44, and 45 patients, respectively. Of these three inflammatory biomarkers, elevated CRP and ESR were associated with a poorer OS (CRP: P = 0.050; ESR: P = 0.001), DFS (CRP: P = 0.023; ESR: P = 0.003), and DMFS (CRP: P = 0.015; ESR: P = 0.001). By multivariate analysis, an elevated ESR was found to be an independent prognostic factor for OS (HR 3.580, P = 0.025) and DMFS (HR 3.850, P = 0.036) after adjustment for other established prognostic factors. CONCLUSIONS: The preoperative ESR level is a simple and useful surrogate biomarker for predicting survival outcomes in STS patients and might improve the identification of high-risk patients of tumor relapse in clinical practice.


Assuntos
Sedimentação Sanguínea/efeitos da radiação , Extremidades/efeitos da radiação , Extremidades/cirurgia , Recidiva Local de Neoplasia/mortalidade , Radioterapia Adjuvante/mortalidade , Sarcoma/mortalidade , Procedimentos Cirúrgicos Operatórios/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores Tumorais/análise , Terapia Combinada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/patologia , Recidiva Local de Neoplasia/terapia , Prognóstico , Curva ROC , Estudos Retrospectivos , Sarcoma/patologia , Sarcoma/terapia , Taxa de Sobrevida , Adulto Jovem
7.
J Surg Oncol ; 120(4): 746-752, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31286523

RESUMO

BACKGROUND AND OBJECTIVES: Local recurrence in Ewing sarcoma (ES) is associated with poor prognosis. The purpose of the study is to determine what factors affect overall survival after local recurrence and whether wide excision constitutes appropriate treatment. METHODS: From 1992 to 2017, 26 patients were treated for local recurrence of ES. Sixteen patients presented with local recurrence only while 10 had metastasis. The median follow-up was 23 months (range, 3-255 months). Overall survival was assessed with Kaplan-Meier analysis. RESULTS: At the last follow-up, seven of 26 (27%) patients were alive. Overall survival after local recurrence was 28% at 5 years. Later onset of local recurrence (P = .041), surgical treatment (P < .001), and complete eradication of all recurrent disease (P < .001) predicted better survival. Metastasis was associated with worse survival (P = .014). All three patients who survived more than 10 years were treated with wide local excision. A second local recurrence developed in seven patients (28%) but did not predict worse overall survival. CONCLUSIONS: Overall survival after local recurrence is better for patients with nonmetastatic disease treated surgically. Wide excision can be compatible with long survival. We do not advocate amputation on a routine basis for local recurrence. Complete eradication of all diseases is associated with better survival.


Assuntos
Neoplasias Ósseas/mortalidade , Recidiva Local de Neoplasia/mortalidade , Sarcoma de Ewing/mortalidade , Procedimentos Cirúrgicos Operatórios/mortalidade , Adolescente , Adulto , Neoplasias Ósseas/patologia , Neoplasias Ósseas/cirurgia , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/patologia , Recidiva Local de Neoplasia/cirurgia , Prognóstico , Sarcoma de Ewing/patologia , Sarcoma de Ewing/cirurgia , Taxa de Sobrevida , Adulto Jovem
12.
J Trauma Acute Care Surg ; 87(1): 140-146, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31259872

RESUMO

BACKGROUND: As the geriatric population grows, the need for hospitals performing high quality emergency general surgery (EGS) on older patients will increase. Identifying clusters of high-performing geriatric emergency general surgery hospitals would substantiate the need for in-depth analyses of hospital-specific structures and practices that benefit older EGS patients. The objectives of this study were therefore to identify clusters of hospitals based on mortality performance for geriatric patients undergoing common EGS operations and to determine if hospital performance was similar for all operation types. METHODS: Hospitals in the California State Inpatient Database were included if they performed a range of eight common EGS operations in patients 65 years or older, with a minimum requirement of three of each operation performed over 2 years. Multivariable beta regression models were created to define hospital-level risk-adjusted mortality. Centroid cluster analysis was used to identify groups of hospitals based on mortality and to determine if mortality-performance differed by operation. RESULTS: One hundred seven hospitals were included, performing a total of 24,279 operations in older patients. Hospitals separated into three distinct clusters: high, average, and low performers. The high-performing hospitals had survival rates 1 to 2 standard deviations better than the low-performers (p < 0.001). For each cluster, high performance in any one EGS operation consistently translated into high performance across all EGS operations. CONCLUSION: Hospitals conducting EGS operations in the geriatric patient population cluster into three distinct groups based on their survival performance. High-performing hospitals significantly outperform the average and low performers across every operation. The high-performers achieve reliable, high-quality results regardless of operation type. Further qualitative research is needed to investigate the perioperative drivers of hospital performance in the geriatric EGS population. LEVEL OF EVIDENCE: Study Type Prognostic, level III.


Assuntos
Hospitais/normas , Procedimentos Cirúrgicos Operatórios/normas , Idoso , California , Análise por Conglomerados , Emergências , Mortalidade Hospitalar , Hospitais/estatística & dados numéricos , Humanos , Procedimentos Cirúrgicos Operatórios/mortalidade , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos
13.
J Surg Oncol ; 120(4): 753-760, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31355444

RESUMO

BACKGROUND: Calls for multivisceral resection (MVR) of retroperitoneal sarcoma (RPS) are increasing, although the risks and benefits remain controversial. We sought to analyze current 30-day morbidity and mortality rates, and trends in utilization of MVR in a national database. METHODS: Overall morbidity, severe morbidity, mortality rates, and temporal trends were analyzed utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). RESULTS: From 2012 to 2015, a total of 564 patients underwent RPS resection with 233 patients (41%) undergoing MVR. The MVR group had a higher rate of preoperative weight loss and larger tumors overall. When comparing MVR to non-MVR, there was no significant difference in overall morbidity (22% vs 17%, P = .13), severe morbidity (11% vs 8%, P = .18), or mortality (<1% vs 2%, P = .25). On multivariate analysis, MVR was not associated with increased overall morbidity or severe morbidity. Mortality rates were too low for meaningful statistical analysis. Annual rates of MVR ranged from 37% to 46% with no significant change over time (P = .47). RESULTS: Short-term morbidity and mortality rates after MVR for RPS remain acceptable, but rates of MVR show little change over time in NSQIP hospitals. Concerns about increased morbidity and mortality should not be viewed as a contraindication to wider implementation of MVR for RPS.


Assuntos
Mortalidade/tendências , Complicações Pós-Operatórias/mortalidade , Neoplasias Retroperitoneais/mortalidade , Sarcoma/mortalidade , Procedimentos Cirúrgicos Operatórios/mortalidade , Bases de Dados Factuais , Gerenciamento Clínico , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Morbidade , Prognóstico , Melhoria de Qualidade , Neoplasias Retroperitoneais/patologia , Neoplasias Retroperitoneais/cirurgia , Sarcoma/patologia , Sarcoma/cirurgia , Taxa de Sobrevida
14.
Surgery ; 166(2): 193-197, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31151680

RESUMO

BACKGROUND: Management of critically ill patients is a challenge in low resource settings where there is a paucity of trained staff, infrastructure, resources, and drugs. We aimed to study the characteristics of surgical patients admitted in intensive care unit in a limited resource setting and determine factors associated with mortality. METHODS: This was a cross-sectional observational study of all surgical patients admitted to the intensive care unit of a tertiary referral hospital in Rwanda. Data included demographics, diagnosis, management, and outcomes. Logistic regression was used to determine factors associated with mortality. RESULTS: Over a 7-month period, there were 126 surgical patients admitted to the intensive care unit. Common diagnoses included head injury (n = 55, 44%), peritonitis (n = 33, 26%), brain tumor (n = 15, 12%), and trauma (n = 15, 12%). The overall mortality was 47% with the highest mortality seen in patients with peritonitis (76%). Factors associated with mortality on intensive care unit admission included hypotension (odds ratio, 12.50; 95% confidence interval, 3.04, 51.32) and having any comorbidity (odds ratio 5.69, 95% confidence interval, 1.58, 20.50). CONCLUSION: Surgical patients admitted to the intensive care unit bear a significant mortality. Common surgical intensive care unit diagnoses include head injury and peritonitis. We recommend a review of the admission policy to optimize utility of the intensive care unit.


Assuntos
Causas de Morte , Estado Terminal/mortalidade , Mortalidade Hospitalar , Complicações Pós-Operatórias/mortalidade , Procedimentos Cirúrgicos Operatórios/mortalidade , Fatores Etários , Estudos Transversais , Países em Desenvolvimento , Feminino , Hospitais Universitários , Humanos , Unidades de Terapia Intensiva , Estimativa de Kaplan-Meier , Masculino , Análise Multivariada , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/terapia , Estudos Retrospectivos , Medição de Risco , Ruanda , Fatores Sexuais , Procedimentos Cirúrgicos Operatórios/métodos
15.
J Trauma Acute Care Surg ; 87(1): 35-42, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31242499

RESUMO

BACKGROUND: Few diseases truly require emergency surgery today. We investigated the relationship between access to operating room (OR) and outcomes for patients with life-threatening emergency general surgery (LT-EGS) diseases at US hospitals. METHODS: In 2015, we surveyed 2,811 US hospitals on EGS practices, including how OR access is assured (e.g., OR staffing, block time). There were 1,690 (60%) hospitals that responded. We anonymously linked survey data to 2015 Statewide Inpatient Sample data (17 states) using American Hospital Association identifiers. Adults admitted with life-threatening diagnoses (e.g., necrotizing fasciitis, perforated viscus) who underwent operative intervention the same calendar day as hospital admission were included. Primary outcome was in-hospital mortality. Univariate and multivariable regression analyses, clustered by treating hospital and adjusted for patient factors, were performed to examine hospital-level OR access variables. RESULTS: Overall, 3,620 patients were admitted with LT-EGS diseases. The median age was 63 years (interquartile range, 51-75), with half having three or more comorbidities (50%). Thirty-four percent had one or more major systemic complication, and 5% died. The majority got care at hospitals with less than 1 day of EGS block time but with policies to ensure emergency access to the OR. After adjusting for age, sex, race, insurance status, comorbidities, systemic complications, and surgical complications, we found that less presence of an in-house EGS surgeon, compared with around the clock, was associated with increased mortality (rarely/never in-house surgeon: odds ratio, 2.4; 95% confidence interval [CI],1.1-5.3; sometimes in-house surgeon: odds ratio, 1.6; 95% CI, 1.1-2.3). In addition, after controlling for other factors, on-call overnight recovery room nurse, compared with in-house, was associated with an increased mortality (odds ratio, 2.2; 95% CI, 1.5-3.1). CONCLUSION: Round-the-clock availability of personnel, specifically emergency general surgeons and recovery room nurses, is associated with decreased mortality. These findings have implications for the creation of EGS patient triage criteria and Acute Care Surgery Centers of Excellence. LEVEL OF EVIDENCE: Therapeutic, level III.


Assuntos
Salas Cirúrgicas/organização & administração , Procedimentos Cirúrgicos Operatórios/mortalidade , Idoso , Emergências , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Salas Cirúrgicas/estatística & dados numéricos , Recursos Humanos em Hospital/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/métodos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Inquéritos e Questionários , Fatores de Tempo , Estados Unidos/epidemiologia
16.
Surg Oncol ; 29: 142-147, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31196480

RESUMO

BACKGROUND: The objective of this retrospective study is to compare the outcomes of laparoscopic and open surgery for T2 gallbladder cancer (GBC) performed at our hospital for last 13 years. METHODS: Of 247 GBC patients who were treated at our hospital between Apr 2004 and Apr 2017, 151 patients with pathologic stage T2 were reviewed. Patients were divided into laparoscopic surgery group (LS group) and open (OS group). Medical recordings were reviewed to check perioperative outcomes, overall survival rates, and disease free survival rates. RESULTS: Fifty-five patients in LS group and 44 in OS met the inclusion criteria. Incidences of postoperative complication were similar between two groups (12.7% vs 13.6%, p = 1.000). Average postoperative hospital stay was significantly shorter in LS group (5.8 vs 9.5 days, p < 0.001). LS group showed significantly higher disease free survival rate (p = 0.0171). There was no significant difference in terms of disease free survival between T2N0 (p = 0.107) and T2N1 patients (p = 0.969) of LS group and OS group. In terms of overall survival rate there was no significant difference (p = 0.116). Overall survival rate was also not significantly different between T2N0 (p = 0.0941) and T2N1 (p = 0.579) patients of LS group and OS group. CONCLUSIONS: Laparoscopic approach for treatment of T2 GBC was comparable to open approach in terms of disease free survival, overall survival and complication rate. Further prospective study with higher number of patients should be done to confirm this result in the future.


Assuntos
Neoplasias da Vesícula Biliar/cirurgia , Laparoscopia/mortalidade , Procedimentos Cirúrgicos Operatórios/mortalidade , Idoso , Feminino , Seguimentos , Neoplasias da Vesícula Biliar/patologia , Humanos , Masculino , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida
17.
Surg Oncol ; 29: 53-63, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31196494

RESUMO

Retroperitoneal sarcomas (RPS) are rare mesenchymal tumours. Their rarity challenges our ability to understand expected outcomes. The aim of this systematic review was to examine 30-day morbidity and mortality, overall survival rates and prognostic predictors from population-based studies for patients undergoing curative resection for primary RPS. A systematic literature review of EMBASE, MEDLINE, PUBMED and the Cochrane library was performed using PRISMA for population-based studies reporting from nationally registered databases on primary RPS surgical resections in adults. The main outcomes evaluated were 30-day morbidity and mortality and overall survival rates. The use of additional treatment modalities and predictors of overall survival were also examined. Fourteen studies (n = 12 834 patients) reporting from 3 national databases, (Surveillance, Epidemiology and End Results (SEER), the United States National Cancer Database (US NCDB) and the American College of Surgeons' National Surgical Quality Improvement Program (ACS NSQIP)) were analysed. The reported overall 30-day morbidity and mortality were 23% (n = 191/846) and 3% (n = 278/10 181) respectively. Reported use of perioperative radiotherapy was 28%. No study reported loco-regional recurrence rates. Overall reported 5-year survival ranged from 52% to 62%. Independent predictors of overall survival were age of the patient, resection margin, tumour grade and size, histological subtype and receipt of radiotherapy. This review of population-based data demonstrated relatively low 30-day morbidity rates in patients undergoing curative surgical resections for primary RPS. Thirty-day mortality rates were similar to other abdominal tumour groups. There remains a paucity of data reporting recurrence rates, however 5-year survival rates ranged from 52 to 62%.


Assuntos
Bases de Dados Factuais , Recidiva Local de Neoplasia/diagnóstico , Complicações Pós-Operatórias , Neoplasias Retroperitoneais/cirurgia , Sarcoma/cirurgia , Procedimentos Cirúrgicos Operatórios/mortalidade , Humanos , Incidência , Recidiva Local de Neoplasia/epidemiologia , Prognóstico , Neoplasias Retroperitoneais/epidemiologia , Neoplasias Retroperitoneais/patologia , Sarcoma/epidemiologia , Sarcoma/patologia , Taxa de Sobrevida
18.
Surg Oncol ; 29: 84-89, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31196499

RESUMO

BACKGROUND: Patients with well-differentiated liposarcoma (WDLPS) of the extremity are mostly treated surgically, thereby possibly inducing severe morbidities. Despite the excellent prognosis, the natural history is barely studied. The aim of this study was to evaluate the natural history of extremity WDLPS by evaluating the outcome of patients treated with active surveillance (AS), who thereby exhibited the natural history of extremity WDLPS, and of patients treated surgically. METHODS: A large retrospective database of patients with extremity WDLPS was assessed to evaluate treatment, dedifferentiation and disease-specific survival. Lastly, our experience with patients treated with AS was explored. RESULTS: Distant metastases (5/191 patients, 2.6%) were mainly seen after a dedifferentiated local recurrence. Death of disease occurred in 4/191 patients (2.1%); two patients died from metastatic disease (although not pathologically proven), two patients died of treatment-related complications. In our center, 24 patients are treated with AS. Time of AS varied from 0.1 to 8.9 years (median 1.8). Four patients eventually underwent surgery after a period of AS (range 14-52 months) because of symptoms and/or tumor growth. No areas of dedifferentiation were found in these resection specimens. The other patients are still under active surveillance. CONCLUSION: Since surgical treatment might induce morbidity and even mortality, there might be overtreatment of these patients. Evaluation of the natural history of extremity WDLPS showed that AS could be a reasonable option for selected patients. Prospective studies in patients with extremity WDLPS are needed to assess the safety of AS as a treatment option.


Assuntos
Extremidades/cirurgia , Lipossarcoma/cirurgia , Procedimentos Cirúrgicos Operatórios/mortalidade , Conduta Expectante , Idoso , Extremidades/patologia , Feminino , Seguimentos , Humanos , Lipossarcoma/patologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida , Fatores de Tempo
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA