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1.
Acta Orthop Traumatol Turc ; 53(5): 351-355, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31358402

RESUMO

OBJECTIVE: The aim of this study was to measure the cartilaginous coverage of the acetabulum using magnetic resonance imaging (MRI) and to analyze its effect on the timing and necessity of secondary operations in residual acetabular dysplasia (RAD). METHODS: The MRI results of 33 children (30 girls and 3 boys) aged between 5 and 9 years who were operated on unilaterally via a posteromedial limited approach were compared with the radiographical findings of acetabular dysplasia at follow-up. The acetabular index (AI) and the center-edge (CE) angles were measured. MRI was used to measure the osseous acetabular index (OAI), cartilage acetabular index (CAI), and cartilaginous center-edge angles (CCE). The Children's Hospital's Oakland Hip Evaluation Score (CHOHES) was used for the assessment of clinical and functional results. The Severin scoring system was used to evaluate the radiographic results. The Mann-Whitney U test and Spearman correlation tests were used for statistical analysis. RESULTS: In all, 30 (90.9%) girls and 3 (9.1%) boys with an average age of 7.4 years (range: 5-9 years) and a mean follow-up period of 6.1 years (range: 4-8 years) were included. While there was a significant difference between non-dislocated hips and operated hips in 3 measurements (AI, Wiberg CE, and Ogata CE) using X-rays (p < 0.05), no significant difference was found in the MRI measurements (OAI, CAI, and CCE) (p > 0.05). The CAI values were lower than the AI measured on X-ray (p = 0.035). The mean CCE was higher than the mean CE (p = 0.022). The mean CHOHES score was 83.1 (range: 52-100) and the score of 62% patients was above 90. There was no significant difference in terms of CHOHES score according to age at the time of operation (p = 0.43). Three (9.1%) patients were Severin class I, 8 (24.3%) patients were class II, 12 (36.3%) patients were class III and 10 (30.3%) patients were class IV. There was no correlation between preoperative hip dislocation and Severin score (p = 0.056). No significant difference was found between the ambulatory and non-ambulatory groups in terms of Severin classification (p = 0.063). CONCLUSION: Cartilaginous acetabulum should be taken into account in RAD measurements. MRI may be a more appropriate option for the evaluation of acetabular cartilaginous coverage in the evaluation of RAD and the decision to perform surgery, though X-rays are currently the most used method. The results revealed no effect on functional or radiological scores as a result of being of walking age. LEVEL OF STUDY: Level III, Diagnostic Study.


Assuntos
Acetábulo , Cartilagem , Luxação Congênita de Quadril , Imagem por Ressonância Magnética/métodos , Complicações Pós-Operatórias , Radiografia/métodos , Reoperação , Acetábulo/diagnóstico por imagem , Acetábulo/patologia , Fatores Etários , Cartilagem/diagnóstico por imagem , Cartilagem/patologia , Criança , Feminino , Seguimentos , Luxação Congênita de Quadril/diagnóstico , Luxação Congênita de Quadril/fisiopatologia , Luxação Congênita de Quadril/cirurgia , Humanos , Masculino , Seleção de Pacientes , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Reoperação/métodos , Reoperação/normas , Estudos Retrospectivos , Tempo para o Tratamento
2.
World Neurosurg ; 130: e199-e205, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31203083

RESUMO

BACKGROUND: Dysphagia is one of the most common complications of anterior cervical spine surgery, and there is a need to establish that the means of testing for it are reliable and valid. The objective of this study was to measure observer variability of the fiberoptic endoscopic evaluation of swallowing (FEES) test, specifically when used for evaluation of dysphagia in patients undergoing revisionary anterior cervical decompression and fusion (ACDF). METHODS: Images from patients undergoing revision ACDF at a single institution were collected from May 1, 2010, through July 1, 2014. Two senior certified speech pathologists independently evaluated the swallowing function of patients preoperatively and at 2 weeks postoperatively. Their numeric evaluations of the Rosenbeck Penetration-Aspiration Scale and the Swallowing Performance Scale during the FEES were then compared for interrater reliability. RESULTS: Positive agreement between raters was 94% for the preoperative Penetration-Aspiration Scale (prevalence-adjusted bias-adjusted κ, 0.77). The postoperative Penetration-Aspiration Scale showed reliability coefficients for κ, Kendall's W, and intraclass correlation coefficient (ICC) of 0.34 (fair agreement), 0.70 (extremely strong agreement), and 0.35 (poor agreement), respectively. The preoperative Swallowing Performance Scale showed strong agreement, with a Kendall's W coefficient of 0.68, and fair reliability, with an ICC of 0.40. The postoperative Swallowing Performance Scale indicated extremely strong agreement between raters, with a Kendall's W of 0.82, and good agreement, with an ICC of 0.53. CONCLUSIONS: The FEES test appears to be a reliable assessor of dysphagia in patients undergoing ACDF and may be a useful measure for exploring outcomes in this population.


Assuntos
Vértebras Cervicais/cirurgia , Deglutição/fisiologia , Discotomia/normas , Tecnologia de Fibra Óptica/normas , Neuroendoscopia/normas , Fusão Vertebral/normas , Estudos de Coortes , Descompressão Cirúrgica/métodos , Descompressão Cirúrgica/normas , Discotomia/métodos , Feminino , Tecnologia de Fibra Óptica/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Neuroendoscopia/métodos , Avaliação de Resultados da Assistência ao Paciente , Reoperação/métodos , Reoperação/normas , Reprodutibilidade dos Testes , Fusão Vertebral/métodos
3.
J Arthroplasty ; 34(2): 206-210, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30448324

RESUMO

BACKGROUND: Revision total joint arthroplasty (TJA) is associated with increased readmissions, complications, and expense compared to primary TJA. Bundled payment methods have been used to improve value of care in primary TJA, but little is known of their impact in revision TJA patients. The purpose of this study is to evaluate the impact of a care redesign for a bundled payment model for primary TJA on quality metrics for revision patients, despite absence of a targeted intervention for revisions. METHODS: We compared quality metrics for all revision TJA patients including readmission rate, use of post-acute care facility after discharge, length of stay, and cost, between the year leading up to the redesign and the 2 years following its implementation. Changes in the primary TJA group over the same time period were also assessed for comparison. RESULTS: Despite a volume increase of 37% over the study period, readmissions declined from 8.9% to 5.8%. Use of post-acute care facilities decreased from 42% to 24%. Length of stay went from 4.84 to 3.92 days. Cost of the hospital episode declined by 5%. CONCLUSION: Our health system experienced a halo effect from our bundled payment-influenced care redesign, with revision TJA patients experiencing notable improvements in several quality metrics, though not as pronounced as in the primary TJA population. These changes benefitted the patients, the health system, and the payers. We attribute these positive changes to an altered institutional mindset, resulting from an invested and aligned care team, with active physician oversight over the care episode.


Assuntos
Artroplastia de Quadril/normas , Artroplastia do Joelho/normas , Procedimentos Clínicos/normas , Pacotes de Assistência ao Paciente/normas , Reoperação/normas , Idoso , Artroplastia de Quadril/economia , Artroplastia de Quadril/estatística & dados numéricos , Artroplastia do Joelho/economia , Artroplastia do Joelho/estatística & dados numéricos , Procedimentos Clínicos/economia , Procedimentos Clínicos/estatística & dados numéricos , Cuidado Periódico , Gastos em Saúde , Hospitais , Humanos , Pessoa de Meia-Idade , Pacotes de Assistência ao Paciente/economia , Pacotes de Assistência ao Paciente/estatística & dados numéricos , Alta do Paciente , Reoperação/economia , Reoperação/estatística & dados numéricos , Estudos Retrospectivos
4.
Spine (Phila Pa 1976) ; 44(1): 79-83, 2019 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-29894451

RESUMO

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: The aim of this study was to compare 30-day postoperative outcomes between patients undergoing outpatient and inpatient single-level cervical total disc replacement (TDR) surgery. SUMMARY OF BACKGROUND DATA: Cervical TDR is a motion-sparing treatment for cervical radiculopathy and myelopathy. It is an alternative to anterior cervical discectomy and fusion (ACDF) with a similar complication rate. Like ACDF, it may be performed in the inpatient or outpatient setting. Efforts to reduce health care costs are driving spine surgery to be performed in the outpatient setting. As cervical TDR surgery continues to gain popularity, the safety of treating patients on an outpatient basis needs to be validated. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was queried for patients who underwent single-level cervical disc replacement surgery between 2006 and 2015. Complication data including 30-day complications, reoperation rate, readmission rate, and length of stay data were compared between the inpatient and outpatient cohort using univariate analysis. RESULTS: There were 531 (34.2%) patients treated as outpatients and 1022 (65.8%) were treated on an inpatient basis. The two groups had similar baseline characteristics. The overall 30-day complication rate was 1.4% for inpatients and 0.6% for outpatients. Reoperation rate was 0.6% for inpatient and 0.4% for outpatients. Readmission rate was 0.9% and 0.8% for inpatient and outpatient, respectively. There were no statistical differences identified in rates of readmission, reoperation, or complication between the inpatient and outpatient cohorts. CONCLUSION: There was no difference between 30-day complications, readmission, and reoperation rates between inpatients and outpatients who underwent a single-level cervical TDR. Furthermore, the overall 30-day complication rates were low. This study supports that single-level cervical TDR can be performed safely in an outpatient setting. LEVEL OF EVIDENCE: 3.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/tendências , Vértebras Cervicais/cirurgia , Hospitalização/tendências , Radiculopatia/cirurgia , Doenças da Medula Espinal/cirurgia , Substituição Total de Disco/tendências , Adulto , Idoso , Procedimentos Cirúrgicos Ambulatórios/normas , Estudos de Coortes , Bases de Dados Factuais/normas , Bases de Dados Factuais/tendências , Feminino , Humanos , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Melhoria de Qualidade/normas , Melhoria de Qualidade/tendências , Radiculopatia/diagnóstico , Reoperação/normas , Reoperação/tendências , Estudos Retrospectivos , Doenças da Medula Espinal/diagnóstico , Fatores de Tempo , Substituição Total de Disco/efeitos adversos , Resultado do Tratamento
5.
Medicine (Baltimore) ; 97(50): e13408, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30557995

RESUMO

Unicompartmental knee arthroplasty (UKA) is one of the effective surgical methods for the treatment of unicompartmental knee arthritis. When UKA fails, a revised surgery to total knee arthroplasty (TKA) is often necessary. The purpose of this study was to compare the clinical outcomes of revision of failed UKAs to TKAs with primary TKAs. The hypothesis was that the TKAs revised from UKAs had inferior clinical outcomes compared with primary TKAs.This meta-analysis was conducted in accordance with the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. Newcastle-Ottawa Scale (NOS) proposed by the Cochrane Collaboration was used for evaluating the methodological quality of the studies. PubMed, Medline, Embase, Web of Science, and the Cochrane Library were searched to identify studies that compared the revision of UKA to TKA with primary TKA. Primary outcomes included Range of motion (ROM); Knee society score (KSS); (re-)revision rate and complications. Secondary outcomes were blood loss and length of hospital stay.A total of 8 eligible retrospective comparative studies were identified from a keyword search. Results revealed that the primary TKAs group has a better ROM (MD = -7.29, 95% CI:-14.03-0.56, P < .05), higher Knee Society Knee scores (MD = -0.54, 95% CI:-1.12-0.04, P < .05), higher Knee Society function score (MD = -0.65,95% CI:-1.25-0.06, P < .05), lower (re-)revision rate (MD = 4.15, 95% CI:2.37-7.25, P < .05) than rUKAs. There was no significant difference in postoperative complications, blood loss and length of stay between the 2 groups.Our meta-analysis revealed that compared with primary TKAs, TKAs revised from UKAs had inferior clinical outcomes.


Assuntos
Artroplastia do Joelho/normas , Complicações Pós-Operatórias/cirurgia , Reoperação/métodos , Resultado do Tratamento , Artroplastia do Joelho/métodos , Humanos , Estudos Observacionais como Assunto , Complicações Pós-Operatórias/etiologia , Reoperação/normas
6.
Arq Bras Cardiol ; 111(5): 686-696, 2018 11.
Artigo em Inglês, Português | MEDLINE | ID: mdl-30281686

RESUMO

BACKGROUND: Venous obstructions are common in patients with transvenous cardiac implantable electronic devices, but they rarely cause immediate clinical problems. The main consequence of these lesions is the difficulty in obtaining venous access for additional leads implantation. OBJECTIVES: We aimed to assess the prevalence and predictor factors of venous lesions in patients referred to lead reoperations, and to define the role of preoperative venography in the planning of these procedures. METHODS: From April 2013 to July 2016, contrast venography was performed in 100 patients referred to device upgrade, revision and lead extraction. Venous lesions were classified as non-significant (< 50%), moderate stenosis (51-70%), severe stenosis (71-99%) or occlusion (100%). Collateral circulation was classified as absent, discrete, moderate or accentuated. The surgical strategy was defined according to the result of the preoperative venography. Univariate analysis was used to investigate predictor factors related to the occurrence of these lesions, with 5% of significance level. RESULTS: Moderate venous stenosis was observed in 23%, severe in 13% and occlusions in 11%. There were no significant differences in relation to the device side or the venous segment. The usefulness of the preoperative venography to define the operative tactic was proven, and in 99% of the cases, the established surgical strategy could be performed according to plan. CONCLUSIONS: The prevalence of venous obstruction is high in CIED recipients referred to reoperations. Venography is highly indicated as a preoperative examination for allowing the adequate surgical planning of procedures involving previous transvenous leads.


Assuntos
Desfibriladores Implantáveis/efeitos adversos , Flebografia/métodos , Cuidados Pré-Operatórios/métodos , Reoperação/métodos , Doenças Vasculares/diagnóstico por imagem , Adulto , Idoso , Terapia de Ressincronização Cardíaca/efeitos adversos , Constrição Patológica/diagnóstico por imagem , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Marca-Passo Artificial/efeitos adversos , Complicações Pós-Operatórias/prevenção & controle , Prevalência , Reoperação/normas , Doenças Vasculares/epidemiologia
7.
Am J Sports Med ; 46(13): 3174-3181, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30234997

RESUMO

BACKGROUND: High-grade acromioclavicular (AC) joint separations are relatively rare injuries that are often treated surgically, yet more information is needed about the risks of various surgical procedures in terms of considering and counseling patients regarding operative versus nonoperative treatment. PURPOSE: To calculate whether the volume of surgical treatment of AC joint separations increased over a recent 12-year period; to examine the nature and frequency of complications, reoperations, and readmissions associated with these procedures; and to assess whether patient- and surgeon-specific factors or surgical technique affected these rates. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: The American Board of Orthopaedic Surgery (ABOS) database for orthopaedic surgeons taking the Part II examination was reviewed from 2005 to 2016 to identify surgical treatment of AC joint separations. The authors calculated the percentage of all surgical cases in the ABOS database and rates of complications, reoperations, and readmissions. Association of these sequelae with patient- and surgeon-specific factors and surgical techniques was assessed. RESULTS: There was no difference in the number or percentage of cases per year over the study period. There was an overall complication rate of 24.5%, a reoperation rate of 7.3%, and a readmission rate of 1.9%. Patients ≥40 years of age had significantly higher complication, reoperation, and readmission rates as compared with patients <40 years of age. There were significant differences in complication, reoperation, readmission, and displacement rates dependent on the type of surgical procedure performed. The highest complication rates were seen with open suspensory fixation, screw fixation, open reduction internal fixation, and arthroscopic coracoclavicular ligament repair or reconstruction. The highest reoperation rates were seen with screw fixation, open reduction internal fixation, and open suspensory fixation. CONCLUSION: The volume of surgical treatment for AC joint separations did not change significantly over the study period. Complication, reoperation, and readmission rates were dependent on the type of surgical procedure performed and patient age. This information should assist surgeons in discussing risks when considering and counseling patients regarding operative versus nonoperative treatment.


Assuntos
Articulação Acromioclavicular/patologia , Luxações Articulares/cirurgia , Ortopedia/métodos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Reoperação/normas , Adulto , Estudos Transversais , Feminino , Humanos , Masculino , Ortopedia/classificação , Complicações Pós-Operatórias/etiologia
8.
Curr Opin Urol ; 28(6): 591-597, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30102624

RESUMO

PURPOSE OF REVIEW: Transurethral resection of bladder cancer (TURB) is the critical step in the management of nonmuscle invasive bladder cancer (NMIBC). This review presents new improvements in the strategy and technique of TURB as well as in technological developments used for tumour visualization and removal. RECENT FINDINGS: The goal of TURB is to perform complete resection of NMIBC. Tumor visualization during procedure can be improved by enhanced optical technologies. Fluorescence-guided photodynamic diagnosis (PDD) and narrow-band imaging (NBI) used during TURB can improve tumour detection and potentially reduce recurrence rate, their influence on progression, however, remains controversial. TURB can be performed using monopolar or bipolar electrocautery without significant differences in results or safety. To overcome limitations of traditional TURB, the technique of en-bloc resection was introduced to improve the quality of tumour removal. In selected cases, an early re-resection (re-TURB) within 2-6 weeks after initial procedure is recommended. SUMMARY: TURB is a fundamental step in diagnosis and treatment of NMIBC. Urologists should be aware of promising innovations including new imaging and surgical techniques and their potential benefits. Hopefully, new technologies and performance of TURB bring improved outcomes, which can alter the indication criteria for re-TURB.


Assuntos
Cistectomia/métodos , Imagem de Banda Estreita/métodos , Recidiva Local de Neoplasia/prevenção & controle , Reoperação/métodos , Neoplasias da Bexiga Urinária/cirurgia , Cistectomia/normas , Cistectomia/tendências , Progressão da Doença , Humanos , Imagem de Banda Estreita/tendências , Invasividade Neoplásica/patologia , Guias de Prática Clínica como Assunto , Reoperação/normas , Reoperação/tendências , Bexiga Urinária/diagnóstico por imagem , Bexiga Urinária/patologia , Bexiga Urinária/cirurgia , Neoplasias da Bexiga Urinária/diagnóstico por imagem , Neoplasias da Bexiga Urinária/patologia
9.
BMC Musculoskelet Disord ; 19(1): 240, 2018 Jul 19.
Artigo em Inglês | MEDLINE | ID: mdl-30025529

RESUMO

BACKGROUND: The number of revision rotator cuff cases is increasing. The literature is lacking guidance or biomechanical evaluation for fixation strength in a revision case scenario. Therefore, the aim of the study was to provide biomechanical data investigating primary fixation strength of a transosseous technique after anchor pullout failure of a single row reconstruction. It was hypothesized that an arthroscopic transosseous repair system as a procedure for rotator cuff revisions is providing equivalent stability compared to a primary single row suture anchor fixation due to change of fixation site. METHODS: Eight matched pairs (n = 16) of fresh frozen human shoulders were tested. The paired specimen shoulders were randomly divided into two repair groups (A single row and B primary transosseous repair). The potted specimens were mounted onto the Servohydraulic test system. Both groups were tested under cyclic loading followed by load to failure testing. Suture anchor repair shoulders (group A) that were tested to failure underwent a revision transosseous repair and were subsequently tested again using the same setup and protocol (group C). RESULTS: The mean native footprint areas did not show a significant difference between groups. The reconstructed footprint area showed a significantly greater coverage in favor of the transosseous repair. Ultimate load to failure of reconstructions with the primary anchor fixation (344.73 N ± 63.19) and the primary transosseous device (375.36 N ± 70.27) was not significantly higher compared to the revision repair (332.19 N ± 119.01 p = 0.45, p = 0.53). CONCLUSION: The tested transosseous anchor device is a suitable option to widely used suture anchors, providing equivalent fixation properties even in a revision case scenario. LEVEL OF EVIDENCE: Basic Science Study, Biomechanics.


Assuntos
Artroscopia/métodos , Reoperação/métodos , Manguito Rotador/cirurgia , Articulação do Ombro/cirurgia , Idoso , Artroscopia/normas , Fenômenos Biomecânicos/fisiologia , Feminino , Humanos , Masculino , Reoperação/normas , Manguito Rotador/patologia , Lesões do Manguito Rotador/patologia , Lesões do Manguito Rotador/cirurgia , Articulação do Ombro/patologia , Falha de Tratamento
12.
Int J Colorectal Dis ; 33(6): 755-762, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29602975

RESUMO

PURPOSE: Anastomotic leakage (AL) and surgical site infection (SSI) are prevalent complications of colorectal surgery. To lower this risk, we standardized our surgical procedures in 2012, with a preferential use of laparoscopic approach (LS) for both colon and rectal surgery, combined with triangulating anastomosis (TA) for colon surgery and defunctioning ileostomy (DI) for low anterior resection. Our aim was to evaluate the outcomes of our standardized procedures. METHODS: The incidence rate of AL (primary outcome) and of reoperation and SSI (secondary outcome) was compared before (early period, n = 648) and after (late period, n = 541) standardization, through a retrospective analysis. RESULTS: The incidence rate of AL (6.6 versus 1.8%; P = 0.001), reoperation (3.5 versus 0.7%; P = 0.0012), and SSI (7.7 versus 4.6%; P = 0.029) was lower in late than in the early period. For colon cancer, TA and LS reduced the risk of AL (2.1 versus 0.3%, P = 0.020, for TA, and 3.2 versus 0.4%, P = 0.0027, for LS) and reoperation (2.9 versus 0.3%, P = 0.003, for TA, and 2.5 versus 0.2%, P = 0.0040, for LS). For rectal cancer, the incidence of all adverse outcomes (AL, reoperation, and SSI) was lower in cases treated by LS. However, the incidence of AL was lower in the late than in early period (P = 0.002) and with LS (P = 0.002). On multivariate analysis, late period and LS were independent factors of a lower risk of adverse outcomes. CONCLUSIONS: Our surgical standardization seems to be effective in lowering the risks of AL, reoperation, and SSI after colorectal cancer surgery.


Assuntos
Fístula Anastomótica/epidemiologia , Fístula Anastomótica/etiologia , Neoplasias Colorretais/cirurgia , Cirurgia Colorretal/efeitos adversos , Cirurgia Colorretal/normas , Reoperação/normas , Infecção da Ferida Cirúrgica/etiologia , Idoso , Feminino , Humanos , Ileostomia , Laparoscopia , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Padrões de Referência , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
13.
BMC Musculoskelet Disord ; 19(1): 124, 2018 Apr 20.
Artigo em Inglês | MEDLINE | ID: mdl-29678204

RESUMO

BACKGROUND: The objective of this analysis is to evaluate the necessity of large clinical trials using FLOW trial data. METHODS: The FLOW pilot study and definitive trial were factorial trials evaluating the effect of different irrigation solutions and pressures on re-operation. To explore treatment effects over time, we analyzed data from the pilot and definitive trial in increments of 250 patients until the final sample size of 2447 patients was reached. At each increment we calculated the relative risk (RR) and associated 95% confidence interval (CI) for the treatment effect, and compared the results that would have been reported at the smaller enrolments with those seen in the final, adequately powered study. RESULTS: The pilot study analysis of 89 patients and initial incremental enrolments in the FLOW definitive trial favored low pressure compared to high pressure (RR: 1.50, 95% CI: 0.75-3.04; RR: 1.39, 95% CI: 0.60-3.23, respectively), which is in contradiction to the final enrolment, which found no difference between high and low pressure (RR: 1.04, 95% CI: 0.81-1.33). In the soap versus saline comparison, the FLOW pilot study suggested that re-operation rate was similar in both the soap and saline groups (RR: 0.98, 95% CI: 0.50-1.92), whereas the FLOW definitive trial found that the re-operation rate was higher in the soap treatment arm (RR: 1.28, 95% CI: 1.04-1.57). CONCLUSIONS: Our findings suggest that studies with smaller sample sizes would have led to erroneous conclusions in the management of open fracture wounds. TRIAL REGISTRATION: NCT01069315 (FLOW Pilot Study) Date of Registration: February 17, 2010, NCT00788398 (FLOW Definitive Trial) Date of Registration: November 10, 2008.


Assuntos
Estudos Multicêntricos como Assunto/métodos , Procedimentos Ortopédicos/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Reoperação/métodos , Humanos , Estudos Multicêntricos como Assunto/normas , Procedimentos Ortopédicos/normas , Projetos Piloto , Ensaios Clínicos Controlados Aleatórios como Assunto/normas , Reoperação/normas , Irrigação Terapêutica/métodos , Irrigação Terapêutica/normas
15.
Dis Colon Rectum ; 61(5): 622-628, 2018 May.
Artigo em Inglês | MEDLINE | ID: mdl-29578920

RESUMO

BACKGROUND: Surgical site infection is a frequent cause of morbidity after colorectal resection and is a quality measure for hospitals and surgeons. In an effort to reduce the risk of postoperative infections, many wounds are left open at the time of surgery for secondary or delayed primary wound closure. OBJECTIVE: The purpose of this study was to evaluate the impact of delayed wound closure on the rate of surgical infections and resource use. DESIGN: This retrospective propensity-matched study compared colorectal surgery patients with wounds left open with a cohort of patients with primary skin closure. SETTINGS: The American College of Surgeons National Quality Improvement Program Participant Use file for 2014 was queried. PATIENTS: A total of 50,212 patients who underwent elective or emergent colectomy, proctectomy, and stoma creation were included. MAIN OUTCOME MEASURES: Rates of postoperative infections and discharge to medical facilities were measured. RESULTS: Surgical wounds were left open in 2.9% of colorectal cases (n = 1466). Patients with skin left open were broadly higher risk, as evidenced by a significantly higher median estimated probability of 30-day mortality (3.40% vs 0.45%; p < 0.0001). After propensity matching (n = 1382 per group), there were no significant differences between baseline characteristics. Within the matched cohort, there were no differences in the rates of 30-day mortality, deep or organ space infection, or sepsis (all p > 0.05). Resource use was higher for patients with incisions left open, including longer length of stay (11 vs 10 d; p = 0.006) and higher rates of discharge to a facility (34% vs 27%; p < 0.001). LIMITATIONS: This study was limited by its retrospective design and a large data set with a bias toward academic institutions. CONCLUSIONS: In a well-matched colorectal cohort, secondary or delayed wound closure eliminates superficial surgical infections, but there was no decrease in deep or organ space infections. In addition, attention should be given to the possibility for increased resource use associated with open surgical incisions. See Video Abstract at http://links.lww.com/DCR/A560.


Assuntos
Colectomia/efeitos adversos , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Pontuação de Propensão , Melhoria de Qualidade , Reoperação/normas , Infecção da Ferida Cirúrgica/prevenção & controle , Idoso , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/diagnóstico , Infecção da Ferida Cirúrgica/epidemiologia , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologia
16.
Int Urogynecol J ; 29(2): 297-306, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-28577172

RESUMO

INTRODUCTION AND HYPOTHESIS: Surgical work encompasses important aspects of personal and manual skills. In major surgery, there is a positive correlation between surgical experience and results. For pelvic organ prolapse (POP), this relationship has to our knowledge never been examined. In any clinical practice, there is always a certain proportion of inexperienced surgeons. In Sweden, most prolapse surgeons have little experience in performing prolapse operations, 74% conducting the procedure once a month or less. Simultaneously, surgery for POP globally has failure rates of 25-30%. In other words, for most surgeons, the operation is a low-frequency procedure, and outcomes are unsatisfactory. The aim of this study was to clarify the acceptability of having a high proportion of low-volume surgeons in the management of POP. METHODS: A group of 14,676 exclusively primary anterior or posterior repair patients was assessed. Data were analyzed by logistic regression and as a group analysis. RESULTS: Experienced surgeons had shorter operation times and hospital stays. Surgical experience did not affect surgical or patient-reported complication rates, organ damage, reoperation, rehospitalization, or patient satisfaction, nor did it improve patient-reported failure rates 1 year after surgery. Assistant experience, similarly, had no effect on the outcome of the operation. CONCLUSIONS: A management model for isolated anterior or posterior POP surgery that includes a high proportion of low-volume surgeons does not have a negative impact on the quality or outcome of anterior or posterior colporrhaphy. Consequently, the high recurrence rate was not due to insufficient experience of the surgeons performing the operation.


Assuntos
Competência Clínica/estatística & dados numéricos , Procedimentos Cirúrgicos em Ginecologia/estatística & dados numéricos , Prolapso de Órgão Pélvico/cirurgia , Cirurgiões/estatística & dados numéricos , Adulto , Idoso , Feminino , Procedimentos Cirúrgicos em Ginecologia/normas , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Reoperação/normas , Reoperação/estatística & dados numéricos , Cirurgiões/normas , Suécia , Resultado do Tratamento
17.
Spine (Phila Pa 1976) ; 42 Suppl 24: S108-S111, 2017 Dec 15.
Artigo em Inglês | MEDLINE | ID: mdl-29176486

RESUMO

: Long-term data are now available to support the safety and efficacy of lumbar total disc replacement (TDR). Five-year randomized and controlled trials, meta-analyses, and observational studies support a similar or lower risk of complications with lumbar TDR compared with fusion. The panel concluded that published data on commercially available lumbar TDR devices demonstrate minimal concerns with late-onset complications, and that the risk of adjacent segment degeneration and reoperations can be reduced with lumbar TDR versus fusion. Survey results of surgeon practice experiences supported the evidence, revealing a low rate of complications with TDR. Panelists acknowledged the importance of adhering to selection criteria to help minimize patient complications.


Assuntos
Consenso , Degeneração do Disco Intervertebral/cirurgia , Vértebras Lombares/cirurgia , Substituição Total de Disco/métodos , Adulto , Feminino , Humanos , Degeneração do Disco Intervertebral/diagnóstico , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Reoperação/métodos , Reoperação/normas , Fusão Vertebral/métodos , Substituição Total de Disco/normas , Resultado do Tratamento
18.
Pain Physician ; 20(6): E863-E871, 2017 09.
Artigo em Inglês | MEDLINE | ID: mdl-28934804

RESUMO

BACKGROUND: The number of interventions on intervertebral discs rapidly increased and the treatment options for lumbar disc surgery quickly evolved. It is important that the safety and efficacy of all new innovative procedures be compared with currently accepted forms of treatment; however, the previous pairwise meta-analyses could not develop the hierarchy of these treatments. OBJECTIVES: The purpose of the study is to perform a network meta-analysis to evaluate the clinical results of 7 surgical interventions for the treatment of lumbar disc herniation. STUDY DESIGN: Network meta-analysis of randomized controlled trials (RCTs) for multiple treatment comparisons of lumbar disc herniation. METHODS: We performed a Bayesian-framework network meta-analysis of RCTs to compare 7 surgical interventions for people with lumbar disc herniation. The eligible RCTs were identified by searching Embase, Pubmed, the Cochrane Central Register of Controlled Trials (CENTRAL), and Google scholar. Data from 3 outcomes (success, complications, and reoperation rate) were independently extracted by 2 authors. RESULTS: A total of 29 RCTs including 3,146 participants were finally included into this article. Our meta-analysis provides hierarchies of these 7 interventions. For the success rate the rank probability (from best to worst): percutaneous endoscopic lumber discectomy (PELD) > standard open discectomy (SOD) > standard open microsurgical discectomy (SOMD) > chemonucleolysis (CN) > microendoscopic discectomy (MED) > percutaneous laser disc decompression (PLDD) > automated percutaneous lumber discectomy (APLD). For the complication rate the rank probability (from best to worst): PELD > SOMD > SOD > MED > PLDD > CN > APLD. For the reoperation rate the rank probability (from best to worst): SOMD > SOD > MED > PLDD > PELD > CN > APLD. LIMITATIONS: The limitations of this network meta-analysis include the range of study populations and inconformity of the follow-up times and outcome measurements. CONCLUSIONS: This meta-analysis provides evidence that PELD might be the best choice to increase the success rate and decrease the complication rate, moreover SOMD might be the best option to drop the reoperation rate. APLD might lead to the lowest success rate and the highest complication and reoperation rate. Higher quality RCTs and direct head to head trials are needed to confirm these results.Key words: Lumbar disc herniation, discectomy, minimally invasive surgery, network meta-analysis.


Assuntos
Discotomia/métodos , Degeneração do Disco Intervertebral/cirurgia , Deslocamento do Disco Intervertebral/cirurgia , Vértebras Lombares/cirurgia , Descompressão Cirúrgica/métodos , Descompressão Cirúrgica/normas , Discotomia/normas , Discotomia Percutânea/métodos , Discotomia Percutânea/normas , Endoscopia/métodos , Endoscopia/normas , Humanos , Disco Intervertebral/diagnóstico por imagem , Disco Intervertebral/cirurgia , Degeneração do Disco Intervertebral/diagnóstico por imagem , Deslocamento do Disco Intervertebral/diagnóstico por imagem , Vértebras Lombares/diagnóstico por imagem , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/normas , Meta-Análise em Rede , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Reoperação/métodos , Reoperação/normas
19.
Chirurg ; 88(7): 574-581, 2017 Jul.
Artigo em Alemão | MEDLINE | ID: mdl-28573532

RESUMO

Restorative proctocolectomy under formation of an ileoanal/ileorectal J­pouch has become the procedure of choice in the therapy of ulcerative colitis. Although patients experience a dramatic improvement of their quality of life, surgery is not successful in about 5-10% of all treated patients. The reasons for failure are chronic pouchitis, incontinence, delayed diagnosis of Crohn's disease, fistula, surgical complications, too long remnant rectal stump, chronic abscess, and surgical technical errors. Some of the reasons do not always prevent the loss of a well-functioning ileoanal pouch. In many cases, correction, closure of fistulas or even a complete reconstruction of the ileoanal pouch are possible. Based on a review of the literature and our own experience, we show in 887 patients a success rate of 75% with acceptable pouch function. Indications, technics, and results are presented.


Assuntos
Colite Ulcerativa/cirurgia , Bolsas Cólicas , Complicações Pós-Operatórias/cirurgia , Proctocolectomia Restauradora , Terapia de Salvação , Colite Ulcerativa/diagnóstico , Humanos , Complicações Pós-Operatórias/diagnóstico , Reto/cirurgia , Reoperação/normas , Fatores de Risco , Falha de Tratamento
20.
Interact Cardiovasc Thorac Surg ; 25(6): 912-917, 2017 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-28641394

RESUMO

OBJECTIVES: We reviewed reoperations following mitral valve repair (MVR) that used glutaraldehyde-treated autologous pericardium for mitral regurgitation (MR) to analyse the durability and risk factors for reoperation. METHODS: We retrospectively analysed 144 patients (mean age 57.9 years) who underwent MVR using glutaraldehyde-treated pericardium from March 1992 to December 2011. A total of 19 reoperations were necessary during the follow-up period (mean 6.9 years). The follow-up rate was 97.8%. RESULTS: At initial MVR, there were no differences in mitral leaflet augmentation applied to the anterior or posterior leaflets (P = 0.75 and P = 0.40) in both groups. Reoperations were required in 19 patients, and the mean interval between initial and redo operations was 6.7 years. Indications for reoperation included recurrent MR (n = 8), progressive mitral stenosis (n = 8) and recurrent infective endocarditis (n = 3). The rates of freedom from reoperation at 5, 10 and 15 years were 95.2 ± 1.9%, 83.5 ± 4.8% and 66.9 ± 8.5%, respectively. Four patients underwent redo MVR for recurrent MR, and the remaining 15 patients underwent mitral valve replacement. The freedom from reoperation rate in the group who underwent leaflet augmentation was statistically lower than that in the non-augmentation group (96.9 ± 2.2% vs 93.4 ± 3.2% at 5 years and 89.7 ± 4.5% vs 68.8 ± 13.7% at 10 years; log-rank, P = 0.008). Predictors of reoperation were absence of leaflet augmentation (P = 0.086, hazard ratio = 0.194) and persistent MR (P = 0.003, hazard ratio = 5.759). CONCLUSIONS: We must regularly pay careful attention to implanted pericardium, especially when augmented, as it constitutes a risk factor for reoperations. In addition, secure MVR is mandatory to control persistent MR.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Previsões , Glutaral/farmacologia , Insuficiência da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Pericárdio/transplante , Reoperação/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Ecocardiografia , Feminino , Fixadores/farmacologia , Seguimentos , Humanos , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/diagnóstico , Insuficiência da Valva Mitral/mortalidade , Pericárdio/efeitos dos fármacos , Recidiva , Reoperação/normas , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Transplante Autólogo , Resultado do Tratamento , Adulto Jovem
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