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1.
Ann Surg ; 2024 Jul 02.
Artigo em Inglês | MEDLINE | ID: mdl-38953216

RESUMO

OBJECTIVE: To determine if lymph node yield (LNY) is associated with improved overall survival (OS) and time to recurrence (TTR) in patients with node-negative pancreatic ductal adenocarcinoma (PDAC) treated with neoadjuvant therapy (NAT). BACKGROUND: Lymph node yield has been associated with survival in solid gastrointestinal cancers, including PDAC. METHODS: Patients with pathological T stage I-III, node-negative (N0), PDAC treated with NAT followed by pancreatoduodenectomy were identified in the Massachusetts General Hospital (MGH) pancreatectomy database and the National Cancer Database (NCDB). A cutoff point of 22 nodes was identified in the NCDB using the point with the optimal (log-rank test) split. Overall survival and TTR were evaluated using univariate and multivariable analyses. RESULTS: In the MGH cohort, 233 node-negative patients following NAT were included. A LNY ≥ 22 was associated with prolonged median OS (59 months vs. 25 months, P<0.001) and prolonged TTR (32 months vs. 14 months, P=0.019). On multivariable analysis, LNY was an independent predictor of survival (HR 0.97, 95% CI 0.95-0.99, P=0.034) per sampled node. In the NCDB, 2,029 node-negative patients following NAT were included. A LNY ≥ 22 was associated with prolonged median OS (49 months vs. 33 months, P<0.001). On multivariable analysis, LNY was an independent predictor of survival (HR 0.99, 95% CI 0.98-0.99, P<0.001) per sampled node. CONCLUSION: Lymph node yield was associated with improved oncologic outcomes in patients treated with NAT followed by pancreatoduodenectomy in two independent datasets. Responsible mechanisms by which LNY impacts the outcomes of node-negative patients following NAT warrant further exploration.

2.
J Surg Res ; 283: 540-549, 2023 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-36442253

RESUMO

INTRODUCTION: Management of hemorrhage from pelvic fractures is complex and requires multidisciplinary attention. Pelvic angioembolization (AE) has become a key intervention to aid in obtaining definitive hemorrhage control. We hypothesized that pelvic AE would be associated with an increased risk of venous thromboembolism (VTE). METHODS: All adults (age >16) with a severe pelvic fracture (Abbreviated Injury Scale ≥ 4) secondary to a blunt traumatic mechanism in the 2017-2019 American College of Surgeons Trauma Quality Improvement Program database were included. Patients who did not receive VTE prophylaxis during their admission were excluded. Patients who underwent pelvic AE during the first 24 h of admission were compared to those who did not using propensity score matching. Matching was performed based on patient demographics, admission physiology, comorbidities, injury severity, associated injuries, other hemorrhage control procedures, and VTE prophylaxis type, and time to initiation of VTE prophylaxis. The rates of VTE (deep vein thrombosis and pulmonary embolism) were compared between the matched groups. RESULTS: Of 72,985 patients with a severe blunt pelvic fracture, 1887 (2.6%) underwent pelvic AE during the first 24 h of admission versus 71,098 (97.4%) who did not. Pelvic AE patients had a higher median Injury Severity Score and more often required other hemorrhage control procedures, with laparotomy being most common (24.7%). The median time to initiation of VTE prophylaxis in pelvic AE versus no pelvic AE patients was 60.1 h (interquartile range = 36.6-98.6) versus 27.7 h (interquartile range = 13.9-52.4), respectively. After propensity score matching, pelvic AE patients were more likely to develop VTE compared to no pelvic AE patients (11.8% versus 9.5%, P = 0.03). CONCLUSIONS: Pelvic AE for control of hemorrhage from severe pelvic fractures is associated with an increased risk of in-hospital VTE. Patients who undergo pelvic AE are especially high risk for VTE and should be started as early as safely possible on VTE prophylaxis.


Assuntos
Fraturas Ósseas , Embolia Pulmonar , Tromboembolia Venosa , Adulto , Humanos , Tromboembolia Venosa/prevenção & controle , Embolia Pulmonar/prevenção & controle , Fraturas Ósseas/complicações , Escala Resumida de Ferimentos , Escala de Gravidade do Ferimento , Anticoagulantes/uso terapêutico , Estudos Retrospectivos
3.
J Surg Res ; 267: 37-47, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34130237

RESUMO

BACKGROUND: Body mass index (BMI) does not reliably predict Surgical site infections (SSI). We hypothesize that abdominal wall thickness (AWT) would serve as a better predictor of SSI for patients undergoing emergency colon operations. METHODS: We retrospectively evaluated our Emergency Surgery Database (2007-2018). Emergency colon operations for any indication were included. AWT was measured by pre-operative CT scans at 5 locations. Only superficial and deep SSIs were considered as SSI in the analysis. Univariate then multivariable analyses were used to determine predictors of SSI. RESULTS: 236 patients met inclusion criteria. The incidence of post-operative SSI was 25.8% and the median BMI was 25.8kg/m2 [22.5-30.1]. The median AWT between patients with and without SSI was significantly different (2.1cm [1.4, 2.8] and 1.8cm [1.2, 2.5], respectively). A higher BMI trended toward increased rates of SSI, but this was not statistically significant. In overweight (BMI 25-29.9kg/m2) and obese (BMI ≥30kg/m2) patients, SSI versus no SSI rates were (50.0% versus 41.9% and 47.4% versus 36.4%, P = 0.365 and 0.230) respectively. The incidence of SSI in patients with an average AWT < 1.8cm was 20% and 30% for patients with average AWT ≥1.8cm. On multivariable analysis, AWT ≥1.8cm at 2cm inferior to umbilicus was an independent predictor of SSI (OR 2.98, 95%CI 1.34-6.63, P = 0.007). CONCLUSIONS: AWT is a better predictor of SSI than BMI. Preoperative imaging of AWT may direct intraoperative decisions regarding wound management. Future clinical outcomes research in emergency surgery should include abdominal wall thickness as an important patient variable.


Assuntos
Parede Abdominal , Colo , Procedimentos Cirúrgicos do Sistema Digestório , Infecção da Ferida Cirúrgica , Parede Abdominal/anatomia & histologia , Parede Abdominal/diagnóstico por imagem , Parede Abdominal/cirurgia , Colo/cirurgia , Humanos , Estudos Retrospectivos , Fatores de Risco , Infecção da Ferida Cirúrgica/diagnóstico por imagem , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/etiologia
4.
Ann Surg ; 272(3): 469-478, 2020 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-32657946

RESUMO

BACKGROUND AND OBJECTIVE: Reltecimod, a CD 28 T-lymphocyte receptor mimetic, inhibits T-cell stimulation by an array of bacterial pathogens. A previous phase 2 trial demonstrated improved resolution of organ dysfunction after NSTI. We hypothesized that early administration of reltecimod would improve outcome in severe NSTI. METHODS: Randomized, double-blind, placebo-controlled trial of single dose reltecimod (0.5 mg/kg) administered within 6 hours of NSTI diagnosis at 65 of 93 study sites. Inclusion: surgical confirmation of NSTI and organ dysfunction [modified Sequential Organ Failure Assessment Score (mSOFA) score ≥3]. Primary analysis was modified Intent-to-Treat (mITT), responder analysis using a previously validated composite endpoint, necrotizing infection clinical composite endpoint, defined as: alive at day 28, ≤3 debridements, no amputation beyond first operation, and day 14 mSOFA ≤1 with ≥3 point reduction (organ dysfunction resolution). A prespecified, per protocol (PP) analysis excluded 17 patients with major protocol violations before unblinding. RESULTS: Two hundred ninety patients were enrolled, mITT (Reltecimod 142, Placebo 148): mean age 55 ±â€Š15 years, 60% male, 42.4% diabetic, 28.6% perineal infection, screening mSOFA mean 5.5 ±â€Š2.4. Twenty-eight-day mortality was 15% in both groups. mITT necrotizing infection clinical composite endpoint success was 48.6% reltecimod versus 39.9% placebo, P = 0.135 and PP was 54.3% reltecimod versus 40.3% placebo, P = 0.021. Resolution of organ dysfunction was 65.1% reltecimod versus 52.6% placebo, P = 0.041, mITT and 70.9% versus 53.4%, P = 0.005, PP. CONCLUSION: Early administration of reltecimod in severe NSTI resulted in a significant improvement in the primary composite endpoint in the PP population but not in the mITT population. Reltecimod was associated with improved resolution of organ dysfunction and hospital discharge status.


Assuntos
Antígenos CD28/administração & dosagem , Desbridamento/métodos , Fasciite Necrosante/terapia , Relação Dose-Resposta a Droga , Método Duplo-Cego , Esquema de Medicação , Feminino , Humanos , Fatores Imunológicos/administração & dosagem , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
5.
Pancreatology ; 20(8): 1576-1581, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33077381

RESUMO

Current management of infected pancreatic necrosis is focused on a minimally invasive step-up approach. The step-up approach consists of initial percutaneous or endoscopic drainage of infected pancreatic necrosis, followed, if necessary, by minimally invasive surgical or endoscopic debridement. While there is reduced morbidity and mortality, vascular complications can be life-threatening. Reported vascular complications have been limited to arterial bleeding. Venous bleeding has not been previously reported. We present two cases of portal venous bleeding in patients who underwent treatment for infected pancreatic necrosis with a step-up approach. We discuss the clinical presentation, diagnosis, and initial management. Moreover, we present two different techniques that can be used to successfully manage venous bleeding in patients who have percutaneous drains in place as part of a step-up approach. These techniques involve tamponading the cavity or drain tract with topical hemostatics and direct embolization of the bleeding vein. These experiences can serve as a guide for managing portal venous bleeding in patients with infected pancreatic necrosis.


Assuntos
Hemorragia , Procedimentos Cirúrgicos Minimamente Invasivos , Pancreatite Necrosante Aguda , Drenagem/métodos , Endoscopia , Hemorragia/etiologia , Hemorragia/terapia , Humanos , Infecções Intra-Abdominais , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Pancreatite Necrosante Aguda/complicações , Sistema Porta
6.
Am J Emerg Med ; 38(10): 2028-2033, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-33142169

RESUMO

INTRODUCTION: Emergency department (ED) crowding is associated with increased mortality and delays in care. We developed a rapid admission pathway targeting critically-ill trauma patients in the ED. This study investigates the sustainability of the pathway, as well as its effectiveness in times of increased ED crowding. MATERIALS & METHODS: This was a retrospective cohort study assessing the admission of critically-ill trauma patients with and without the use of a rapid admission pathway from 2013 to 2018. We accessed demographic and clinical data from trauma registry data and ED capacity logs. Statistical analyses included univariate and multivariate testing. RESULTS: A total of 1700 patients were included. Of this cohort, 434 patients were admitted using the rapid admission pathway, whereas 1266 were admitted using the traditional pathway. In bivariate analysis, mean ED LOS was 1.54 h (95% Confidence Interval [CI]: 1.41, 1.66) with the rapid pathway, compared with 5.88 h (95% CI: 5.64, 6.12) with the traditional pathway (p < 0.01). We found no statistically significant relationship between rapid admission pathway use and survival to hospital discharge. During times of increased crowding, rapid pathway use continued to be associated with reduction in ED LOS (p < 0.01). The reduction in ED LOS was sustained when comparing initial results (2013-2014) to recent data (2015-2018). CONCLUSION: This study found that a streamlined process to admit critically-ill trauma patients is sustainable and associated with reduction in ED LOS. As ED crowding remains pervasive, these findings support restructured care processes to limit prolonged ED boarding times for critically-ill patients.


Assuntos
Aglomeração , Admissão do Paciente/normas , Fatores de Tempo , Ferimentos e Lesões/complicações , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Estado Terminal/terapia , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/tendências , Estudos Retrospectivos , Estatísticas não Paramétricas
7.
World J Surg ; 43(8): 1890-1897, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30963204

RESUMO

BACKGROUND: Spontaneous retroperitoneal and rectus sheath hemorrhage (SRRSH) is associated with high mortality in the literature, but studies on the subject are lacking. The objective of this study was to identify early predictors of the need for angiographic or surgical intervention (ASI) in patients with SRRSH and define risk factors for mortality. METHODS: We conducted a retrospective cohort study at a tertiary academic hospital. All patients with computed tomography-identified SRRSH between 2012 to 2017 were included. Exclusion criteria were age below 18 years, possible mechanical cause of SRRSH, aortic aneurysm rupture or dissection, and traumatic or iatrogenic sources of SRRSH. The primary outcome was the incidence of ASI and/or mortality. RESULTS: Of 100 patients included (median age 70 years, 52% males), 33% were transferred from another hospital, 82% patients were on therapeutic anticoagulation, and 90% had serious comorbidities. Overall mortality was 22%, but SRRSH-related mortality was only 6%. Sixteen patients underwent angiographic intervention (n = 10), surgical intervention (n = 5), or both (n = 1). Flank pain (OR 4.15, 95% CI 1.21-14.16, p = 0.023) and intravenous contrast extravasation (OR 3.89, 95% CI 1.23-12.27, p = 0.020) were independent predictors of ASI. Transfer from another hospital (OR 3.72, 95% CI 1.30-10.70, p = 0.015), age above 70 years (OR 4.24, 95% CI 1.25-14.32, p = 0.020), and systolic blood pressure below 110 mmHg at the time of diagnosis (OR 4.59, 95% CI 1.19-17.68, p = 0.027) were independent predictors of mortality. CONCLUSIONS: SRRSH is associated with high mortality but is typically not the direct cause. Most SRRSHs are self-limited and require no intervention. Pattern identification of ASI is hard.


Assuntos
Hemorragia/terapia , Reto do Abdome , Espaço Retroperitoneal , Idoso , Angiografia , Anticoagulantes/efeitos adversos , Comorbidade , Gerenciamento Clínico , Feminino , Hemorragia/diagnóstico por imagem , Hemorragia/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Reto do Abdome/diagnóstico por imagem , Espaço Retroperitoneal/diagnóstico por imagem , Estudos Retrospectivos , Fatores de Risco , Gestão de Riscos , Tomografia Computadorizada por Raios X
8.
Am J Emerg Med ; 37(1): 61-66, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-29724580

RESUMO

OBJECTIVE: We sought to develop a practical Bedside Score for the diagnosis of cholecystitis and test its accuracy against the Tokyo Guidelines (TG13). METHODS: We conducted a retrospective study of 438 patients undergoing urban, academic Emergency Department (ED) evaluation of RUQ pain. Symptoms, physical signs, ultrasound signs, and labs were scoring system candidates. A random split-sample approach was used to develop and validate a new clinical score. Multivariable regression analysis using development data was conducted to identify predictors of cholecystitis. Cutoff values were chosen to ensure positive/negative predictive values (PPV, NPV) of at least 0.95. The score was externally validated in 80 patients at a different hospital undergoing RUQ pain evaluation. RESULTS: 230 patients (53%) had cholecystitis. Five variables predicted cholecystitis and were included in the scores: gallstones, gallbladder thickening, clinical or ultrasonographic Murphy's sign, RUQ tenderness, and post-prandial symptoms. A clinical prediction score was developed. When dichotomized at 4, overall accuracy for acute cholecystitis was 90% for the development cohort, 82% and 86% for the internal and external validation cohorts; TG13 accuracy was 62%-79%. CONCLUSIONS: A clinical prediction score for cholecystitis demonstrates accuracy equivalent to TG13. Use of this score may streamline work-up by decreasing the need for comprehensive ultrasound evaluation and CRP measurement and may shorten ED length of stay.


Assuntos
Colecistite Aguda/diagnóstico , Técnicas de Diagnóstico do Sistema Digestório , Serviço Hospitalar de Emergência , Cálculos Biliares/diagnóstico , Sistemas Automatizados de Assistência Junto ao Leito , Adulto , Colecistite Aguda/etiologia , Diagnóstico Diferencial , Técnicas de Diagnóstico do Sistema Digestório/normas , Feminino , Cálculos Biliares/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Estudos Retrospectivos , Sensibilidade e Especificidade , Tóquio
9.
Gut ; 67(4): 697-706, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-28774886

RESUMO

OBJECTIVE: Minimally invasive surgical necrosectomy and endoscopic necrosectomy, compared with open necrosectomy, might improve outcomes in necrotising pancreatitis, especially in critically ill patients. Evidence from large comparative studies is lacking. DESIGN: We combined original and newly collected data from 15 published and unpublished patient cohorts (51 hospitals; 8 countries) on pancreatic necrosectomy for necrotising pancreatitis. Death rates were compared in patients undergoing open necrosectomy versus minimally invasive surgical or endoscopic necrosectomy. To adjust for confounding and to study effect modification by clinical severity, we performed two types of analyses: logistic multivariable regression and propensity score matching with stratification according to predicted risk of death at baseline (low: <5%; intermediate: ≥5% to <15%; high: ≥15% to <35%; and very high: ≥35%). RESULTS: Among 1980 patients with necrotising pancreatitis, 1167 underwent open necrosectomy and 813 underwent minimally invasive surgical (n=467) or endoscopic (n=346) necrosectomy. There was a lower risk of death for minimally invasive surgical necrosectomy (OR, 0.53; 95% CI 0.34 to 0.84; p=0.006) and endoscopic necrosectomy (OR, 0.20; 95% CI 0.06 to 0.63; p=0.006). After propensity score matching with risk stratification, minimally invasive surgical necrosectomy remained associated with a lower risk of death than open necrosectomy in the very high-risk group (42/111 vs 59/111; risk ratio, 0.70; 95% CI 0.52 to 0.95; p=0.02). Endoscopic necrosectomy was associated with a lower risk of death than open necrosectomy in the high-risk group (3/40 vs 12/40; risk ratio, 0.27; 95% CI 0.08 to 0.88; p=0.03) and in the very high-risk group (12/57 vs 28/57; risk ratio, 0.43; 95% CI 0.24 to 0.77; p=0.005). CONCLUSION: In high-risk patients with necrotising pancreatitis, minimally invasive surgical and endoscopic necrosectomy are associated with reduced death rates compared with open necrosectomy.


Assuntos
Desbridamento , Drenagem , Duodenoscopia , Pâncreas/patologia , Pancreatite Necrosante Aguda/cirurgia , Adulto , Idoso , Brasil , Canadá , Desbridamento/métodos , Drenagem/métodos , Duodenoscopia/métodos , Feminino , Alemanha , Hospitais , Humanos , Hungria , Índia , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Necrose , Países Baixos , Pancreatite Necrosante Aguda/mortalidade , Pancreatite Necrosante Aguda/patologia , Estudos Prospectivos , Resultado do Tratamento , Estados Unidos
11.
World J Surg ; 42(1): 82-87, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-28762168

RESUMO

BACKGROUND: The exact role of IV contrast-enhanced computed tomography (CT) in the diagnosis of necrotizing soft tissue infections (NSTIs) has not yet been established. We aimed to explore the role of CT in patients with clinical suspicion of NSTI and assess its sensitivity and specificity for NSTI. METHODS: The medical records of patients admitted between 2009 and 2016, who received IV contrast-enhanced CT to rule out NSTI, were reviewed. CT was considered positive in case of: (a) gas in soft tissues, (b) multiple fluid collections, (c) absence or heterogeneity of tissue enhancement by the IV contrast, and (d) significant inflammatory changes under the fascia. NSTI was confirmed only by the presence of necrotic tissue during surgical exploration. NSTI was considered absent if surgical exploration failed to identify necrosis, or if the patient was successfully treated non-operatively. RESULTS: Of the 184 patients, 17 had a positive CT and hence underwent surgical exploration with NSTI being confirmed in 13 of them (76%). Of the 167 patients that had a negative CT, 38 (23%) underwent surgical exploration due to the high clinical suspicion for NSTI and were all found to have non-necrotizing infections; the remaining 129 (77%) were managed non-operatively with successful resolution of symptoms. The sensitivity of CT in identifying NSTI was 100%, the specificity 98%, the positive predictive value 76%, and the negative predictive value 100%. CONCLUSIONS: A negative IV contrast-enhanced CT scan can reliably rule out the need for surgical intervention in patients with initial suspicion of NSTI.


Assuntos
Infecções dos Tecidos Moles/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Necrose , Estudos Retrospectivos , Sensibilidade e Especificidade , Infecções dos Tecidos Moles/patologia
12.
World J Surg ; 42(10): 3143-3149, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29626246

RESUMO

BACKGROUND: Patients with gallstone pancreatitis (GP) or choledocholithiasis (CDL) may have common bile duct (CBD) stones that persist until cholangiography. The aim of this study is to evaluate pre-cholangiogram factors that predict persistent CBD stones. METHODS: Multiple logistic regression analyses were performed to identify demographic, laboratory, and radiologic predictors of persistent CBD stones and non-therapeutic cholangiography among adults with GP or CDL. RESULTS: In 152 patients from 2010 to 2015, preoperative diagnosis, presence of a CBD stone on US, and age ≥ 60 years were associated with persistent CBD stones. Two risk factors alone had a PPV of 88% and the absence of all risk factors had a NPV of 94%. Age < 60 years and the absence of a CBD stone on US were most predictive of non-therapeutic cholangiography. CONCLUSION: Age, LFTs, and US help predict persistent CBD stones in patients initially presenting with GP or CDL and help minimize non-therapeutic preoperative cholangiography.


Assuntos
Colangiografia , Coledocolitíase/diagnóstico por imagem , Cálculos Biliares/diagnóstico por imagem , Pancreatite/diagnóstico por imagem , Adulto , Idoso , Coledocolitíase/complicações , Feminino , Cálculos Biliares/complicações , Humanos , Testes de Função Hepática , Masculino , Pessoa de Meia-Idade , Pancreatite/complicações , Período Pré-Operatório , Análise de Regressão , Fatores de Risco , Resultado do Tratamento
13.
Ann Surg ; 265(6): 1119-1125, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-27805961

RESUMO

OBJECTIVE: We sought to assess the impact of intraoperative adverse events (iAEs) on 30-day postoperative mortality, 30-day postoperative morbidity, and postoperative length of stay (LOS) among patients undergoing abdominal surgery. We hypothesized that iAEs would be associated with significant increases in each outcome. SUMMARY OF BACKGROUND DATA: The relationship between iAEs and postoperative clinical outcomes remains largely unknown. METHODS: The 2007 to 2012 institutional ACS-NSQIP and administrative databases for abdominal surgeries were matched then screened for iAEs using the Agency for Healthcare Research and Quality's 15 Patient Safety Indicator, "Accidental Puncture/Laceration". Each chart flagged during the initial screen was then manually reviewed to confirm whether an iAE occurred. Univariate then multivariable logistic regression models were constructed to assess the independent impact of iAEs on 30-day mortality, 30-day morbidity, and prolonged (≥7 days) postoperative LOS, controlling for preoperative/intraoperative variables (eg, age, comorbidities, ASA, wound classification), procedure type (eg, laparoscopic vs open, intestinal, foregut, hepatopancreaticobiliary vs abdominal wall procedure), and complexity (eg, adhesions; relative value units). Propensity score analyses were conducted with each iAE patient matched with 5 non-iAE patients. Sensitivity analyses were performed. RESULTS: A total of 9288 cases were included; 183 had iAEs. Most iAEs consisted of bowel (44%) or vessel (29%) injuries and were addressed intraoperatively (92%). In multivariable analyses, iAEs were independently associated with increased 30-day mortality [OR = 3.19, 95% confidence interval (CI) 1.52-6.71, P = 0.002], 30-day morbidity (OR = 2.68, 95% CI 1.89-3.81, P < 0.001), and prolonged postoperative LOS (OR = 1.85, 95% CI 1.27-2.70, P = 0.001). Postoperative complications associated with iAEs included deep/organ-space surgical site infection (OR = 1.94, 95% CI 1.20-3.14), P = 0.007), sepsis (OR = 2.14, 95% CI 1.32-3.47, P = 0.002), pneumonia (OR = 2.18, 95% CI 1.11-4.26, P = 0.023), and failure to wean ventilator (OR = 3.88, 95% CI 2.17-6.95, P < 0.001). Propensity score matching confirmed these findings, as did multiple sensitivity analyses. CONCLUSIONS: iAEs are independently associated with substantial increases in postoperative mortality, morbidity, and prolonged LOS. Quality improvement efforts should focus on iAE prevention, mitigation of harm after iAEs occur, and risk/severity-adjusted iAE tracking and benchmarking.


Assuntos
Abdome/cirurgia , Mortalidade Hospitalar , Complicações Intraoperatórias , Tempo de Internação/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Análise de Variância , Benchmarking , Bases de Dados Factuais , Feminino , Humanos , Cuidados Intraoperatórios/normas , Complicações Intraoperatórias/classificação , Complicações Intraoperatórias/prevenção & controle , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Salas Cirúrgicas , Pontuação de Propensão , Estudos Retrospectivos
15.
Pancreatology ; 16(5): 788-90, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27344627

RESUMO

Enteric fistula is a serious complication of necrotizing pancreatitis. Endoscopic transluminal drainage and necrosectomy can significantly reduce the incidence of enterocutaneous fistula after pancreatic debridement. However, endoscopic necrosectomy may not be well-suited to debridement of necrosis that tracks laterally to the paracolic gutters, which is often more efficiently addressed by video-assisted retroperitoneal debridement (VARD). We report the combined use of endoscopic transgastric drainage and VARD for treatment of a 76 year old man with severe necrotizing acute pancreatitis complicated by infected, walled-off pancreatic necrosis. Computed tomography showed laterally tracking pancreatic necrosis and flouroscopic drain injection after percutaneous drainage demonstrated with fistulas to the stomach, duodenum, and colon. The infection and fistulas resolved completely. This approach combined the major advantage of VARD with the major advantage of endoscopic transluminal drainage. We are not aware of any reports of combining these techniques and believe the combination offers a minimally invasive approach for patients with extensive necrosis and a high likelihood of enteric or pancreatic fistulas.


Assuntos
Desbridamento/métodos , Drenagem/métodos , Endoscopia/métodos , Pâncreas/cirurgia , Fístula Pancreática/terapia , Pancreatite Necrosante Aguda/terapia , Cirurgia Assistida por Computador/métodos , Idoso , Fluoroscopia , Humanos , Masculino , Pâncreas/diagnóstico por imagem , Fístula Pancreática/complicações , Fístula Pancreática/cirurgia , Pancreatite Necrosante Aguda/complicações , Pancreatite Necrosante Aguda/cirurgia , Stents , Tomografia Computadorizada por Raios X , Resultado do Tratamento
18.
World J Surg ; 39(2): 380-6, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25277981

RESUMO

BACKGROUND: Main concern during the practice of selective non-operative management (SNOM) for abdominal stab wounds (SW) and gunshot wounds (GSW) is the potential for harm in patients who fail SNOM and receive a delayed laparotomy (DL). The aim of this study is to determine whether such patients suffer adverse sequelae because of delays in diagnosis and treatment when managed under a structured SNOM protocol. METHODS: 190 patients underwent laparotomy after an abdominal GSW or SW (5/04-10/12). Patients taken to operation within 120 min of admission were included in the early laparotomy (EL) group (n =153, 80.5 %) and the remaining in the DL group (n =37, 19.5 %). Outcomes included mortality, hospital stay, and postoperative complications. RESULTS: The median time from hospital arrival to operation was 43 min (range: 17-119) for EL patients and 249 min (range: 122-1,545) for DL patients. The average number and type of injuries were similar among the groups. Mortality and negative laparotomy were observed only in the EL group. There was no significant difference in the hospital stay between the groups. The overall complications were higher in the EL group (44.4 vs. 24.3 %, p =0.026). DL was independently associated with a lower likelihood for complications (OR 0.39, 95 % CI 0.16-0.98, p =0.045). Individual review of all DL patients did not reveal an incident in which complications could be directly attributed to the delay. CONCLUSIONS: In a structured protocol, patients who fail SNOM and require an operation are recognized and treated promptly. The delay in operation does not cause unnecessary morbidity or mortality.


Assuntos
Traumatismos Abdominais/cirurgia , Laparotomia , Ferimentos por Arma de Fogo/cirurgia , Ferimentos Perfurantes/cirurgia , Traumatismos Abdominais/terapia , Adolescente , Adulto , Protocolos Clínicos , Diagnóstico Tardio , Feminino , Mortalidade Hospitalar , Humanos , Laparotomia/efeitos adversos , Tempo de Internação , Masculino , Fatores de Tempo , Tempo para o Tratamento , Ferimentos por Arma de Fogo/terapia , Ferimentos Perfurantes/terapia , Adulto Jovem
19.
World J Surg ; 39(11): 2685-90, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26239776

RESUMO

BACKGROUND: The value of additional imaging in clearing the cervical spine (C-spine) of alert trauma patients with tenderness on clinical exam and a negative computed tomographic (CT) scan is still unclear. METHODS: All adult trauma patients with a Glasgow Coma Scale of 15, C-spine tenderness in the absence of neurologic signs, and a negative C-spine CT were included. The study period extended from September 2011 to June 2012. C-spine CT scans were interpreted in detail and considered negative in the absence of any findings indicating bony, ligamentous, or soft tissue injury around the C-spine. The incidence of C-spine injury was evaluated using early (<24 h) repeat physical examination, MRI, and/or flexion-extension films. RESULTS: Of 2015 patients with a C-spine CT, 383 (19 %) fulfilled the inclusion criteria. The median age was 43 (IQR: 30-53) and 44.7 % were female. Thirty-six patients (9.4 %) underwent MRI (3.7 %), flexion-extension imaging (5.2 %), or both (0.5 %), with no significant injuries identified and subsequent removal of the collar allowed. The remaining patients were clinically cleared within 24 h of presentation. None of the patients developed neurological signs following removal of the collar. On bivariate analysis, no variable except for evaluation by trauma surgery was associated with performance of additional imaging. CONCLUSION: C-spine precautions can be withdrawn without additional imaging in most blunt trauma patients with C-spine tenderness but negative neurologic evaluation and C-spine CT. Focus should be placed on the detailed and comprehensive interpretation of the C-spine CT.


Assuntos
Vértebras Cervicais/diagnóstico por imagem , Traumatismos da Coluna Vertebral/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Adulto , Vértebras Cervicais/lesões , Feminino , Escala de Coma de Glasgow , Humanos , Imageamento por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade
20.
Ann Surg ; 260(4): 706-14; discussion 714-5, 2014 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25203888

RESUMO

OBJECTIVE: To determine the role of intestinal alkaline phosphatase (IAP) in enteral starvation-induced gut barrier dysfunction and to study its therapeutic effect as a supplement to prevent gut-derived sepsis. BACKGROUND: Critically ill patients are at increased risk for systemic sepsis and, in some cases, multiorgan failure leading to death. Years ago, the gut was identified as a major source for this systemic sepsis syndrome. Previously, we have shown that IAP detoxifies bacterial toxins, prevents endotoxemia, and preserves intestinal microbiotal homeostasis. METHODS: WT and IAP-KO mice were used to examine gut barrier function and tight junction protein levels during 48-hour starvation and fed states. Human ileal fluid samples were collected from 20 patients postileostomy and IAP levels were compared between fasted and fed states. To study the effect of IAP supplementation on starvation-induced gut barrier dysfunction, WT mice were fasted for 48 hours +/- IAP supplementation in the drinking water. RESULTS: The loss of IAP expression is associated with decreased expression of intestinal junctional proteins and impaired barrier function. For the first time, we demonstrate that IAP expression is also decreased in humans who are deprived of enteral feeding. Finally, our data demonstrate that IAP supplementation reverses the gut barrier dysfunction and tight junction protein losses due to a lack of enteral feeding. CONCLUSIONS: IAP is a major regulator of gut mucosal permeability and is able to ameliorate starvation-induced gut barrier dysfunction. Enteral IAP supplementation may represent a novel approach to maintain bowel integrity in critically ill patients.


Assuntos
Fosfatase Alcalina/administração & dosagem , Fosfatase Alcalina/metabolismo , Estado Terminal , Suplementos Nutricionais , Mucosa Intestinal/enzimologia , Síndrome de Resposta Inflamatória Sistêmica/prevenção & controle , Administração Oral , Animais , Nutrição Enteral , Humanos , Íleo/enzimologia , Íleo/imunologia , Inflamação/enzimologia , Jejuno/enzimologia , Jejuno/imunologia , Camundongos , Permeabilidade , Inanição , Proteínas de Junções Íntimas/metabolismo , Regulação para Cima
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