Risk of Prolonged Opioid Use Among Opioid-Naïve Patients Following Common Hand Surgery Procedures.

PubMed

Johnson, Shepard P; Chung, Kevin C; Zhong, Lin; Shauver, Melissa J; Engelsbe, Michael J; Brummett, Chad; Waljee, Jennifer F

2016-10-01

To evaluate prolonged opioid use in opioid-naïve patients after common hand surgery procedures in the United States. We studied insurance claims from the Truven MarketScan databases to identify opioid-naïve adult patients (no opioid exposure 11 months before the perioperative period) who underwent an elective (carpal tunnel release, carpometacarpal arthroplasty/arthrodesis, cubital tunnel release, or trigger finger release) or trauma-related (closed distal radius fracture fixation, flexor tendon repair, metacarpal fracture fixation, or phalangeal fracture fixation) hand surgery procedure between 2010 and 2012 (N = 77,573 patients). Patients were observed for 6 months to determine the number, timing, duration, and oral morphine equivalent dosage of postoperative opioid prescriptions. We assessed prolonged postoperative opioid use, defined as patients who filled a perioperative opioid prescription followed by a prescription between 90 and 180 days after surgery, and evaluated associated risk factors using multivariable logistic regression. In this cohort, 59,725 opioid-naïve patients (77%) filled a perioperative opioid prescription. Of these, 13% of patients continued to fill prescriptions between 90 and 180 days after surgery. Elective surgery patients were more likely to continue to fill opioid prescriptions after 90 days compared with trauma patients (13.5% vs 10.5%). Younger age, female gender, lower income, comprehensive insurance, higher Elixhauser comorbidity index, mental health disorders, and tobacco dependence or abuse were associated with prolonged opioid use. Approximately 13% of opioid-naïve patients continue to fill opioid prescriptions after hand surgery procedures 90 days after surgery. Preoperative interventions centered on opioid alternatives and early cessation, particularly among patients at risk for long-term use, is critical to addressing the prescription opioid crisis in the United States. The current national opioid use epidemic requires an assessment of the prevalence of hand surgery patients who receive and fill opioid prescriptions after common hand surgery procedures. Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Chest physiotherapy during immediate postoperative period among patients undergoing upper abdominal surgery: randomized clinical trial.

PubMed

Manzano, Roberta Munhoz; Carvalho, Celso Ricardo Fernandes de; Saraiva-Romanholo, Beatriz Mangueira; Vieira, Joaquim Edson

2008-09-01

Abdominal surgical procedures increase pulmonary complication risks. The aim of this study was to evaluate the effectiveness of chest physiotherapy during the immediate postoperative period among patients undergoing elective upper abdominal surgery. This randomized clinical trial was performed in the post-anesthesia care unit of a public university hospital. Thirty-one adults were randomly assigned to control (n = 16) and chest physiotherapy (n = 15) groups. Spirometry, pulse oximetry and anamneses were performed preoperatively and on the second postoperative day. A visual pain scale was applied on the second postoperative day, before and after chest physiotherapy. The chest physiotherapy group received treatment at the post-anesthesia care unit, while the controls did not. Surgery duration, length of hospital stay and postoperative pulmonary complications were gathered from patients' medical records. The control and chest physiotherapy groups presented decreased spirometry values after surgery but without any difference between them (forced vital capacity from 83.5 +/- 17.1% to 62.7 +/- 16.9% and from 95.7 +/- 18.9% to 79.0 +/- 26.9%, respectively). In contrast, the chest physiotherapy group presented improved oxygen-hemoglobin saturation after chest physiotherapy during the immediate postoperative period (p < 0.03) that did not last until the second postoperative day. The medical record data were similar between groups. Chest physiotherapy during the immediate postoperative period following upper abdominal surgery was effective for improving oxygen-hemoglobin saturation without increased abdominal pain. Breathing exercises could be adopted at post-anesthesia care units with benefits for patients.

Risk Factors and Independent Predictors of 30-Day Readmission for Altered Mental Status After Elective Spine Surgery for Spine Deformity: A Single-Institutional Study of 1090 Patients.

PubMed

Elsamadicy, Aladine A; Adogwa, Owoicho; Reddy, Gireesh B; Sergesketter, Amanda; Warwick, Hunter; Jones, Terrell; Cheng, Joseph; Bagley, Carlos A; Karikari, Isaac O

2017-05-01

Altered mental status (AMS) has been associated with inferior surgical outcomes. The factors leading to AMS after spine surgery are unknown. The aim of this study is to determine the risk factors and independent predictors of 30-day readmission for AMS in patients with spine deformity after undergoing elective spine surgery. The medical records of 1090 adult (≥18 years old) patients with spine deformity undergoing elective spine surgery at a major academic institution from 2005 to 2015 were reviewed. We identified 18 patients (1.65%) who had AMS as the primary driver for 30-day readmission after surgery. Patient demographics, comorbidities, and intraoperative and postoperative complication rates were collected for each patient. The primary outcome investigated in this study was risk factors associated with 30-day readmission for AMS. Patient demographics and comorbidities were similar between both groups, with the AMS cohort being significantly older than the no-AMS cohort (70.11 vs. 61.93; P = 0.003). There were no significant differences in intraoperative variables and complication rates within the cohorts. The AMS cohort had a significantly higher proportion of patients transferred to the intensive care unit (AMS, 61.11% vs. no-AMS, 19.76%; P = 0.0002) and rate of pulmonary embolism (AMS, 11.11 vs. no-AMS, 0.93; P = 0.02) after surgery. Other postoperative complication rates were similar between the cohorts. In a multivariate stepwise regression analysis, age (P = 0.013) and ICU transfer (P = 0.0002) were independent predictors of 30-day readmission for AMS. Our study suggests that increasing age and intensice care unit transfer are independent predictors of 30-day readmission for AMS after spine surgery in patients with spine deformity. Copyright © 2017 Elsevier Inc. All rights reserved.

Perioperative management of trauma patients admitted on clopidogrel (Plavix). A survey of orthopaedic departments across the United Kingdom.

PubMed

Inman, Dominic S; Michla, Yusuf; Partington, Paul F

2007-05-01

Clopidogrel (Plavix) is an anti-platelet drug recommended as lifelong treatment by NICE for all patients following stroke, MI, and peripheral vascular disease. It is also indicated for short-term use following cardiac stent insertion. It irreversibly inhibits platelets for up to 7 days. Current recommendations are to stop treatment 7 days before elective surgery. Current evidence shows that delay to surgery more than 4 days in patients with hip fractures increases postoperative mortality. To determine current practice of orthopaedic surgeons in their management of patients taking clopidogrel admitted following a hip fracture to trauma units in the UK with respect to its peri-operative withdrawal and subsequent timing of surgery. To perform a review of the available literature and produce a suggested protocol for the peri-operative management of this rapidly increasing cohort of patients. National postal survey. Orthopaedic consultants representing each unit receiving trauma patients in the United Kingdom. There was a 57% response rate (139/244 UK trauma units). 41% (56) stop clopidogrel and operate immediately, 11% (15) stop clopidogrel for between 5 and 10 days pre-operatively, 10% (14) stop clopidogrel for 10 days preoperatively, 19% (26) continue clopidogrel and operate immediately, 19% (26) have another protocol. 15% (20) have written departmental guidelines. 2%(3) quoted published evidence for their practice. This study demonstrates that there are a wide variety of practices, largely based on anecdotal evidence. Most units (85%) have no formal guidelines. There is evidence in the cardiac literature of increased intra-operative bleeding in patients operated on while taking clopidogrel. There is likely to be an exponential rise in such patients presenting to trauma units and further research is required to guide best practice. Following review of the literature we propose an interim protocol for the withdrawal and resumption of clopidogrel peri-operatively in patients with hip fractures.

Restricted Albumin Utilization Is Safe and Cost Effective in a Cardiac Surgery Intensive Care Unit.

PubMed

Rabin, Joseph; Meyenburg, Timothy; Lowery, Ashleigh V; Rouse, Michael; Gammie, James S; Herr, Daniel

2017-07-01

Volume expansion is often necessary after cardiac surgery, and albumin is often administered. Albumin's high cost motivated an attempt to reduce its utilization. This study analyzes the impact limiting albumin infusion in a cardiac surgery intensive care unit. This retrospective study analyzed albumin use between April 2014 and April 2015 in patients admitted to a cardiac surgery intensive care unit. During the first 9 months, there were no restrictions. In January 2015, institutional guidelines limited albumin use to patients requiring more than 3 L crystalloid in the early postoperative period, hypoalbuminemic patients, and to patients considered fluid overloaded. Albumin utilization was obtained from pharmacy records and compared with outcome quality metrics. In all, 1,401 patients were admitted over 13 months. Albumin use, mortality, ventilator days, patients receiving transfusions, and length of stay were compared for 961 patients before and 440 patients after guidelines were initiated. After restrictive guidelines were instituted, albumin utilization was reduced from a mean of 280 monthly doses to a mean of 101 monthly doses (p < 0.001). There was also a trend toward reduced ventilator days. Mortality, length of stay, and transfusion requirements demonstrated no significant change. Based on an average wholesale price and an average monthly reduction of 180 albumin doses, the cardiac surgery intensive care unit demonstrated more than $45,000 of wholesale savings per month after restrictions were implemented. Albumin restriction in the cardiac surgery intensive care unit was feasible and safe. Significant reductions in utilization and cost with no changes in morbidity or mortality were demonstrated. These findings may provide a strategy for reducing cost while maintaining quality of care. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

[Plastic surgery in day hospital conditions: comparison between two hospital models].

PubMed

Faga, A; Carminati, M; Falconi, D; Gatti, S; Rottino, A

2003-12-01

Personal experience of plastic surgery carried out in Day Hospital conditions is reported. The experience took place within the hospital structure through two different organisational models called here transversal and divisional organisation models: characteristic of the former is that it uses a dedicated interdivisional structure within the hospital involving the centralization of all day-surgery activities, whereas the latter organizes Day Surgery activities within the operating unit whose structures it shares. On the basis of a comparison between the two models we were able to note advantages and disadvantages. We can review our experience in brief by stating that our own preference went to the transversal model which presents the indubitable advantage of being a logistic structure which is hinged on daytime activity and is ready therefore to satisfy on the one hand the needs of this type of patient and, on the other, the needs of the structure itself in efficiency terms. We propose to correct the disadvantages of the transversal model which can be outlined in its lack of homogeneity in the pathology treated and in the subtraction of the criterion of clinical priority in waiting lists through the attainment of a critical dimensional threshold such as to permit programmable sessions with patients with homogeneous pathology (i.e. belonging to the same hospital unit) and through the maintenance of a certain number of Day Hospital beds (around 25%) reserved for new emergency clinical cases.

Individualized strategy for clopidogrel suspension in patients undergoing off-pump coronary surgery for acute coronary syndrome: a case-control study.

PubMed

Mannacio, Vito; Meier, Pascal; Antignano, Anita; Di Tommaso, Luigi; De Amicis, Vincenzo; Vosa, Carlo

2014-10-01

An increasing number of patients presenting for urgent coronary surgery have been exposed to clopidogrel, which constitutes a risk of bleeding and related events. Based on the wide variability in clopidogrel response and platelet function recovery after cessation, we evaluated the role of point-of-care platelet function testing to define the optimal time for off-pump coronary artery bypass graft (CABG) surgery in a case-control study. Three equally matched groups (300 patients in total) undergoing isolated off-pump CABG for acute coronary syndrome were compared. Group A were treated with clopidogrel and prospectively underwent a strategy guided by platelet function testing. Outcomes were compared with 2 propensity score matched groups: group B underwent CABG after the currently recommended 5 days without clopidogrel; group C were never exposed to clopidogrel. Patients in group A had reduced postoperative bleeding compared with those in group B (523±202 mL vs 851±605 mL; P<.001) and a lower number of units packed red blood cells (PRBCs) transfused during the postoperative hospital stay (1.2±1.6 units vs 1.9±1.8 units; P=.004). Postoperative bleeding and the number of units of PRBCs transfused were similar in group A and group C. There was no difference in blood-derived products and platelet consumption, mortality, or the need for reoperation among the groups. Patients in group A waited 3.6±1.7 days for surgery. The strategy used for group A saved 280 days of hospital stay in total. The strategy guided by platelet function testing for off-pump CABG offers improved guidance for optimal timing of CABG in patients treated with clopidogrel. This strategy significantly reduces postoperative bleeding and blood consumption, and has a shorter waiting time for surgery than current clinical practice. Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Laparoscopic telesurgery between the United States and Singapore.

PubMed

Lee, B R; Png, D J; Liew, L; Fabrizio, M; Li, M K; Jarrett, J W; Kavoussi, L R

2000-09-01

Telemedicine is the use of electronic digital signals to transfer information from one site to another. With the advent of a telepresence operative system and development of remote robotic arms to hold and manoeuvre the laparoscope, telemedicine is finding its role in surgery, especially laparoscopic surgery. CLINICAL FEATURES AND TREATMENT: We report two successful cases of laparoscopic surgery--radical nephrectomy and varicocelectomy for a 3-cm renal tumour and for bilateral varicoceles causing pain, where a less experienced laparoscopic surgeon in Singapore was telementored by an experienced laparoscopic surgeon located remotely in the United States. Both patients recovered uneventfully and returned home on postoperative day 4 and on the day of surgery, respectively. This study demonstrates that telementored laparoscopic systems are feasible and safe, between countries halfway across the world. As the Internet expands in utility and the cost of higher bandwidth telecommunication lines decreases, even to remote countries, telementoring systems will become more affordable and may potentially pave the way for advanced surgical and laparoscopic applications and training for the future.

Alarmins and Clinical Outcomes After Major Abdominal Surgery-A Prospective Study.

PubMed

Máca, Jan; Burša, Filip; Ševčík, Pavel; Sklienka, Peter; Burda, Michal; Holub, Michal

2017-06-01

Tissue injury causing immune response is an integral part of surgical procedure. Evaluation of the degree of surgical trauma could help to improve postoperative management and determine the clinical outcomes. We analyzed serum levels of alarmins, including S100A5, S100A6, S100A8, S100A9, S100A11, and S100A12; high-mobility group box 1; and heat-shock protein 70, after elective major abdominal surgery (n = 82). Blood samples were collected for three consecutive days after surgery. The goals were to evaluate the relationships among the serum levels of alarmins and selected surgical characteristics and to test potential of alarmins to predict the clinical outcomes. Significant, positive correlations were found for high-mobility group box 1 with the length of surgery, blood loss, and intraoperative fluid intake for all three days of blood sampling. The protein S100A8 serum levels showed positive correlations with intensive care unit length of stay, 28-day and in-hospital mortality. The protein S100A12 serum levels had significant, positive correlations with intensive care unit length of stay, 28-day mortality, and in-hospital mortality. We did not find significant differences in alarmin levels between cancer and noncancer subjects. The high-mobility group box 1 serum levels reflect the degree of surgical injury, whereas proteins S100A8 and S100A12 might be considered good predictors of major abdominal surgery morbidity and mortality.

Intravenous Acetaminophen Does Not Decrease Persistent Surgical Pain After Cardiac Surgery.

PubMed

Turan, Alparslan; Karimi, Nika; Zimmerman, Nicole M; Mick, Stephanie L; Sessler, Daniel I; Mamoun, Negmeldeen

2017-12-01

The authors investigated the hypothesis that perioperative acetaminophen reduces incisional pain at 30 and 90 days. This was a prospective, randomized, double-blind trial. Tertiary-care hospital (single center) cardiac surgery unit. Patients undergoing cardiac surgery via median sternotomy. Patients were assigned randomly to intravenous (IV) acetaminophen or IV placebo. Patients were given 4 doses of 1 g of IV acetaminophen or an equal volume of saline placebo over 15 minutes every 6 hours for 24 hours starting in the operating room after sternal closure. Study participants were assessed by phone for incisional pain severity 30 and 90 days after surgery. Those reporting any incisional pain were asked to complete the Neuropathic Pain Questionnaire-Short Form and the modified Brief Pain Inventory. Patients were compared on 30- and 90-day incisional pain severity using separate multivariable linear regression models. IV acetaminophen had no effect on 30- and 90-day incisional pain, with an estimated difference in means (confidence interval) of 0.06 (-0.87 to 0.99) at 30 days (p = 0.88) and 0.07 (-0.71 to 0.86) at 90 days (p = 0.83). Low pain severity, neuropathic pain, and interference at both 30 and 90 days after surgery, regardless of treatment group, were observed. IV acetaminophen did not reduce the incidence or intensity of incisional pain at 30 days and 90 days after surgery. Copyright © 2017 Elsevier Inc. All rights reserved.

Introduction of enhanced recovery for elective caesarean section enabling next day discharge: a tertiary centre experience.

PubMed

Wrench, I J; Allison, A; Galimberti, A; Radley, S; Wilson, M J

2015-05-01

The widespread adoption of enhanced recovery programmes in various surgical specialties has resulted in patient benefits including reduced morbidity, reduced length of stay and an earlier return to normal activities. This evidence, along with the increased financial pressures in the UK National Health Service, has led many units to consider introducing such a programme for obstetric surgery. We report our experience in setting up an enhanced recovery programme for women undergoing elective caesarean section and a prospective analysis of factors that influence length of stay. An enhanced recovery pathway was designed by a multidisciplinary team and introduced in March 2012. Factors influencing length of stay were determined using a log normal model. The proportion of women discharged on Day 1 increased from 1.6% in the first quarter of 2012 to 25.2% in the first quarter of 2014. The 30-day readmission rate was 4.4% for those discharged on Day 1 and 5.6% for Day 2. Earlier gestation, multiple birth, intention to breast feed, longer surgery and more time in the post-anaesthesia recovery unit were all independently associated with a longer postoperative stay. Women presenting for obstetric surgery with the indication "one previous caesarean section" were more likely to leave hospital earlier compared to most other indications. An enhanced recovery programme was successfully introduced into our unit. Many of the interventions were straightforward and could be adopted easily elsewhere. Copyright © 2015 Elsevier Ltd. All rights reserved.

Review of laparoscopic training in pediatric surgery in the United Kingdom.

PubMed

Stormer, Emma J; Sabharwal, Atul J

2009-04-01

To review the exposure pediatric surgery trainees have to laparoscopic surgery in the United Kingdom (UK). A confidential postal questionnaire was sent to all trainees working at registrar level in centers responsible for pediatric surgical training in the UK. Questions assessed the number of consultants with an interest in laparoscopic surgery, types of cases performed laparoscopically, and trainees' role in laparoscopic appendicectomy (LA). Questionnaires were sent to 112 trainees with a 55% response rate (62 replies). At least one response was received from each unit. Based on responses, 49 to 67 consultants in 21 training centers have an interest in laparoscopic surgery (0%-100% of consultants per unit). LA was offered in 20 out of 21 training centers. There was no significant difference in the proportion of appendicectomies performed laparoscopically by junior (years 1-3) and senior (years 4-6) trainees. A significantly higher proportion of junior trainees had not performed any LAs (P = 0.02). Seventy-three percent of trainees were the principal operator. For trainees who were principal operators, the cameraperson was a consultant in 52% and a junior trainee in 17%. The time of day affected the likelihood of a procedure being carried out laparoscopically in 43 (81%) responses. The majority of trainees' exposure to laparoscopic surgery could be viewed as suboptimal; however, the exposure gained varies significantly between different units throughout the UK. In an age moving in favor of minimal access surgery, all units must be in a position to offer pediatric laparoscopic surgical training.

A case for the expansion of day surgery.

PubMed

Ogg, T; Heath, P; Brownlie, G

1989-12-01

The efficiency of the National Health Service (NHS) is currently under scrutiny and the problems faced by the surgical services include a shortage of financial resources, fewer beds, poor nursing recruitment and rising waiting lists. During 1984-1988 a purpose built, separate 12-bedded day surgery unit at Addenbrooke's Hospital, Cambridge operated upon 13,000 patients, with a readmission rate of less than 1%. Senior medical staff are involved and the overall surgical waiting list has been reduced by 40.9%. Nurse recruitment has been excellent, and the community medical and nursing services have not been overburdened. The results detailed in this paper suggest that day surgery deserves special consideration as one acceptable solution to some of the current NHS problems.

Transperitoneal laparoscopic adrenalectomy. Our experience.

PubMed

Antonino, Antonio; Rosato, Andrea; Zenone, Pasquale; Ranieri, Raffaele; Maglio, Mauro; Lupone, Gennaro; Gragnano, Eugenio; Sangiuliano, Nicola; Docimo, Giovanni; De Palma, Maurizio

2013-01-01

Laparoscopic adrenalectomy is considered the standard technique for the surgical removal of the adrenal gland. This report is about a 4-year single experience in our Endocrine and General Surgery Unit with laparoscopic adrenalectomy. A total of 24 lateral transperitoneal laparoscopic adrenalectomies were performed. The indications for laparoscopic surgery were: aldosteronoma in 3 patients, pheochromocytoma in 6 patients, nonfunctioning adenoma in 6 patients, adenoma causing Cushing's syndrome in 3 patients, 1 lymphangioma-like adenomatoid tumor, 1 myelolipoma, 1 complicated adrenal cyst, 2 adrenocortical carcinomas, 1 lung metastasis. All except two had successful laparoscopic adrenalectomy. Complication occurred in one patient. 3 patients underwent other associated laparoscopic procedures. Operative time ranged from 100 to 240 minutes for laparoscopic adrenalectomy, from 180 to 210 minutes in the cases with two associated laparoscopic procedures, 5 hours for bilateral adrenalectomy; the postoperative hospital stay for laparoscopic adrenalectomy ranged from 4 to 8 days (6,79 days) and from 7 to 13 days (9,12 days) for patients undergoing the open or converted procedure. Laparoscopic adrenalectomy is technically feasible and reproducible. We evaluate the effectiveness of laparoscopic adrenalectomy for a variety of endocrine disorders except in the case of invasive carcinoma or large masses. Antonio Cardarelli Endocrine and General Surgery Unit in Naples is known as a specialized center for thyroid and parathyroid surgery; in future, we could also become a high-volume laparoscopic referral center for adrenal gland pathologies.

Influence of patient-related and surgery-related risk factors on cognitive performance, emotional state, and convalescence after cardiac surgery.

PubMed

Ille, Rottraut; Lahousen, Theresa; Schweiger, Stefan; Hofmann, Peter; Kapfhammer, Hans-Peter

2007-01-01

Cardiac surgery may account for complications such as cognitive impairment, depression, and delay of convalescence. This study investigated the influence of different risk factors on cognitive performance, emotional state, and convalescence. We included 83 patients undergoing cardiac surgery who had no indication of postoperative delirium. Psychometric testing was performed 1 day before and 7 days after surgery. Neuron-specific enolase (NSE) levels were measured 1 day before and 36 h after surgery. Depression score increased after surgery, but patients showed no clinically significant depression. Postoperative cognitive performance correlated with postoperative depression level and preoperative cognitive performance. Forty-three percent of patients showed postoperative decline. Older patients exhibited a higher postoperative increase in NSE concentrations. Patients undergoing coronary artery bypass grafts or combined procedures exhibited more medical risk factors than those undergoing valve surgery alone. The number of bypass grafts was associated with time of hospitalization, and the number of patient-related risk factors correlated with stay in intensive care unit. For elderly patients undergoing cardiac surgery, older age, total preexisting medical risk factors, and surgery duration seem to be the most important factors influencing cognitive outcome and convalescence. Results show that, also for patients without postoperative delirium, medical risk factors and intraoperative parameters can result in delay of convalescence.

Gelatin-thrombin hemostatic matrix in neurosurgical procedures: hemostasis effectiveness and economic value of clinical and surgical procedure-related benefits.

PubMed

Esposito, Felice; Cappabianca, Paolo; Angileri, Filippo F; Cavallo, Luigi M; Priola, Stefano M; Crimi, Salvatore; Solari, Domenico; Germanò, Antonino F; Tomasello, Francesco

2016-07-26

Gelatin-thrombin hemostatic matrix (FloSeal®) use is associated with shorter surgical times and less blood loss, parameters that are highly valued in neurosurgical procedures. We aimed to assess the effectiveness of gelatin-thrombin in neurosurgical procedures and estimate its economic value. In a 6-month retrospective evaluation at 2 hospitals, intraoperative and postoperative information were collected from patients undergoing neurosurgical procedures where bleeding was controlled with gelatin-thrombin matrix or according to local bleeding control guidelines (control group). Study endpoints were: length of surgery, estimated blood loss, hospitalization duration, blood units utilized, intensive care unit days, postoperative complications, and time-to-recovery. Statistical methods compared endpoints between the gelatin-thrombin and control groups and resource utilization costs were estimated. Seventy-eight patients (38 gelatin-thrombin; 40 control) were included. Gelatin-thrombin was associated with a shorter surgery duration than control 166±40 versus 185±55, p=0.0839); a lower estimated blood loss (185±80 versus 250±95ml; p=0.0017); a shorter hospital stay (10±3 versus 13±3 days; p<0.001); fewer intensive care unit days (10 days/3 patients and 20 days/4 patients); and shorter time-to-recovery (3±2.2 versus 4±2.8 weeks; p=0861). Fewer gelatin-thrombin patients experienced postoperative complications (3 minor) than the control group (5 minor; 3 major). No gelatin-thrombin patient required blood transfusion; 5 units were administered in the control group. The cost of gelatin-thrombin (€268.40/unit) was offset by the shorter surgery duration (difference of 19 minutes at €858 per hour) and the economic value of improved the other endpoint outcomes (ie, shorter hospital stay, less blood loss/lack of need for transfusion, fewer intensive care unit days, and complications). Gelatin-thrombin hemostatic matrix use in patients undergoing neurosurgical procedures was associated with better intra- and post-operative parameters than conventional hemostasis methods, with these parameters having substantial economic benefits.

Admission to dedicated pediatric cardiac intensive care units is associated with decreased resource use in neonatal cardiac surgery.

PubMed

Johnson, Joyce T; Wilkes, Jacob F; Menon, Shaji C; Tani, Lloyd Y; Weng, Hsin-Yi; Marino, Bradley S; Pinto, Nelangi M

2018-06-01

Neonates undergoing congenital heart surgery require highly specialized, resource-intensive care. Location of care and degree of specialization can vary between and within institutions. Using a multi-institutional cohort, we sought to determine whether location of admission is associated with an increase in health care costs, resource use and mortality. We retrospectively analyzed admission for neonates (<30 days) undergoing congenital heart surgery between 2004 and 2013 by using the Pediatric Health Information Systems database (44 children's hospitals). Multivariate generalized estimating equations adjusted for center- and patient-specific risk factors and stratified by age at admission were performed to examine the association of admission intensive care unit (ICU) with total hospital costs, mortality, and length of stay. Of 19,984 neonates (60% male) identified, 39% were initially admitted to a cardiac ICU (CICU), 48% to a neonatal ICU (NICU), and 13% to a pediatric ICU. In adjusted models, admission to a CICU versus NICU was associated with a $20,440 reduction in total hospital cost for infants aged 2 to 7 days at admission (P = .007) and a $23,700 reduction in total cost for infants aged 8 to 14 days at admission (P = .01). Initial admission to a CICU or pediatric ICU versus NICU at <15 days of age was associated with shorter hospital and ICU length of stay and fewer days of mechanical ventilation. There was no difference in adjusted mortality by admission location. Admission to an ICU specializing in cardiac care is associated with significantly decreased hospital costs and more efficient resource use for neonates requiring cardiac surgery. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

An Analysis of First Duty Station Placement and New Graduate Transition Education on Retention in the Navy Nurse Corps

DTIC Science & Technology

2010-03-01

coronary by-pass (CABG) surgery patients would stay in the Coronary Care Step-Down Unit for at least a week while not getting out of bed for most of that...time. Whereas today, those same patients are out of the bed, sitting up in a chair within hours of surgery and sent home 48 hours post surgery ...hospital, flat on their backs, for a week and spend months at home recovering. Today, the surgery is done as a same-day surgery procedure and patients

Impact of Music Therapy on Hospitalized Patients Post-Elective Orthopaedic Surgery: A Randomized Controlled Trial.

PubMed

Gallagher, Lisa M; Gardner, Vickie; Bates, Debbie; Mason, Shelley; Nemecek, Jeanine; DiFiore, Jacquelyn Baker; Bena, James; Li, Manshi; Bethoux, Francois

Music therapy (MT) research has demonstrated positive effects on fatigue, depressed mood, anxiety, and pain in perioperative care areas. However, there has been limited research on the effects of MT for surgical patients on orthopaedic units. The purpose of this study was to understand the impact of MT sessions on post-elective orthopaedic surgery patients' pain, mood, nausea, anxiety, use of narcotics and antiemetics, and length of stay. This was a randomized controlled study with an experimental arm (MT sessions) and a control arm (standard medical care). Patients received MT within 24 hours of admission to the unit, as well as every day of their stay. Same-day pre- and postdata were collected 30 minutes apart for both arms, including patient self-reported mood, pain, anxiety, and nausea. Use of medications and length of stay were gleaned from the electronic medical record. Data were obtained for 163 patients, age 60.5 ± 11.1 years, 56% of whom were male. Joints targeted by surgeries were hips (54%), knees (42%), and shoulders (4%). There were significantly greater changes favoring the MT group on Day 1 (pain, anxiety, and mood), Day 2 (pain, anxiety, mood, and nausea), and Day 3 (pain, anxiety, and mood). Among participants with a pre-pain score of 2 or more on Day 1, a decrease of at least 2 points was noted in 36% of the MT group and 10% of the control group (P < .001). Overall, 73% of MT patients versus 41% of control patients reported improved pain (P < .001). No significant between-group differences in medications or length of stay were noted. We observed greater same-day improvements of pain, emotional status, and nausea with MT sessions, compared to usual care, in patients hospitalized after elective orthopaedic surgeries. Effects on narcotic and antiemetic usage, as well as length of stay, were not observed. More research needs to be conducted to better understand the benefits of MT pre- and post-elective orthopaedic surgery.

Development of a diagnosis- and procedure-based risk model for 30-day outcome after pediatric cardiac surgery.

PubMed

Crowe, Sonya; Brown, Kate L; Pagel, Christina; Muthialu, Nagarajan; Cunningham, David; Gibbs, John; Bull, Catherine; Franklin, Rodney; Utley, Martin; Tsang, Victor T

2013-05-01

The study objective was to develop a risk model incorporating diagnostic information to adjust for case-mix severity during routine monitoring of outcomes for pediatric cardiac surgery. Data from the Central Cardiac Audit Database for all pediatric cardiac surgery procedures performed in the United Kingdom between 2000 and 2010 were included: 70% for model development and 30% for validation. Units of analysis were 30-day episodes after the first surgical procedure. We used logistic regression for 30-day mortality. Risk factors considered included procedural information based on Central Cardiac Audit Database "specific procedures," diagnostic information defined by 24 "primary" cardiac diagnoses and "univentricular" status, and other patient characteristics. Of the 27,140 30-day episodes in the development set, 25,613 were survivals, 834 were deaths, and 693 were of unknown status (mortality, 3.2%). The risk model includes procedure, cardiac diagnosis, univentricular status, age band (neonate, infant, child), continuous age, continuous weight, presence of non-Down syndrome comorbidity, bypass, and year of operation 2007 or later (because of decreasing mortality). A risk score was calculated for 95% of cases in the validation set (weight missing in 5%). The model discriminated well; the C-index for validation set was 0.77 (0.81 for post-2007 data). Removal of all but procedural information gave a reduced C-index of 0.72. The model performed well across the spectrum of predicted risk, but there was evidence of underestimation of mortality risk in neonates undergoing operation from 2007. The risk model performs well. Diagnostic information added useful discriminatory power. A future application is risk adjustment during routine monitoring of outcomes in the United Kingdom to assist quality assurance. Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Years Versus Days Between Successive Surgeries, After an Initial Outpatient Procedure, for the Median Patient Versus the Median Surgeon in the State of Iowa.

PubMed

Dexter, Franklin; Jarvie, Craig; Epstein, Richard H

2018-03-01

Previously, we studied the relative importance of different institutional interventions that the largest hospital in Iowa could take to grow the anesthesia department's outpatient surgical care. Most (>50%) patients having elective surgery had not previously had surgery at the hospital. Patient perioperative experience was unimportant for influencing total anesthesia workload and numbers of patients. More important was the availability of surgical clinic appointments within several days. These results would be generalizable if the median time from surgery to a patient's next surgical procedure was large (eg, >2 years), among all hospitals in Iowa with outpatient surgery, and without regard to the hospital where the next procedure was performed. There were 37,172 surgical cases at hospital outpatient departments of any of the 117 hospitals in Iowa from July 1, 2013, to September 30, 2013. Data extracted about each case included its intraoperative work relative value units. The 37,172 cases were matched to all inpatient and outpatient records for the next 2 years statewide using patient linkage identifiers; from these were determined whether the patient had surgery again within 2 years. Furthermore, the cases' 1820 surgeons were matched to the surgeon's next outpatient or inpatient case, both including and excluding other cases performed on the date of the original case. By patient, the median time to their next surgical case, either outpatient or inpatient, exceeded 2 years, tested with weighting by intraoperative relative value units and repeated when unweighted (both P < .0001). Specifically, with weighting, 65.9% (99% confidence interval [CI], 65.2%-66.5%) of the patients had no other surgery within 2 years, at any hospital in the state. The median time exceeded 2 years for multiple categories of patients and similar measures of time to next surgery (all P < .01). In comparison, by surgeon, the median time to the next outpatient surgical case was 1 calendar day (99% CI, 0-1 day). The median was 3 days to the next date with at least 1 outpatient case (99% CI, 3-3 days). The median time to the next surgery was >2 years for patients versus 1 day for surgeons. Thus, although patients' experiences are an important attribute of quality of care, surgeons' experiences are orders of magnitude more important from the vantage point of marketing and growth of an anesthesia practice.

Predictive Factors of Long-Term Stay in the ICU after Cardiac Surgery: Logistic CASUS Score, Serum Bilirubin Dosage and Extracorporeal Circulation Time

PubMed Central

Pimentel, Marcio Fernandes; Soares, Marcelo José Ferreira; Murad Junior, Jamil Alli; de Oliveira, Marcos Aurelio Barboza; Faria, Fernanda Luiza; Faveri, Vinicius Zani; Iano, Yuzo; Guido, Rodrigo Capobianco

2017-01-01

Objective To test the capacity of the Logistic CASUS Score on the second postoperative day, the total serum bilirubin dosage on the second postoperative day and the extracorporeal circulation time, as possible predictive factors of long-term stay in Intensive Care Unit after cardiac surgery. Methods Eight-two patients submitted to cardiac surgery with extracorporeal circulation were selected. The Logistic CASUS Score on the second postoperative day was calculated and bilirubin dosage on the second postoperative day was measured. The extracorporeal circulation time was also registered. Patients were divided into two groups: Group A, those who were discharged up to the second day of postoperative care; Group B, those who were discharged after the second day of postoperative care. Results In this study, 40 cases were listed in Group A and 42 cases in Group B. The mean extracorporeal circulation time was 83.9±29.4 min in Group A and 95.8±29.31 min in Group B. Extracorporeal circulation time was not significant in this study (P=0.0735). The level of P significance of bilirubin dosage on the second postoperative day was 0.0003 and an area under the ROC curve of 0.708 with a cut-off point at 0.51 mg/dl was registered. The level of P significance of Logistic CASUS Score on the second postoperative day was 0.0001 and an area under the ROC curve of 0.723 with a cut-off point at 0.40% was registered. Conclusion The Logistic CASUS Score on the second postoperative day has shown to be better than the bilirubin dosage on the second postoperative day as a predictive tool for calculating the length of stay in intensive care unit during the postoperative care period of patients. Notwithstanding, extracorporeal circulation time has failed to prove itself as an efficient tool to predict an extended length of stay in intensive care unit. PMID:29211215

Predictive Factors of Long-Term Stay in the ICU after Cardiac Surgery: Logistic CASUS Score, Serum Bilirubin Dosage and Extracorporeal Circulation Time.

PubMed

Pimentel, Marcio Fernandes; Soares, Marcelo José Ferreira; Murad, Jamil Alli; Oliveira, Marcos Aurelio Barboza de; Faria, Fernanda Luiza; Faveri, Vinicius Zani; Iano, Yuzo; Guido, Rodrigo Capobianco

2017-01-01

To test the capacity of the Logistic CASUS Score on the second postoperative day, the total serum bilirubin dosage on the second postoperative day and the extracorporeal circulation time, as possible predictive factors of long-term stay in Intensive Care Unit after cardiac surgery. Eight-two patients submitted to cardiac surgery with extracorporeal circulation were selected. The Logistic CASUS Score on the second postoperative day was calculated and bilirubin dosage on the second postoperative day was measured. The extracorporeal circulation time was also registered. Patients were divided into two groups: Group A, those who were discharged up to the second day of postoperative care; Group B, those who were discharged after the second day of postoperative care. In this study, 40 cases were listed in Group A and 42 cases in Group B. The mean extracorporeal circulation time was 83.9±29.4 min in Group A and 95.8±29.31 min in Group B. Extracorporeal circulation time was not significant in this study (P=0.0735). The level of P significance of bilirubin dosage on the second postoperative day was 0.0003 and an area under the ROC curve of 0.708 with a cut-off point at 0.51 mg/dl was registered. The level of P significance of Logistic CASUS Score on the second postoperative day was 0.0001 and an area under the ROC curve of 0.723 with a cut-off point at 0.40% was registered. The Logistic CASUS Score on the second postoperative day has shown to be better than the bilirubin dosage on the second postoperative day as a predictive tool for calculating the length of stay in intensive care unit during the postoperative care period of patients. Notwithstanding, extracorporeal circulation time has failed to prove itself as an efficient tool to predict an extended length of stay in intensive care unit.

Thirty-day outcomes of sleeve gastrectomy versus Roux-en-Y gastric bypass: first report based on Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database.

PubMed

Chaar, Maher El; Lundberg, Peter; Stoltzfus, Jill

2018-05-01

According to recent American Society for Metabolic and Bariatric Surgery estimates, sleeve gastrectomy (SG) is now the most commonly performed procedure in the United States (~53.8% of all bariatric procedures), followed by Roux-en-Y gastric bypass (RYGB; 23.1% of all procedures). The objective of this study was to evaluate outcomes and safety of these 2 procedures in the first 30 days postoperatively using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry. University health network, United States. We reviewed all SG and RYGB cases entered between January 1 and December 31, 2015 in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry. Demographic characteristics and 30-day outcomes were analyzed based on separate Mann-Whitney rank sums tests, χ 2 , or Fisher's exact tests as appropriate, with P<.05 denoting statistical significance and no adjustment for multiple testing. A total of 141,646 patients were analyzed; 98,292 underwent SG and 43,354 underwent RYGB. Average age was 44.5 and 45.4 years for SG and RYGB, respectively. Preoperative body mass index was 45.1 and 46.1 for SG and RYGB, respectively. The 30-day mortality was .1% for SG and .2% for RYGB (P<.05). The incidence of unplanned intensive care unit admission after RYGB was twice as high compared with SG (1.3% versus .6%, respectively, P<.05). The incidence of at least 1 intervention or reoperation after RYGB was significantly higher compared with SG (2.8% and 2.5% for GB versus 1.2% and 1% for SG, P<.05). After RYGB, .4% of patients had a drain left in place at 30 days postoperatively versus .3% for SG (P<.05). The incidence of readmission was 2.8% for RYGB and 1.2% for SG (P<.05). The incidence of postoperative complications in the first 30 days after surgery is low for both RYGB and SG. However, SG seems to have a better safety profile in the first 30 days postoperatively compared with RYGB. These findings should be considered in the preoperative evaluation and counseling of bariatric patients. Long-term follow-up is needed to compare safety and efficacy of SG versus RYGB. Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.

The effect of race on postsurgical ambulatory medical follow-up among United States Veterans.

PubMed

Schonberger, Robert B; Dai, Feng; Brandt, Cynthia; Burg, Matthew M

2017-08-01

To investigate the association between self-identified black or African American race and the presence of ambulatory internal medicine follow-up in the year after surgery. Our hypothesis was that among US Veterans who presented for surgery, black or African American race would be associated with a decreased likelihood to receive ambulatory internal medicine follow-up in the year after surgery. Retrospective observational. All US Veterans Affairs hospitals. A total of 236,200 Veterans undergoing surgery between 2006 and 2011 who were discharged within 10 days of surgery and survived the full 1-year exposure period. None. Attendance at an internal medicine follow-up appointment within 1 year after surgery. After controlling for year of surgery, age, age ≥65 years, sex, Hispanic ethnicity, and number of inpatient days, black or African American patients were 11% more likely to lack internal medicine follow-up after surgery (adjusted odds ratio, 1.11; 95% confidence interval, 1.06-1.16). When accounting for geographic region, this difference remained significant at the Bonferoni-corrected P < .007 level only in the Midwest United States where black or African American patients were 28% more likely to lack medical follow-up in the year after surgery (odds ratio, 1.28; 95% confidence interval, 1.16-1.42; P < .0001). The disparity in ambulatory medical follow-up following surgery among black or African American vs nonblack or non-African American Veterans in the Midwest region deserves further study and may lead to important quality improvement initiatives aimed specifically at this population. Copyright © 2016 Elsevier Inc. All rights reserved.

Clinical and Economic Burden of Peristomal Skin Complications in Patients With Recent Ostomies

PubMed Central

Taneja, Charu; Netsch, Debra; Rolstad, Bonnie Sue; Inglese, Gary; Lamerato, Lois

2017-01-01

PURPOSE: The purpose of this study was to estimate the risk and economic burden of peristomal skin complications (PSCs) in a large integrated healthcare system in the Midwestern United States. DESIGN: Retrospective cohort study. SUBJECTS AND SETTING: The sample comprised 128 patients; 40% (n = 51) underwent colostomy, 50% (n = 64) underwent ileostomy, and 10% (n = 13) underwent urostomy. Their average age was 60.6 ± 15.6 years at the time of ostomy surgery. METHODS: Using administrative data, we retrospectively identified all patients who underwent colostomy, ileostomy, or urostomy between January 1, 2008, and November 30, 2012. Trained medical abstractors then reviewed the clinical records of these persons to identify those with evidence of PSC within 90 days of ostomy surgery. We then examined levels of healthcare utilization and costs over a 120-day period, beginning with date of surgery, for patients with and without PSC, respectively. Our analyses were principally descriptive in nature. RESULTS: The study cohort comprised 128 patients who underwent ostomy surgery (colostomy, n = 51 [40%]; ileostomy, n = 64 [50%]; urostomy, n = 13 [10%]). Approximately one-third (36.7%) had evidence of a PSC in the 90-day period following surgery (urinary diversion, 7.7%; colostomy, 35.3%; ileostomy, 43.8%). The average time from surgery to PSC was 23.7 ± 20.5 days (mean ± SD). Patients with PSC had index admissions that averaged 21.5 days versus 13.9 days for those without these complications. Corresponding rates of hospital readmission within the 120-day period following surgery were 47% versus 33%, respectively. Total healthcare costs over 120 days were almost $80,000 higher for patients with PSCs. CONCLUSIONS: Approximately one-third of ostomy patients over a 5-year study period had evidence of PSCs within 90 days of surgery. Costs of care were substantially higher for patients with these complications. PMID:28574928

Ventilator-associated pneumonia in patients undergoing major heart surgery: an incidence study in Europe.

PubMed

Hortal, Javier; Muñoz, Patricia; Cuerpo, Gregorio; Litvan, Hector; Rosseel, Peter M; Bouza, Emilio

2009-01-01

Patients undergoing major heart surgery (MHS) represent a special subpopulation at risk for nosocomial infections. Postoperative infection is the main non-cardiac complication after MHS and has been clearly related to increased morbidity, use of hospital resources and mortality. Our aim was to determine the incidence, aetiology, risk factors and outcome of ventilator-associated pneumonia (VAP) in patients who have undergone MHS in Europe. Our study was a prospective study of patients undergoing MHS in Europe who developed suspicion of VAP. During a one-month period, participating units submitted a protocol of all patients admitted to their units who had undergone MHS. Overall, 25 hospitals in eight different European countries participated in the study. The number of patients intervened for MHS was 986. Fifteen patients were excluded because of protocol violations. One or more nosocomial infections were detected in 43 (4.4%) patients. VAP was the most frequent nosocomial infection (2.1%; 13.9 episodes per 1000 days of mechanical ventilation). The microorganisms responsible for VAP in this study were: Enterobacteriaceae (45%), Pseudomonas aeruginosa (20%), methicillin-resistant Staphylococcus aureus (10%) and a range of other microorganisms. We identified the following significant independent risk factors for VAP: ascending aorta surgery (odds ratio (OR) = 6.22; 95% confidence interval (CI) = 1.69 to 22.89), number of blood units transfused (OR = 1.08 per unit transfused; 95% CI = 1.04 to 1.13) and need for re-intervention (OR = 6.65; 95% CI = 2.10 to 21.01). The median length of stay in the intensive care unit was significantly longer (P < 0.001) in patients with VAP than in patients without VAP (23 days versus 2 days). Death was significantly more frequent (P < 0.001) in patients with VAP (35% versus 2.3%). Patients undergoing aortic surgery and those with complicated post-intervention courses, requiring multiple transfusions or re-intervention, constitute a high-risk group probably requiring more active preventive measures.

Geriatric patient profile in the cardiovascular surgery intensive care unit.

PubMed

Korhan, Esra Akin; Hakverdioglu, Gulendam; Ozlem, Maryem; Ozlem, Maryem; Yurekli, Ismail; Gurbuz, Ali; Alp, Nilgun Akalin

2013-11-01

To determine hospitalization durations and mortalities of elderly in the Cardiovascular Surgery Intensive Care Unit. The retrospective study was conducted in a Cardiovascular Surgery Intensive Care Unit in Turkey and comprised patient records from January 1 to December 31, 2011. Computerized epicrisis reports of 255, who had undergone a cardiac surgery were collected. The patients were grouped according to their ages, Group I aged 65-74 and Group II aged 75 and older. European society for Cardiac Operative Risk Evaluation scores of the two groups were compared using SPSS 17. Overall, there were 80 (31.37%) females and 175 (68.62%) males. There were 138 (54.1%) patients in Group I and 117 (45.9%) in Group II. Regarding their hospitalization reasons, it was determined that 70 (27.5%) patients in Group I and 79 (30.9%) patients in Group II were treated with the diagnosis ofcoronary artery disease. The average hospitalization duration of patients in the intensive care unit was determined to be 11.57 +/- 0.40 days. Regarding the EuroSCORE score intervals of patients, 132 (51.8%) had 3-5 and 225 (88.2%) patients were transferred to the Cardiovascular Surgery and then all of them were discharged; 5 (4.1%) had a mortal course; and 11 (7.7%) were transferred to the anaesthesia intensive care unit. The general mortality rates are very low in the Cardiovascular Surgery Intensive Care Unit and the patients have a good prognosis.

Building a model for day case hiatal surgery - Lessons learnt over a 10 year period in a high volume unit: A case series.

PubMed

Mistry, Pritesh; Zaman, Shafquat; Shapey, Iestyn; Daskalakis, Markos; Nijjar, Rajwinder; Richardson, Martin; Super, Paul; Singhal, Rishi

2018-06-01

Laparoscopic anti-reflux surgery has become the standard treatment for symptomatic gastro-oesophageal reflux disease refractory to medical therapy. Successful anti-reflux surgery involves safe, minimally invasive surgery, resulting in symptom resolution with minimal side effects. This study aims to assess the feasibility and safety of day case anti-reflux surgery focussing on peri- and post-operative outcomes as a measure of success. Data was collected from the hospital database from 2003 to 2012. Data collection included demographics, surgeon, mode of admission, length of stay and complications. Electronic records were independently scrutinised for all patients with a length of stay of more than two nights. 723 patients underwent laparoscopic fundoplication ± small hiatus hernia repair (<5 cm) with a day case rate of 67.1%. The 30 day readmission rate in these patients was 2.9% (21/723 patients). Nine patients had a failure of their initial laparoscopic fundoplication (defined as recurrence of symptoms). Three patients required a re-operation within 12 months of their initial procedure (re-operation rate = 0.41% (3/723 patients)). Laparoscopic hiatal surgery can be performed safely as a day case in high volume specialist centres with good outcomes. Raising the national standard for day case fundoplication promotes good practice and should be the model for future commissioning. Crown Copyright © 2018. Published by Elsevier Ltd. All rights reserved.

Avoiding endotracheal intubation of neonates undergoing laser surgery for retinopathy of prematurity.

PubMed

Woodhead, D D; Lambert, D K; Molloy, D A; Schmutz, N; Righter, E; Baer, V L; Christensen, R D

2007-04-01

Respiratory support of neonates during and following laser surgery for retinopathy of prematurity (ROP) is commonly accomplished using endotracheal intubation and mechanical ventilation. However, most patients undergoing ROP surgery have been weaned off mechanical ventilation days or weeks before the surgery. When they are electively re-intubated for ROP surgery, it can be difficult to extubate them postoperatively. One of the three level III neonatal intensive care units (NICUs) in the Intermountain Healthcare system initiated a program of using nasopharyngeal prongs, rather than endotracheal intubation, for respiratory support during ROP surgery. We performed an historic cohort analysis of all neonates undergoing ROP surgery during their NICU stay at the three level III NICU's between 1 January 2002 and 31 March 2006. Data collected included birth weight, gestational age at delivery and corrected gestational age at ROP surgery, whether or not they were intubated in the days immediately preceding the ROP surgery, whether or not they were electively intubated for the ROP surgery, the respiratory modality used during and the 3 days following ROP surgery, and all blood gas determinations and respiratory charges during this period. Fifty-four patients underwent ROP surgery during this period. All 23 from NICUs 'A' and 'B' had endotracheal intubation for surgery, while in NICU 'C' 24 were managed using nasopharyngeal prongs. The birth weights of those intubated for surgery (661+/-180 g, mean+/-s.d.) were similar to those not intubated (732+/-180 g). Similarly, the gestational age at birth did not differ between those intubated for surgery (25.2+/-1.3 week) and those not (25.6+/-2.1 week). The day following surgery, 77% (23/30) of those who had been intubated for surgery remained intubated and on mechanical ventilation, whereas only one (4%) of those not intubated for surgery was intubated in the postoperative period (P<0.001). On day 3 following surgery, 50% (15/30) of those intubated for surgery remained intubated and on mechanical ventilation, whereas none of those not intubated for surgery were intubated (P<0.001). Management with nasopharyngeal prongs did not result in higher PCO(2)s, or lower pH values, during or after surgery. Respiratory charges for the 3 days following surgery were 1762+/-678 dollars (mean+/-s.d.)/patient among those intubated versus 357+/-352 dollars/patient for those managed with nasopharyngeal prongs (P<0.001). Neonates undergoing laser surgery for ROP can often be supported intraoperatively and postoperatively using nasopharyngeal prongs, thus avoiding the need for endotracheal intubation.

Open lung ventilation improves functional residual capacity after extubation in cardiac surgery.

PubMed

Reis Miranda, Dinis; Struijs, Ard; Koetsier, Peter; van Thiel, Robert; Schepp, Ronald; Hop, Wim; Klein, Jan; Lachmann, Burkhard; Bogers, Ad J J C; Gommers, Diederik

2005-10-01

After cardiac surgery, functional residual capacity (FRC) after extubation is reduced significantly. We hypothesized that ventilation according to the open lung concept (OLC) attenuates FRC reduction after extubation. A prospective, single-center, randomized, controlled clinical study. Cardiothoracic operating room and intensive care unit of a university hospital. Sixty-nine patients scheduled for elective coronary artery bypass graft and/or valve surgery with cardiopulmonary bypass. Before surgery, patients were randomly assigned to three groups: (1) conventional ventilation (CV); (2) OLC, started after arrival in the intensive care unit (late open lung); and (3) OLC, started directly after intubation (early open lung). In both OLC groups, recruitment maneuvers were applied until Pao2/Fio2 was >375 Torr (50 kPa). No recruitment maneuvers were applied in the CV group. FRC was measured preoperatively and 1, 3, and 5 days after extubation. Peripheral hemoglobin saturation (Spo2) was measured daily till the third day after extubation while the patient was breathing room air. Hypoxemia was defined by an Spo2 value < or =90%. Averaged over the 5 postoperative days, FRC was significantly higher in the early open lung group and tended to be higher in the late open lung group, in comparison with the CV group (mean +/- sem: CV, 1.8 +/- 0.1; late open lung,1.9 +/- 0.1; and early open lung, 2.2 +/- 0.1l). In the CV group, 37% of the patients were hypoxic on the third day after extubation, compared with none of the patients in both OLC groups. After cardiac surgery, earlier application of OLC resulted in a significantly higher FRC and fewer episodes of hypoxemia than with CV after extubation.

Clopidogrel and bleeding after general surgery procedures.

PubMed

Ozao-Choy, Junko; Tammaro, Yolanda; Fradis, Martin; Weber, Kaare; Divino, Celia M

2008-08-01

Although many studies in the cardiothoracic literature exist about the relationship between clopidogrel and postoperative bleeding, there is scarce data in the general surgery literature. We assessed whether there are increased bleeding complications, morbidity, mortality, and resource utilization in patients who are on clopidogrel (Plavix) within 1 week before undergoing a general surgery procedure. Fifty consecutive patient charts were retrospectively reviewed after identifying patients who had pharmacy orders for clopidogrel and who underwent a general surgery procedure between 2003 and 2007. Patients who took clopidogrel within 6 days before surgery (group I, n = 28) were compared with patients who stopped clopidogrel for 7 days or more (group II, n = 22). A larger percentage of patients who took their last dose of clopidogrel within 1 week of surgery (21.4% vs 9.5%) had significant bleeding after surgery requiring blood transfusion. However, there were no significant differences between the groups in operative or postoperative blood transfusions (P = 0.12, 0.53), decreases in hematocrit (P = 0.21), hospital stay (P = 0.09), intensive care unit stay (P = 0.41), late complications (P = 0.45), or mortality (P = 0.42). Although our cohort is limited in size, these results suggest that in the case of a nonelective general surgery procedure where outcomes depend on timely surgery, clopidogrel taken within 6 days before surgery should not be a reason to delay surgery. However, careful attention must be paid to meticulous hemostasis, and platelets must be readily available for transfusion in the operating room.

[2001 national survey of nosocomial infection prevalence among newborns and under-eighteen children and adolescents in France].

PubMed

Branger, B

2005-07-01

To know nosocomial infections (NI) rates among newborns and hospitalised children according to age and units of hospitalisation, In 2001, the Comité technique des infections nosocomiales (CTIN) initiated a one-day prevalence survey on an arranged date. It was conducted by the 5 centres de coordination de lutte contre les infections nosocomiales (C.CLIN). Paediatric data only were analysed dividing them into 2 groups: newborns (NB) up to 28 days old, whether in maternity, neonatology or intensive care units, and children (CH) from 29 days to 18 years old with separate analysis for surgery, cancer units and intermediate care and rehabilitation centres (ICRC). The survey included 21 596 children under 18 years old: 9136 NB and 12,460 CH, i.e. 7.1% of the total hospital population on that one given day. A total of 2.6% of the patients were infected, with 1.2% of NB and 3.3% of CH. There were 1.09 infections per patient. 456 different microorganisms were responsible for 562 infections, i.e. 81.1%: 18,6% Staphylococcus aureus of which 26.7% were methicillin resistant (MRSA), 21.9% Staphylococcus epidermis, 21.9% enterobacteries, 10.3% Pseudomonas aeruginosa, 4.4% Candida albicans, and 4.2% rotavirus. NB and CH infection factors were studied separately. Selective criteria for hospitalised NB were: gender: male(P < 0.05), level of gravity (P < 0.05), surgery (P < 0.001), catheter (P < 0.01) and hospital type (P < 0.01). For EN, criteria were severity score (P < 0.01), surgery (P < 0.001), catheter (P < 0.01), and hospital type (P < 0.01). The rate for patients hospitalised in cancer units was 13.2% with no significant factors found. The rate of infected patients in intensive care units was 7.8% for NB and 16.2% for CH, with 9.6% neonatal, 30.8% heart condition, 26.3% non-specialised units and 14.2% children units. ICRC infection rate was 4.5% while surgery units had a rate of 1.9% with 2.4% orthopaedic, 0.7% children units, 2.0% non-specialised units and 8.1% neurosurgery. The 2001 NI level showed a significant fall from 3.5% in the 1996 survey (all ages) to 2.4%. However, including newborns from private maternity units into the survey may have partly lowered this level. MRSA levels have also dropped from 46% in 1996 to 27% in 2001. It is difficult to compare international data as definitions vary. Furthermore, it should be possible to separate newborns from older children as well as specifying the type of units involved. Infected patients levels are generally lower in the French surveys, no matter the age group or units studied than in other surveys. This survey has enabled the monitoring of the children population in maternity units, on a given day, in France. It showed that the rate of NI in the paediatric population seems low compared to previous data or other countries'data. Efforts need to be made in order to lower it further. Incidence surveillance method is preferable to single out which risk factors can be acted upon. Standardized national protocols are offered to maternity units and should soon be available for newborns units as well as older children units.

Duration of storage influences the hemoglobin rising effect of red blood cells in patients undergoing major abdominal surgery.

PubMed

Hunsicker, Oliver; Hessler, Katarina; Krannich, Alexander; Boemke, Willehad; Braicu, Ioana; Sehouli, Jalid; Meyer, Oliver; Pruß, Axel; Spies, Claudia; Feldheiser, Aarne

2018-04-17

After transfusion of senescent red blood cells (RBCs) a considerable fraction is rapidly cleared from the recipients' circulation. Thus, transfusion of senescent RBCs may be less effective in terms of increasing hemoglobin concentration (cHb) after transfusion. Data were retrospectively obtained in patients who underwent major abdominal surgery between 2006 and 2012. Patients were eligible if they received RBCs during surgery and had at least two arterial blood gas analyses performed. The primary endpoint was the increase of recipients' cHb related to the transfusion of 1 unit of RBCs with respect to different storage periods. Four storage periods were defined according to the distribution of RBC storage of the study population. General estimating equation was used for calculation of the primary endpoint and to adjust for confounding variables. A total of 598 arterial blood gas samples from 120 patients, receiving 429 RBC units, were analyzed. Mean (±SD) RBC storage was 21 (±9) days. RBC storage duration and the increase in recipients' cHb were inversely and gradually related; that is, the older the RBCs, the lower the increase in the recipients' cHb after transfusion (storage < 12 days, ΔcHb per unit RBCs +0.82 [95% confidence interval, 0.42-1.21] g/dL, p < 0.01; storage 12-20 days, +0.66 [0.46-0.86] g/dL, p < 0.01; storage 21-29 days, +0.56 [0.33-0.79] g/dL, p < 0.01; storage ≥30 days, +0.39 [0.07 to 0.71] g/dL, p = 0.02). Transfusion of senescent RBCs increased cHb less effectively than transfusion of fresher RBCs. © 2018 AABB.

Analysis of steps adapted protocol in cardiac rehabilitation in the hospital phase

PubMed Central

Winkelmann, Eliane Roseli; Dallazen, Fernanda; Bronzatti, Angela Beerbaum Steinke; Lorenzoni, Juliara Cristina Werner; Windmöller, Pollyana

2015-01-01

Objective To analyze a cardiac rehabilitation adapted protocol in physical therapy during the postoperative hospital phase of cardiac surgery in a service of high complexity, in aspects regarded to complications and mortality prevalence and hospitalization days. Methods This is an observational cross-sectional, retrospective and analytical study performed by investigating 99 patients who underwent cardiac surgery for coronary artery bypass graft, heart valve replacement or a combination of both. Step program adapted for rehabilitation after cardiac surgery was analyzed under the command of the physiotherapy professional team. Results In average, a patient stays for two days in the Intensive Care Unit and three to four days in the hospital room, totalizing six days of hospitalization. Fatalities occurred in a higher percentage during hospitalization (5.1%) and up to two years period (8.6%) when compared to 30 days after hospital discharge (1.1%). Among the postoperative complications, the hemodynamic (63.4%) and respiratory (42.6%) were the most prevalent. 36-42% of complications occurred between the immediate postoperative period and the second postoperative day. The hospital discharge started from the fifth postoperative day. We can observe that in each following day, the patients are evolving in achieving the Steps, where Step 3 was the most used during the rehabilitation phase I. Conclusion This evolution program by steps can to guide the physical rehabilitation at the hospital in patients after cardiac surgery. PMID:25859866

Analysis of steps adapted protocol in cardiac rehabilitation in the hospital phase.

PubMed

Winkelmann, Eliane Roseli; Dallazen, Fernanda; Bronzatti, Angela Beerbaum Steinke; Lorenzoni, Juliara Cristina Werner; Windmöller, Pollyana

2015-01-01

To analyze a cardiac rehabilitation adapted protocol in physical therapy during the postoperative hospital phase of cardiac surgery in a service of high complexity, in aspects regarded to complications and mortality prevalence and hospitalization days. This is an observational cross-sectional, retrospective and analytical study performed by investigating 99 patients who underwent cardiac surgery for coronary artery bypass graft, heart valve replacement or a combination of both. Step program adapted for rehabilitation after cardiac surgery was analyzed under the command of the physiotherapy professional team. In average, a patient stays for two days in the Intensive Care Unit and three to four days in the hospital room, totalizing six days of hospitalization. Fatalities occurred in a higher percentage during hospitalization (5.1%) and up to two years period (8.6%) when compared to 30 days after hospital discharge (1.1%). Among the postoperative complications, the hemodynamic (63.4%) and respiratory (42.6%) were the most prevalent. 36-42% of complications occurred between the immediate postoperative period and the second postoperative day. The hospital discharge started from the fifth postoperative day. We can observe that in each following day, the patients are evolving in achieving the Steps, where Step 3 was the most used during the rehabilitation phase I. This evolution program by steps can to guide the physical rehabilitation at the hospital in patients after cardiac surgery.

Time of day is not associated with increased rates of mortality in emergency surgery: An analysis of 49,196 surgical procedures.

PubMed

Gabriel, Rodney A; A'Court, Alison M; Schmidt, Ulrich H; Dutton, Richard P; Urman, Richard D

2018-05-01

There is a lack of large, multi-institutional studies analyzing the association of timing of emergency surgery with death occurring either intraoperatively or in the recovery room setting. The primary objective of this study was to determine if time of day for emergency surgeries was associated with mortality. Retrospective analysis. U.S. healthcare facilities. Adult patients undergoing emergency surgery and general anesthesia. No intervention. Utilizing the National Anesthesia Clinical Outcomes Registry database, all emergency non-cardiac, non-obstetric surgeries undergoing general anesthesia occurring between 2010 and 2015 in the United States were identified. We performed mixed effects logistic regression to determine the effect of time of day with mortality occurring during the intraoperative and immediate postoperative period. There were 46,196 cases that were eligible for this analysis, in which 24,247 and 21,949 occurred during day and after-hours shifts, respectively. The overall morality rate was 0.28%. Mortality rates were 0.17% and 0.41% in the day and after-hour shifts, respectively. There was no statistically significant association of time of day with mortality (odds ratio 1.31, 95% CI 0.90-1.92, p = 0.16). American Society of Anesthesiologists physical status classification, age, and operative body part were all associated with mortality. Although, theoretically, health care providers working after-hour shifts may be impacted by sleep deprivation and/or limited resources, we found that time of day was not associated with increased risk of mortality during the intraoperative and immediate postoperative period in emergency surgery. Copyright © 2018 Elsevier Inc. All rights reserved.

Using length of stay data from a hospital to evaluate whether limiting elective surgery at the hospital is an inappropriate decision.

PubMed

Dexter, Franklin; Lubarsky, David A

2004-09-01

At hospitals without detailed managerial accounting data but with overall longer than average diagnosis-related groups (DRG)-adjusted lengths of stays (LOS), some administrators do not aggressively hire the nurses needed to maintain surgical hospital capacity. The consequence of this (long-term) decision is that day-of-surgery admit cases are delayed or cancelled from a lack of beds. The anesthesiologists suffer financially. In this paper, we show how publicly released national LOS data can be applied specifically to these cases. We applied the method to 1 year of data from two academic hospitals. Each case's LOS was compared to the United States national average LOS for cases with the same DRG. A total of 8,050 and 10,099 hospitalizations, respectively. Among all surgical admissions, mean LOS was 2.5 days longer than the national average for Hospital #1 (95% confidence interval [CI], 2.1 to 2.8) and 3.1 days longer for Hospital #2 (95% CI, 2.8 to 3.4). Among patients undergoing elective, scheduled surgery with day of surgery admission, mean LOS was 0.7 days less than average for Hospital #1 (0.6 to 0.9) and 1.2 days less than average for Hospital #2 (1.1 to 1.4). This method can be used by anesthesiologists to show that LOS are not longer than average among patients whose surgeries may be cancelled or delayed for a lack of hospital ward staff.

Routine laparoscopic repair of primary unilateral inguinal hernias--a viable alternative in the day surgery unit?

PubMed

Duff, M; Mofidi, R; Nixon, S J

2007-08-01

In September 2004 the NICE institute revised its guidelines on the management of primary inguinal hernias to include laparoscopic repair of unilateral hernias. While published trials have confirmed the equal efficacy of the two approaches, it is not clear what impact a switch to laparoscopic repairs would have on resources and patient throughput in a Day Surgery Unit. All elective hernia repairs performed in a one-year period were considered. Data were obtained from operation notes, discharge summaries and out-patient records. Operating times are routinely documented in theatre. Of the 351 operations studied, 150 were performed laparoscopically predominantly by an extraperitoneal (TEP)approach. Six required conversion to an open procedure. There was no significant difference in operating times, total theatre time or recovery room times between the two groups (51 min, 75 min and 34 min for the laparoscopic group and 53 min, 74 min and 31 min for the open repair group). Among the laparoscopic repair group there were 48 bilateral hernias and 20 recurrent hernias while 190 of the 201 open repairs were for primary unilateral hernias. Rates of overnight stay and immediate complications were similar between the groups though haematoma was more common following open repair (7 vs 2). There is no difference in theatre times, immediate complication rates or rates of overnight stay between open and laparoscopic repair of inguinal hernia. Routine laparoscopic repair of primary unilateral inguinal hernia is a viable alternative within the Day Surgery Unit.

Effects of red-cell storage duration on patients undergoing cardiac surgery.

PubMed

Steiner, Marie E; Ness, Paul M; Assmann, Susan F; Triulzi, Darrell J; Sloan, Steven R; Delaney, Meghan; Granger, Suzanne; Bennett-Guerrero, Elliott; Blajchman, Morris A; Scavo, Vincent; Carson, Jeffrey L; Levy, Jerrold H; Whitman, Glenn; D'Andrea, Pamela; Pulkrabek, Shelley; Ortel, Thomas L; Bornikova, Larissa; Raife, Thomas; Puca, Kathleen E; Kaufman, Richard M; Nuttall, Gregory A; Young, Pampee P; Youssef, Samuel; Engelman, Richard; Greilich, Philip E; Miles, Ronald; Josephson, Cassandra D; Bracey, Arthur; Cooke, Rhonda; McCullough, Jeffrey; Hunsaker, Robert; Uhl, Lynne; McFarland, Janice G; Park, Yara; Cushing, Melissa M; Klodell, Charles T; Karanam, Ravindra; Roberts, Pamela R; Dyke, Cornelius; Hod, Eldad A; Stowell, Christopher P

2015-04-09

Some observational studies have reported that transfusion of red-cell units that have been stored for more than 2 to 3 weeks is associated with serious, even fatal, adverse events. Patients undergoing cardiac surgery may be especially vulnerable to the adverse effects of transfusion. We conducted a randomized trial at multiple sites from 2010 to 2014. Participants 12 years of age or older who were undergoing complex cardiac surgery and were likely to undergo transfusion of red cells were randomly assigned to receive leukocyte-reduced red cells stored for 10 days or less (shorter-term storage group) or for 21 days or more (longer-term storage group) for all intraoperative and postoperative transfusions. The primary outcome was the change in Multiple Organ Dysfunction Score (MODS; range, 0 to 24, with higher scores indicating more severe organ dysfunction) from the preoperative score to the highest composite score through day 7 or the time of death or discharge. The median storage time of red-cell units provided to the 1098 participants who received red-cell transfusion was 7 days in the shorter-term storage group and 28 days in the longer-term storage group. The mean change in MODS was an increase of 8.5 and 8.7 points, respectively (95% confidence interval for the difference, -0.6 to 0.3; P=0.44). The 7-day mortality was 2.8% in the shorter-term storage group and 2.0% in the longer-term storage group (P=0.43); 28-day mortality was 4.4% and 5.3%, respectively (P=0.57). Adverse events did not differ significantly between groups except that hyperbilirubinemia was more common in the longer-term storage group. The duration of red-cell storage was not associated with significant differences in the change in MODS. We did not find that the transfusion of red cells stored for 10 days or less was superior to the transfusion of red cells stored for 21 days or more among patients 12 years of age or older who were undergoing complex cardiac surgery. (Funded by the National Heart, Lung, and Blood Institute; RECESS ClinicalTrials.gov number, NCT00991341.).

Using predicted 30 day mortality to plan postoperative colorectal surgery care: a cohort study.

PubMed

Swart, M; Carlisle, J B; Goddard, J

2017-01-01

Preoperative identification of high-risk surgical patients might help to reduce postoperative morbidity and mortality. Using a patient's predicted 30 day mortality to plan postoperative high-dependency unit (HDU) care after elective colorectal surgery might be associated with reduced postoperative morbidity. The 30 day postoperative mortality was predicted for 504 elective colorectal surgical patients in a preoperative clinic. The prediction was used to determine postoperative surgical ward or HDU care. Those with a predicted 30 day mortality of 1-3% mortality, and thus deemed at intermediate risk, had either planned HDU care (n=68) or planned ward care (n=139). The main outcome measures were emergency laparotomy and unplanned critical care admission. There were more emergency laparotomies and unplanned critical care admissions in patients with a predicted 30 day mortality of 1-3% who went to an HDU after surgery compared with patients who went to a ward: 0 vs 14 (10%), P=0.0056 and 0 vs 22 (16%), P=0.0002, respectively. Planned postoperative critical care was associated with a lower rate of complications after elective colorectal surgery. © The Author 2016. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Clinic-based nerve conduction studies reduce time to surgery and are cost effective: a comparison with formal electrophysiological testing

PubMed Central

Bourke, Henry E; Read, Jeremy; Kampa, Rebecca; Hearnden, Anthony; Davey, Paul A

2011-01-01

INTRODUCTION Carpal tunnel syndrome is the most common compression neuropathy affecting the upper limb. Clinical diagnosis is not always clear and electrophysiological testing can be indicated when considering a patient for decompression surgery. The downside of electrophysiological testing is cost and increased time to surgery. Newer methods of performing nerve conduction studies in clinic have become available. MATERIALS AND METHODS We investigated the use of a clinic-based, handheld, non-invasive electrophysiological device (NC-stat®) in 71 patients with suspected carpal tunnel syndrome presenting to our hand clinic in a district general hospital. We compared this to a similar cohort of 71 age-matched patients also presenting to our unit in whom formal nerve conduction studies were performed at a local neurophysiology unit. Our outcome measures were time from presentation to carpal tunnel decompression, the cost of each pathway and the practicalities of using the device in a busy hand unit. RESULTS AND CONCLUSIONS The NC-stat® proved to be a successful device when compared with referring patients out for more formal nerve conduction studies, shortening the time from presentation to surgery from 198 days to 102 days (p<0.0001). It was also cost effective with a calculated saving to the hospital of more than £70 per patient. The device is easy to use and acceptable to patients and no adverse effects were noted. PMID:21477439

Identifying predictors of hospital readmission following congenital heart surgery through analysis of a multiinstitutional administrative Database.

PubMed

Smith, Andrew H; Doyle, Thomas P; Mettler, Bret A; Bichell, David P; Gay, James C

2015-01-01

Despite resource burdens associated with hospital readmission, there remains little multiinstitutional data available to identify children at risk for readmission following congenital heart surgery. Children undergoing congenital heart surgery and discharged home between January of 2011 and December 2012 were identified within the Pediatric Health Information System database, a multiinstitutional collection of clinical and administrative data. Patient discharges were assigned to derivation and validation cohorts for the purposes of predictive model design, with 17 871 discharges meeting inclusion criteria. Readmission within 30 days was noted following 956 (11%) of discharges within the derivation cohort (n = 9104), with a median time to readmission of 9 days (interquartile range [IQR] 5-18 days). Readmissions resulted in a rehospitalization length of stay of 4 days (IQR 2-8 days) and were associated with an intensive care unit (ICU) admission in 36% of cases. Independent perioperative predictors of readmission included Risk Adjustment in Congenital Heart Surgery score of 6 (odds ratio [OR] 2.6, 95% confidence interval [CI] 1.8-3.7, P < .001) and ICU length of stay of at least 7 days (OR 1.9 95% CI 1.6-2.2, P < .001). Demographic predictors included Hispanic ethnicity (OR 1.2, 95% CI 1.1-1.4, P = .014) and government payor status (OR 1.2, 95% CI 1.1-1.4, P = .007). Predictive model performance was modest among validation cohort (c statistic 0.68, 95% CI 0.66-0.69, P < .001). Readmissions following congenital heart surgery are common and associated with significant resource consumption. While we describe independent predictors that may identify patients at risk for readmission prior to hospital discharge, there likely remains other unreported factors that may contribute to readmission following congenital heart surgery. © 2014 Wiley Periodicals, Inc.

Nutrition Therapy in Critically Ill Patients Following Cardiac Surgery: Defining and Improving Practice.

PubMed

Rahman, Adam; Agarwala, Ravi; Martin, Claudio; Nagpal, Dave; Teitelbaum, Michael; Heyland, Daren K

2017-09-01

Malnutrition is a predictor of poor outcome following cardiac surgery. We define nutrition therapy after cardiac surgery to identify opportunities for improvement. International prospective studies in 2007-2009, 2011, and 2013 were combined. Sites provided institutional and patient characteristics from intensive care unit (ICU) admission to ICU discharge for a maximum of 12 days. Patients had valvular, coronary artery bypass graft (CABG) surgery, or combined procedures and were mechanically ventilated and staying in the ICU for ≥3 days. There were 787 patients from 144 ICUs. In total, 120 patients (15.2%) had valvular surgery, 145 patients (18.4%) had CABG, and 522 patients (66.3%) underwent a combined procedure. Overall, 60.1% of patients received artificial nutrition support. For these patients, 78% received enteral nutrition (EN) alone, 17% received a combination of EN and parenteral nutrition (PN), and 5% received PN alone. The remaining 314 patients (40%) received no nutrition. The mean (SD) time from ICU admission to EN initiation was 2.3 (1.8) days. The adequacy of calories was 32.4% ± 31.9% from EN and PN and 25.5% ± 27.9% for patients receiving only EN. In EN patients, 57% received promotility agents and 20% received small bowel feeding. There was no significant relationship between increased energy or protein provision and 60-day mortality. Postoperative cardiac surgery patients who stay in the ICU for 3 or more days are at high risk for inadequate nutrition therapy. Further studies are required to determine if targeted nutrition therapy may alter clinical outcomes.

Walking Clinic in ambulatory surgery--A patient based concept: A Portuguese pioneer project.

PubMed

Vinagreiro, M; Valverde, J N; Alves, D; Costa, M; Gouveia, P; Guerreiro, E

2015-06-01

Walking Clinic is an innovative, efficient and easily reproducible concept adapted to ambulatory surgery. It consists of a preoperative single day work-up, with a surgeon, an anesthetist and a nurse. The aim of this study was to evaluate patient satisfaction and its determinants. A survey was applied to 171 patients (101 of the Walking Clinic group and 70 not engaged in this new concept). Patient satisfaction was assessed evaluating five major questionnaire items: secretariat (quality of the information and support given), physical space (overall comfort and cleanliness), nurses and medical staff (willingness and expertise), and patients (waiting time until pre-operative consults and exams, waiting time until being scheduled for surgery, surgery day waiting time and postoperative pain control). Furthermore, overall assessment of the received treatment, and probability of patient recommending or returning to our ambulatory unit were also analyzed. Walking Clinic group had overall better results in the five major questionnaire items assessed, with statistical significance, except for the physical space. It also showed better results regarding the sub-items postoperative pain control, waiting time until being scheduled for surgery and surgery day waiting time. The results confirm better patient satisfaction with this new concept. The Walking Clinic concept complements all the tenets of ambulatory surgery, in a more efficient manner. Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.

Implementation and audit of 'Fast-Track Surgery' in gynaecological oncology surgery.

PubMed

Sidhu, Verinder S; Lancaster, Letitia; Elliott, David; Brand, Alison H

2012-08-01

Fast-track surgery is a multidisciplinary approach to surgery that results in faster recovery from surgery and decreased length of stay (LOS). The aims of this study were as follows: (i) to report on the processes required for the introduction of fast-track surgery to a gynaecological oncology unit and (ii) to report the results of a clinical audit conducted after the protocol's implementation. A fast-track protocol, specific to our unit, was developed after a series of multidisciplinary meetings. The protocol, agreed upon by those involved in the care of women in our unit, was then introduced into clinical practice. An audit was conducted of all women undergoing laparotomy, with known or suspected malignancy. Information on LOS, complication and readmission rates was collected. Descriptive statistics and Poisson regression were used for statistical analysis. The developed protocol involved a multidisciplinary approach to pre-, intra- and postoperative care. The audit included 104 consecutive women over a 6-month period, who were followed for 6 weeks postoperatively. The median LOS was 4 days. The readmission rate was 7% and the complication rate was 19% (1% intraoperative, 4% major and 14% minor). Multivariate analysis revealed that increased duration of surgery and increasing age were predictors of longer LOS. The development of a fast-track protocol is achievable in a gynaecological oncology unit, with input from a multidisciplinary team. Effective implementation of the protocol can result in a short LOS, with acceptable complication and readmission rates when applied non-selectively to gynaecological oncology patients. © 2012 The Authors ANZJOG © 2012 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Lean and Green Hand Surgery.

PubMed

Van Demark, Robert E; Smith, Vanessa J S; Fiegen, Anthony

2018-02-01

Health care in the United States is both expensive and wasteful. The cost of health care in the United States continues to increase every year. Health care spending for 2016 is estimated at $3.35 trillion. Per capita spending ($10,345 per person) is more than twice the average of other developed countries. The United States also leads the world in solid waste production (624,700 metric tons of waste in 2011). The health care industry is second only to the food industry in annual waste production. Each year, health care facilities in the United States produce 4 billion pounds of waste (660 tons per day), with as much as 70%, or around 2.8 billion pounds, produced directly by operating rooms. Waste disposal also accounts for up to 20% of a hospital's annual environmental services budget. Since 1992, waste production by hospitals has increased annually by a rate of at least 15%, due in part to the increased usage of disposables. Reduction in operating room waste would decrease both health care costs and potential environmental hazards. In 2015, the American Association for Hand Surgery along with the American Society for Surgery of the Hand, American Society for Peripheral Nerve Surgery, and the American Society of Reconstructive Microsurgery began the "Lean and Green" surgery project to reduce the amount of waste generated by hand surgery. We recently began our own "Lean and Green" project in our institution. Using "minor field sterility" surgical principles and Wide Awake Local Anesthesia No Tourniquet (WALANT), both surgical costs and surgical waste were decreased while maintaining patient safety and satisfaction. As the current reimbursement model changes from quantity to quality, "Lean and Green" surgery will play a role in the future health care system. Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

[Video-assisted thoracic surgery to treat spinal deformities: climbing the learning curve].

PubMed

Rivo Vázquez, José Eduardo; Cañizares Carretero, Miguel Angel; García Fontán, Eva; Blanco Ramos, Montserrat; Varela Ares, Ermitas; Justo Tarrazo, César

2007-04-01

The aim of this study was to analyze the impact of the learning curve on the preliminary results of video-assisted thoracic surgery for spinal deformities in a general hospital setting. We retrospectively reviewed the medical records of 15 patients who underwent video-assisted thoracic surgery performed by a multidisciplinary team comprising orthopedic and thoracic surgeons. Endoscopic anterior release and fusion were followed by posterior instrumentation in a single procedure. Demographic, orthopedic, morbidity, and mortality statistics were compiled for the 15 patients and compared to results reported for similar series. Endoscopic surgery was indicated for 15 patients: 11 women (73.3%) and 4 men (26.7%). The median age was 15 years (interquartile range [IQR], 14-19 years). Three patients (20%) required conversion to thoracotomy. There were 2 serious (13.3%) and 3 minor complications (20%). They all resolved satisfactorily and there was no perioperative mortality. The median Cobb angle was 71 degrees (IQR, 63.75 degrees -75.25 degrees ) before surgery and 41 degrees (IQR, 30 degrees -50 degrees ) after surgery. Median duration of surgery was 360 minutes (IQR, 300-360 minutes), duration of postoperative recovery unit stay was 1.5 days (IQR, 1-2.75 days), and total hospital stay was 11.5 days (IQR, 8.25-14 days). Despite the complexity of video-assisted thoracic surgical procedures, we believe they will become the standard approach to treating spinal deformities in the near future. By working together in general hospital settings, orthopedic and thoracic surgeons can help to overcome the steep yet manageable learning curve.

Effects of massage therapy on sleep quality after coronary artery bypass graft surgery.

PubMed

Nerbass, Flavia Baggio; Feltrim, Maria Ignez Zanetti; Souza, Silvia Alves de; Ykeda, Daisy Satomi; Lorenzi-Filho, Geraldo

2010-01-01

Having poor sleep quality is common among patients following cardiopulmonary artery bypass graft surgery. Pain, stress, anxiety and poor sleep quality may be improved by massage therapy. This study evaluated whether massage therapy is an effective technique for improving sleep quality in patients following cardiopulmonary artery bypass graft surgery. Participants included cardiopulmonary artery bypass graft surgery patients who were randomized into a control group and a massage therapy group following discharge from the intensive care unit (Day 0), during the postoperative period. The control group and the massage therapy group comprised participants who were subjected to three nights without massage and three nights with massage therapy, respectively. The patients were evaluated on the following mornings (i.e., Day 1 to Day 3) using a visual analogue scale for pain in the chest, back and shoulders, in addition to fatigue and sleep. Participants kept a sleep diary during the study period. Fifty-seven cardiopulmonary artery bypass graft surgery patients were enrolled in the study during the preoperative period, 17 of whom were excluded due to postoperative complications. The remaining 40 participants (male: 67.5%, age: 61.9 years ± 8.9 years, body mass index: 27.2 kg/m² ± 3.7 kg/m²) were randomized into control (n = 20) and massage therapy (n = 20) groups. Pain in the chest, shoulders, and back decreased significantly in both groups from Day 1 to Day 3. The participants in the massage therapy group had fewer complaints of fatigue on Day 1 (p=0.006) and Day 2 (p=0.028) in addition, they reported a more effective sleep during all three days (p=0.019) when compared with the participants in the control group. Massage therapy is an effective technique for improving patient recovery from cardiopulmonary artery bypass graft surgery because it reduces fatigue and improves sleep.

Regional Cerebral Oxygen Saturation Level Predicts 30-Day Mortality Rate After Left Ventricular Assist Device Surgery.

PubMed

Ghosal, Soutik; Trivedi, Jaimin; Chen, James; Rogers, Michael P; Cheng, Allen; Slaughter, Mark S; Kong, Maiying; Huang, Jiapeng

2018-06-01

Left ventricular assist device (LVAD) surgery is complex, high risk, and expensive. The authors' hypothesis is baseline regional cerebral oxygen saturation (rSO 2 ) might be a predictor of postoperative clinical outcomes. Retrospective review of 210 consecutive continuous flow LVAD patients between 2008 and 2014. The primary measure is 30-day mortality rate and secondary measures include modified major adverse cardiocerebral events (MACE), length of stay (LOS), and intensive care unit (ICU) stay. Multiple logistic regression models were applied to examine if a binary outcome variable, such as 30-day mortality and MACE, is associated with rSO 2 at baseline. Log-linear model was used to examine whether LOS or ICU stay hours is associated with rSO 2 at baseline. Single institution, academic hospital. Patients who received LVAD surgery ​at Jewish Hospital, Louisville, KY. All patients received LVAD surgery. Cerebral oximetry monitoring was used in both the preoperative and intraoperative periods. The authors found that higher rSO 2 at baseline is associated with lower 30-day mortality with an odds ratio of 0.94 and 95% confidence interval (0.888, 0.995) for every 1% increase of rSO 2 . For secondary outcomes, baseline rSO 2 was not significantly associated with MACE, requirement for postoperative renal failure/dialysis, reoperation for bleeding, and LOS or ICU hours. Regional cerebral oxygen saturation levels at baseline are significantly associated with 30-day mortality after LVAD surgeries. Copyright © 2017 Elsevier Inc. All rights reserved.

Serious mental illnesses associated with receipt of surgery in retrospective analysis of patients in the Veterans Health Administration.

PubMed

Copeland, Laurel A; Zeber, John E; Sako, Edward Y; Mortensen, Eric M; Pugh, Mary Jo; Wang, Chen-Pin; Restrepo, Marcos I; Flynn, Julianne; MacCarthy, Andrea A; Lawrence, Valerie A

2015-06-18

The STOPP study (Surgical Treatment Outcomes for Patients with Psychiatric Disorders) analyzed variation in rates and types of major surgery by serious mental illness status among patients treated in the Veterans Health Administration (VA). VA patients are veterans of United States military service who qualify for federal care by reason of disability, special service experiences, or poverty. STOPP conducted a secondary data analysis of medical record extracts for seven million VA patients treated Oct 2005-Sep 2009. The retrospective study aggregated inpatient surgery events, comorbid diagnoses, demographics, and postoperative 30-day mortality. Serious mental illness -- schizophrenia, bipolar disorder, posttraumatic stress disorder, or major depressive disorder, was identified in 12 % of VA patients. Over the 4-year study period, 321,131 patients (4.5 %) underwent surgery with same-day preoperative or immediate post-operative admission including14 % with serious mental illness. Surgery patients were older (64 vs. 61 years) and more commonly African-American, unmarried, impoverished, highly disabled (24 % vs 12 % were Priority 1), obese, with psychotic disorder (4.3 % vs 2.9 %). Among surgery patients, 3.7 % died within 30 days postop. After covariate adjustment, patients with pre-existing serious mental illness were relatively less likely to receive surgery (adjusted odds ratios 0.4-0.7). VA patients undergoing major surgery appeared, in models controlling for comorbidity and demographics, to disproportionately exclude those with serious mental illness. While VA preferentially treats the most economically and medically disadvantaged veterans, the surgery subpopulation may be especially ill, potentially warranting increased postoperative surveillance.

National Comparative Audit of Blood Use in Elective Primary Unilateral Total Hip Replacement Surgery in the UK

PubMed Central

Boralessa, H; Goldhill, DR; Tucker, K; Mortimer, AJ; Grant-Casey, J

2009-01-01

INTRODUCTION Blood is a scarce and expensive product. Although it may be life-saving, in recent years there has been an increased emphasis on the potential hazards of transfusion as well as evidence supporting the use of lower transfusion thresholds. Orthopaedic surgery accounts for some 10% of transfused red blood cells and evidence suggests that there is considerable variation in transfusion practice. PATIENTS AND METHODS NHS Blood and Transplant, in collaboration with the Royal College of Physicians, undertook a national audit on transfusion practice. Each hospital was asked to provide information relating to 40 consecutive patients undergoing elective, primary unilateral total hip replacement surgery. The results were compared to indicators and standards. RESULTS Information was analysed relating to 7465 operations performed in 223 hospitals. Almost all hospitals had a system for referring abnormal pre-operative blood results to a doctor and 73% performed a group-and-save rather than a cross-match before surgery. Of hospitals, 47% had a transfusion policy. In 73%, the policy recommended a transfusion threshold at a haemoglobin concentration of 8 g/dl or less. There was a wide variation in transfusion rate among hospitals. Of patients, 15% had a haemoglobin concentration less than 12 g/dl recorded in the 28 days before surgery and 57% of these patients were transfused compared to 20% with higher pre-operative values. Of those who were transfused, 7% were given a single unit and 67% two units. Of patients transfused two or more units during days 1–14 after surgery, 65% had a post transfusion haemoglobin concentration of 10 g/dl or more. CONCLUSIONS Pre-operative anaemia, lack of availability of transfusion protocols and use of different thresholds for transfusion may have contributed to the wide variation in transfusion rate. Effective measures to identify and correct pre-operative anaemia may decrease the need for transfusion. A consistent, evidence-based, transfusion threshold should be used and transfusion of more than one unit should only be given if essential to maintain haemoglobin concentrations above this threshold. PMID:19686612

Antimicrobial efficacy and aqueous humor concentration of preoperative and postoperative topical trimethoprim/polymyxin B sulfate versus tobramycin.

PubMed

Osher, R H; Amdahl, L D; Cheetham, J K

1994-01-01

We compared trimethoprim sulfate 0.1%/polymyxin B sulfate 10,000 units/mL with tobramycin 0.3% for preoperative sterilization of the ocular surface, aqueous humor concentration, and ocular safety and comfort in 99 patients who had cataract extraction and intraocular lens implantation. The organisms most frequently cultured from the conjunctiva at baseline were Staphylococcus epidermidis, Corynebacterium species, and Staphylococcus aureus, which were isolated from 66%, 15%, and 8% of the 95 specimens eligible for evaluation. All organisms identified in positive baseline conjunctival cultures except Staphylococcus epidermidis were completely eradicated in both groups on the day of surgery and five to seven days postoperatively. Staphylococcus epidermidis was eradicated on the day of surgery in 58% of patients in the trimethoprim/polymyxin group and in 68% in the tobramycin group. This organism was eradicated five to seven days postoperatively in 85% of patients in both groups. Mean aqueous humor concentration of trimethoprim sulfate at surgery was greater than the mean tobramycin concentration, but neither reached clinically significant inhibitory levels for most organisms. No significant differences were found in ocular safety and comfort.

Factors affecting survival in neonatal surgery unit in a tertiary care university hospital during 26 years.

PubMed

Özden, Önder; Karnak, İbrahim; Çiftçi, Arbay Özden; Tanyel, F Cahit; Şenocak, Mehmet Emin

2016-01-01

This clinical study was designed to evaluate mortality rate and the factors that may affect survival in neonatal surgery unit. Randomly chosen 300 (ß: 0.20) patients among 1,439 patients treated in neonatal surgery unit during years 1983 to 2009, were evaluated retrospectively. The patients were separated into three groups according to date of treatment; Group A: 1983 - 1995, Group B: 1996 - 2005 and Group C: 2005 - 2009. M/F ratios did not differ between non-survived and survived patient populations. Mortality rates were 37%, 22% and 13% in Group A, B, and C respectively (p < 0.001). Parenteral nutrition, maternal age, time until admission and gestational age did not affect mortality rate, however median age of newborn was lower in non-survived cases (1 day vs. 3 days, p < 0.001). Associating abnormality, low birth weight ( < 1,500 g), associating sepsis, need of globulin and requirement of respiratory support were determinants of lower survival (p < 0.001). The mortality rate for patients that underwent thoracotomy (42%) and laparotomy (41%) were higher than patients that underwent other operations (8%) and observation (10%) (p < 0.001). Diaphragmatic hernia had higher mortality rates than the other pathologies (p < 0.001). Survival rate is increasing to date in newborn pediatric surgery unit; it is independent from parenteral nutrition, maternal age, time to admission and gestational age however it is affected adversely by the age of patient, associating abnormality, low birth weight, presence of sepsis and requirement of respiratory support. Increase in survival could be related to various additional factors such as development of delicate respiratory support machines, broad spectrum antibiotics, hospital infection control teams, central venous catheters, use of TPN by central route, volume adjustable infusion pumps, monitoring devices, neonatal surgical techniques, prenatal diagnosis of pediatric surgical conditions and developments of environmental control methods in neonatal surgical units.

A multi-institutional cohort study confirming the risks of Clostridium difficile infection associated with prolonged antibiotic prophylaxis.

PubMed

Kirkwood, Katherine A; Gulack, Brian C; Iribarne, Alexander; Bowdish, Michael E; Greco, Giampaolo; Mayer, Mary Lou; O'Sullivan, Karen; Gelijns, Annetine C; Fumakia, Nishit; Ghanta, Ravi K; Raiten, Jesse M; Lala, Anuradha; Ladowski, Joseph S; Blackstone, Eugene H; Parides, Michael K; Moskowitz, Alan J; Horvath, Keith A

2018-02-01

The incidence and severity of Clostridium difficile infection (CDI) have increased rapidly over the past 2 decades, particularly in elderly patients with multiple comorbidities. This study sought to characterize the incidence and risks of these infections in cardiac surgery patients. A total of 5158 patients at 10 Cardiothoracic Surgical Trials Network sites in the US and Canada participated in a prospective study of major infections after cardiac surgery. Patients were followed for infection, readmission, reoperation, or death up to 65 days after surgery. We compared clinical and demographic characteristics, surgical data, management practices, and outcomes for patients with CDI and without CDI. C difficile was the third most common infection observed (0.97%) and was more common in patients with preoperative comorbidities and complex operations. Antibiotic prophylaxis for >2 days, intensive care unit stay >2 days, and postoperative hyperglycemia were associated with increased risk of CDI. The median time to onset was 17 days; 48% of infections occurred after discharge. The additional length of stay due to infection was 12 days. The readmission and mortality rates were 3-fold and 5-fold higher, respectively, in patients with CDI compared with uninfected patients. In this large multicenter prospective study of major infections following cardiac surgery, CDI was encountered in nearly 1% of patients, was frequently diagnosed postdischarge, and was associated with extended length of stay and substantially increased mortality. Patients with comorbidities, longer surgery time, extended antibiotic exposure, and/or hyperglycemic episodes were at increased risk for CDI. Copyright © 2017 The American Association for Thoracic Surgery. All rights reserved.

Impact of empiric nesiritide or milrinone infusion on early postoperative recovery after Fontan surgery: a randomized, double-blind, placebo-controlled trial.

PubMed

Costello, John M; Dunbar-Masterson, Carolyn; Allan, Catherine K; Gauvreau, Kimberlee; Newburger, Jane W; McGowan, Francis X; Wessel, David L; Mayer, John E; Salvin, Joshua W; Dionne, Roger E; Laussen, Peter C

2014-07-01

We sought to determine whether empirical nesiritide or milrinone would improve the early postoperative course after Fontan surgery. We hypothesized that compared with milrinone or placebo, patients assigned to receive nesiritide would have improved early postoperative outcomes. In a single-center, randomized, double-blinded, placebo-controlled, multi-arm parallel-group clinical trial, patients undergoing primary Fontan surgery were assigned to receive nesiritide, milrinone, or placebo. A loading dose of study drug was administered on cardiopulmonary bypass followed by a continuous infusion for ≥12 hours and ≤5 days after cardiac intensive care unit admission. The primary outcome was days alive and out of the hospital within 30 days of surgery. Secondary outcomes included measures of cardiovascular function, renal function, resource use, and adverse events. Among 106 enrolled subjects, 35, 36, and 35 were randomized to the nesiritide, milrinone, and placebo groups, respectively, and all were analyzed based on intention to treat. Demographics, patient characteristics, and operative factors were similar among treatment groups. No significant treatment group differences were found for median days alive and out of the hospital within 30 days of surgery (nesiritide, 20 [minimum to maximum, 0-24]; milrinone, 18 [0-23]; placebo, 20 [0-23]; P=0.38). Treatment groups did not significantly differ in cardiac index, arrhythmias, peak lactate, inotropic scores, urine output, duration of mechanical ventilation, intensive care or chest tube drainage, or adverse events. Compared with placebo, empirical perioperative nesiritide or milrinone infusions are not associated with improved early clinical outcomes after Fontan surgery. http://www.clinicaltrials.gov. Unique identifier: NCT00543309. © 2014 American Heart Association, Inc.

C-reactive protein and procalcitonin for the early detection of anastomotic leakage after elective colorectal surgery: pilot study in 100 patients.

PubMed

Lagoutte, N; Facy, O; Ravoire, A; Chalumeau, C; Jonval, L; Rat, P; Ortega-Deballon, P

2012-10-01

Anastomotic leakage is the most important complication after colorectal surgery. Its prognosis depends on its early diagnosis. C-reactive protein (CRP) has already shown its usefulness for the early detection of anastomotic leaks. Procalcitonin (PCT) is widely used in intensive care units and is more expensive, but its usefulness in the postoperative period of digestive surgery is not well established. Between May 2010 and June 2011, 100 patients undergoing elective colorectal surgery were prospectively included in a database. CRP and PCT were measured before surgery and daily until postoperative day 4. All intraabdominal infections were considered as anastomotic leaks, regardless of their clinical impact and their management. The kinetics of PCT and CRP were recorded, as well as their accuracy for the detection of anastomotic fistula. The incidence of fistula was 13% and the overall mortality rate was 2%. Both CRP and PCT were significantly higher in patients with leakage. Areas under the receiver-operating characteristics (ROC) for CRP were higher than those for PCT each day. The best accuracy was obtained for CRP on postoperative day 4 (areas under the ROC curve were 0.869 for CRP and 0.750 for PCT). Procalcitonin is neither earlier nor more accurate than CRP for the detection of anastomotic leakage after elective colorectal surgery. Copyright © 2012 Elsevier Masson SAS. All rights reserved.

Independence and mobility after infrainguinal lower limb bypass surgery for critical limb ischemia.

PubMed

Ambler, Graeme K; Dapaah, Andrew; Al Zuhir, Naail; Hayes, Paul D; Gohel, Manjit S; Boyle, Jonathan R; Varty, Kevin; Coughlin, Patrick A

2014-04-01

Critical limb ischemia (CLI) is a common condition associated with high levels of morbidity and mortality. Most work to date has focused on surgeon-oriented outcomes such as patency, but there is increasing interest in patient-oriented outcomes such as mobility and independence. This study was conducted to determine the effect of infrainguinal lower limb bypass surgery (LLBS) on postoperative mobility in a United Kingdom tertiary vascular surgery unit and to investigate causes and consequences of poor postoperative mobility. We collected data on all patients undergoing LLBS for CLI at our institution during a 3-year period and analyzed potential factors that correlated with poor postoperative mobility. During the study period, 93 index LLBS procedures were performed for patients with CLI. Median length of stay was 11 days (interquartile range, 11 days). The 12-month rates of graft patency, major amputation, and mortality were 75%, 9%, and 6%, respectively. Rates of dependence increased fourfold during the first postoperative year, from 5% preoperatively to 21% at 12 months. Predictors of poor postoperative mobility were female sex (P = .04) and poor postoperative mobility (P < .001), initially and at the 12-month follow-up. Patients with poor postoperative mobility had significantly prolonged hospital length of stay (15 vs 8 days; P < .001). Patients undergoing LLBS for CLI suffer significantly impaired postoperative mobility, and this is associated with prolonged hospital stay, irrespective of successful revascularization. Further work is needed to better predict patients who will benefit from revascularization and in whom a nonoperative strategy is optimal. Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

A Case Study of the Environmental Experience of a Hospitalized Newborn Infant With Complex Congenital Heart Disease.

PubMed

Daniels, Jacki M; Harrison, Tondi M

2016-01-01

Infants with complex congenital heart disease are at high risk for developmental delays. Although the etiology of these delays is multifactorial, the physical environment may be a contributory factor. Extensive studies have been conducted in neonatal intensive care units measuring environmental influences on development, resulting in policy and practice changes. Cardiothoracic intensive care units and cardiac step-down units are new environments in which newborns with heart disease receive care. No environmental studies have been conducted in units caring for newborn infants recovering from cardiac surgery. The aim of this study is to examine the environmental experience of a newborn infant with heart disease after surgical intervention within the first month of life. Measurements of illumination, sound levels, and sleep were recorded on 1 infant for 2 consecutive postoperative days in the cardiothoracic intensive care unit and 2 consecutive days in the step-down unit. Although average daily noise exposure remained below recommended guidelines on 3 of 4 days, the infant experienced intermittent periods of excessive noise (≥55 dBA) during 59 of 87 hours and 110 episodes of acute noise events greater than 70 dBA. Average daily light exposure was below the recommended guidelines. However, light levels were more than twice the recommended levels at multiple points daily. For each of the 4 observation days, the infant experienced 66 to 102 awakenings during sleep, and sleep durations were less than 30 minutes 90% of the time. This study provides the first report of potential environmental stressors in newborn infants cared for in cardiac specialty units. Excessive levels of light and noise as well as frequent interruptions for medical and nursing care may contribute to disorganized sleep and increased patient distress and may impact subsequent neurodevelopment. Studies are needed to identify potentially adverse aspects of the intensive caregiving environment for newborn infants who have undergone cardiac surgery.

Therapeutic efficacy of bromelain in impacted third molar surgery: a randomized controlled clinical study.

PubMed

Ordesi, Paolo; Pisoni, Luca; Nannei, Pierluigi; Macchi, Maurizia; Borloni, Roberto; Siervo, Sandro

2014-09-01

Bromelain is the name given to a family of proteolytic enzymes obtained from Ananas comosus, the pineapple plant. It is considered a potent anti-inflammatory and antiedematous substance. Surgery of impacted third molars in the outpatient setting is one of the procedures most often associated with postoperative pain and swelling. The aim of this study was to evaluate the efficacy of bromelain in reducing postoperative pain and swelling. 80 patients were recruited to the study from patients attending the Maxillofacial Surgery Unit of the Istituto Stomatologico Italiano, Milan, Italy, for impacted third molar surgery. At time 0 when surgery was performed, patients started simultaneous antibiotic and analgesic therapy. On the following day, patients were divided into two groups. Patients in group 1 were prescribed bromelain. Patients in group 2 were prescribed only the analgesic if required. Three parameters were evaluated: pain, edema, and erythema. The first evaluation visit was performed 3 hours after surgery, the second 48 hours after surgery, and the final evaluation 7 days after surgery. Postoperative pain, edema, and erythema were significantly lower in the study group than in the control group. Analgesic consumption, both in terms of days of treatment and number of tablets taken, was slightly lower in the study group. Only one adverse event was recorded, which occurred in a patient in the control group. The present study demonstrates an important anti-inflammatory and anti-edematous effect of bromelain. Statistical analysis shows that in the group treated with bromelain the inflammatory response was significantly less than in the control group.

Comparison of surgical outcomes among infants in neonatal intensive care units treated by pediatric surgeons versus general surgeons: The need for pediatric surgery specialists.

PubMed

Boo, Yoon Jung; Lee, Eun Hee; Lee, Ji Sung

2017-11-01

This study compared the outcomes of infants who underwent surgery in neonatal intensive care units by pediatric surgeons and by general surgeons. This was a retrospective study of infants who underwent surgery in neonatal intensive care units between 2010 and 2014. A total of 227 patients were included. Of these patients, 116 were operated on by pediatric surgeons (PS) and 111 were operated on by general surgeons (GS). The outcome measures were the overall rate of operative complications, unplanned reoperation, mortality rate, length of stay, operative time, and number of total number of operative procedures. The overall operative complication rate was higher in the GS group compared with the PS group (18.7% vs. 7.0%, p=0.0091). The rate of unplanned reoperations was also higher in the GS group (10.8% vs. 3.5%, p=0.0331). The median operation time (90min vs. 75min, p=0.0474) and median length of stay (24days vs. 18days, p=0.0075) were significantly longer in the GS group. The adjusted odd ratios of postoperative complications for GS were 2.9 times higher than that of PS (OR 2.90, p=0.0352). The operative quality and patient outcomes of the PS group were superior to those of the GS group. III. Copyright © 2017 Elsevier Inc. All rights reserved.

The revascularization of pedicle skin flaps in pigs: a functional and morphologic study

DOE Office of Scientific and Technical Information (OSTI.GOV)

Young, C.M.

1982-10-01

Functional and morphologic changes occurring during the revascularization of pedicle flaps have been investigated in the skin of pigs. The skin flaps, 16 cm long by 4 cm wide, were based on a row of segmental vessels arising from the internal mammary artery. Comparative measurements were made in flapped and normal skin. The inherent blood supply in the pedicle of the flap was unable to maintain the whole of the flap in a viable state. Flap viability was ascertained at surgery by the use of the intravital dye Disulphine blue. Injections of the dye after surgery gave a less accuratemore » prediction of viability than when dye was injected prior to surgery. Revascularization between the flap and surrounding skin was evident 3 to 4 days postoperatively at the distal, most hypoxic part of the viable flap. The whole flap had a collateral vascular supply 7 to 10 days after surgery. Isotope clearance studies showed that the greatest functional changes occurred in the distal third of the viable flap, where, after initially slowing, the clearance rate became faster than in normal skin (day 5). Potassium extraction studies indicated similar changes. However, an increase in the red-cell volume on day 1 suggested that vascular shunting was occurring. The results of the morphologic studies indicated a correlation between the number of blood vessels per unit area, the thickness of the dermis, and the recorded functional changes. Seven days after surgery, when isotope clearance rates were very rapid, there was a significant increase in the vascular density and dermal thickness.« less

Reduced 30-day mortality in men after elective coronary artery bypass surgery with minimized extracorporeal circulation-a propensity score analysis

PubMed Central

2012-01-01

Background Impact of minimized extracorporeal circulation (MECC) for coronary surgery on mortality remains controversial and gender significantly influence outcome. Methods We analyzed 3,139 male patients undergoing elective coronary surgery between 01/2004 and 05/2009. Using propensity score matching after binary logistic regression, 1,005 patients (from 1,119 patients) undergoing surgery with MECC could be matched with 1,005 patients (from 2,020 patients) undergoing surgery with conventional extracorporeal circulation (CECC). Primary outcome was 30-day mortality. Results Unadjusted 30-day mortality was 2.7% in patients with CECC and 0.8% in those with MECC (mean difference -1.9%; p < 0.001). The adjusted mean difference (average treatment effect of the treated) after matching was -1.5% (95% confidence interval (CI) -2.6 to -0.4; p = 0.006). Postoperative hospital stay was shorter in patients operated with minimized systems (adjusted mean difference -0.8 days; 95% CI -1.46 to -0.09; p = 0.03) and incidence of postoperative neurocognitive dysfunction was also lower (adjusted mean difference -1.3%; 95% CI -2.2 to -0.4; p = 0.001). Chest tube drainage (adjusted mean difference +22 mL; 95% CI -47 to 91; p = 0.5) and risk for acute kidney injury, kidney injury and failure according to RIFLE criteria (adjusted mean difference -1.0%; 95% CI -2.5 to 0.6; p = 0.24) proved to be insignificant between both groups. Apart from reduced 30-day mortality, however, average treatment effects for intensive care unit stay, postoperative hospital stay, chest tube drainage and kidney injury did not significantly differ. Conclusion Using propensity score analysis, we observed an association between MECC and reduced 30-day mortality in men, but our results call for further analysis. PMID:22424497

Short-term glycemic control is effective in reducing surgical site infection in diabetic rats.

PubMed

Kroin, Jeffrey S; Buvanendran, Asokumar; Li, Jinyuan; Moric, Mario; Im, Hee-Jeong; Tuman, Kenneth J; Shafikhani, Sasha H

2015-06-01

Patients and animals with diabetes exhibit enhanced vulnerability to bacterial surgical infections. Despite multiple retrospective studies demonstrating the benefits associated with glycemic control in reducing bacterial infection after cardiac surgery, there are fewer guidelines on the use of glycemic control for noncardiac surgeries. In the current study, we investigated whether long-term (begun 2 weeks before surgery) or immediate (just before surgery) glycemic controls, continued postoperatively, can reduce surgical site infection in type 1 diabetic-induced rats. Rats were injected with streptozotocin to induce type 1 diabetes. Four groups of animals underwent surgery and thigh muscle Staphylococcus aureus bacteria challenge (1 × 10 colony forming units) at the time of surgery. Group 1 diabetic rats received insulin treatment just before surgery and continued until the end of study (short-term glycemic control group). Group 2 diabetic rats received insulin treatment 2 weeks before surgery and continued until the end of study (long-term glycemic control). Group 3 diabetic rats received no insulin treatment (no glycemic control group). Group 4 nondiabetic rats served as a healthy control group. Rats were euthanized at 3 or 6 days after surgery. Blood glucose and muscle bacterial burden were measured at 3 or 6 days after surgery. Glycemic control was achieved in both long- and short-term insulin-treated diabetic rats. Compared with untreated diabetic rats, the bacterial burden in muscle was significantly lower in both groups of glycemic controlled diabetic rats at 3 (all P < 0.003) and 6 (all P < 0.0001) days after surgery. A short-term glycemic control regimen, initiated just before surgery and bacterial exposure, was as effective in reducing surgical site infection as a long-term glycemic control in type 1 diabetic rats. These data suggest that immediately implementing glycemic control in type 1 diabetic surgical patients before undergoing noncardiac surgery may decrease the risk of infection.

Cardiac surgery fast-track treatment in a postanesthetic care unit: six-month results of the Leipzig fast-track concept.

PubMed

Ender, Joerg; Borger, Michael Andrew; Scholz, Markus; Funkat, Anne-Kathrin; Anwar, Nadeem; Sommer, Marcus; Mohr, Friedrich Wilhelm; Fassl, Jens

2008-07-01

The authors compared the safety and efficacy of a newly developed fast-track concept at their center, including implementation of a direct admission postanesthetic care unit, to standard perioperative management. All fast-track patients treated within the first 6 months of implementation of our direct admission postanesthetic care unit were matched via propensity scores and compared with a historical control group of patients who underwent cardiac surgery prior to fast-track implementation. A total of 421 fast-track patients were matched successfully to 421 control patients. The two groups of patients had a similar age (64 +/- 13 vs. 64 +/- 12 yr for fast-track vs. control, P = 0.45) and European System for Cardiac Operative Risk Evaluation-predicted risk of mortality (4.8 +/- 6.1% vs. 4.6 +/- 5.1%, P = 0.97). Fast-track patients had significantly shorter times to extubation (75 min [45-110] vs. 900 min [600-1140]), as well as shorter lengths of stay in the postanesthetic or intensive care unit (4 h [3.0-5] vs. 20 h [16-25]), intermediate care unit (21 h [17-39] vs. 26 h [19-49]), and hospital (10 days [8-12] vs. 11 days [9-14]) (expressed as median and interquartile range, all P < 0.01). Fast-track patients also had a lower risk of postoperative low cardiac output syndrome (0.5% vs. 2.9%, P < 0.05) and mortality (0.5% vs. 3.3%, P < 0.01). The Leipzig fast-track protocol is a safe and effective method to manage cardiac surgery patients after a variety of operations.

A perspective on the use of an enhanced recovery program in open, non-instrumented day surgery for degenerative lumbar and cervical spinal conditions.

PubMed

Venkata, Hari K; van Dellen, James R

2018-06-01

A means of significantly shortening patients' length of hospital stay, improving their outcome and thereby also reducing costs is to use an enhanced recovery program (ERP) which is increasingly being used in a number of surgical sub-specialties. This paper provides a perspective on its prospective use in a wide-ranging, unselected cohort of patients undergoing open spinal surgery for degenerative lumbar and cervical spinal conditions. Selected spinal cases undergoing day surgery have been increasingly reported. A prospective, unselected, consecutive cohort of 246 cases, over an 18-month period, undergoing open, non-instrumented decompression spinal surgery and using ERP (and the concept of "bundles of care") was analyzed. Nine cases could not be included as they did not fully meet the entry criteria. No routine follow-up was arranged for the study group. The ages ranged widely, from 23-90 years (mean 57). In 187 the surgery for degenerative conditions was lumbar and in 50 cervical. The ASA (American Association of Anesthesiologists) ratings were 108=1; 107=2 and 22=3. Using the United Kingdom (UK) National Health Service (NHS) definitions of length of stay 225 (95%) could be finally classified as "ambulatory" and 12 (5%) were "short stay". A sub-cohort of 126 (53.2%) were "day cases". The follow-up was >1 year for all. There were no wound infections reported; 5 postdischarge cases (2.1%) needed to be seen in the Accident and Emergency (A&E) Department (less than 4 days postsurgery), but none needed re-admission; and there were 7 re-admissions (2.5%), between 4 and 30 days, and of these 6 required a further surgical procedure. There were no long-term instability complications reported in this cohort. ERP can be used for spinal surgery. There were identifiable and correctable medical and social factors found on analysis which could significantly increase the "day cases" number to over 90%.

Determinants of morbidity and mortality following emergency abdominal surgery in children in low-income and middle-income countries.

PubMed

2016-01-01

Child health is a key priority on the global health agenda, yet the provision of essential and emergency surgery in children is patchy in resource-poor regions. This study was aimed to determine the mortality risk for emergency abdominal paediatric surgery in low-income countries globally. Multicentre, international, prospective, cohort study. Self-selected surgical units performing emergency abdominal surgery submitted prespecified data for consecutive children aged <16 years during a 2-week period between July and December 2014. The United Nation's Human Development Index (HDI) was used to stratify countries. The main outcome measure was 30-day postoperative mortality, analysed by multilevel logistic regression. This study included 1409 patients from 253 centres in 43 countries; 282 children were under 2 years of age. Among them, 265 (18.8%) were from low-HDI, 450 (31.9%) from middle-HDI and 694 (49.3%) from high-HDI countries. The most common operations performed were appendectomy, small bowel resection, pyloromyotomy and correction of intussusception. After adjustment for patient and hospital risk factors, child mortality at 30 days was significantly higher in low-HDI (adjusted OR 7.14 (95% CI 2.52 to 20.23), p<0.001) and middle-HDI (4.42 (1.44 to 13.56), p=0.009) countries compared with high-HDI countries, translating to 40 excess deaths per 1000 procedures performed. Adjusted mortality in children following emergency abdominal surgery may be as high as 7 times greater in low-HDI and middle-HDI countries compared with high-HDI countries. Effective provision of emergency essential surgery should be a key priority for global child health agendas. NCT02179112; Pre-results.

Determinants of morbidity and mortality following emergency abdominal surgery in children in low-income and middle-income countries

PubMed Central

Ademuyiwa, Adesoji O

2016-01-01

Background Child health is a key priority on the global health agenda, yet the provision of essential and emergency surgery in children is patchy in resource-poor regions. This study was aimed to determine the mortality risk for emergency abdominal paediatric surgery in low-income countries globally. Methods Multicentre, international, prospective, cohort study. Self-selected surgical units performing emergency abdominal surgery submitted prespecified data for consecutive children aged <16 years during a 2-week period between July and December 2014. The United Nation's Human Development Index (HDI) was used to stratify countries. The main outcome measure was 30-day postoperative mortality, analysed by multilevel logistic regression. Results This study included 1409 patients from 253 centres in 43 countries; 282 children were under 2 years of age. Among them, 265 (18.8%) were from low-HDI, 450 (31.9%) from middle-HDI and 694 (49.3%) from high-HDI countries. The most common operations performed were appendectomy, small bowel resection, pyloromyotomy and correction of intussusception. After adjustment for patient and hospital risk factors, child mortality at 30 days was significantly higher in low-HDI (adjusted OR 7.14 (95% CI 2.52 to 20.23), p<0.001) and middle-HDI (4.42 (1.44 to 13.56), p=0.009) countries compared with high-HDI countries, translating to 40 excess deaths per 1000 procedures performed. Conclusions Adjusted mortality in children following emergency abdominal surgery may be as high as 7 times greater in low-HDI and middle-HDI countries compared with high-HDI countries. Effective provision of emergency essential surgery should be a key priority for global child health agendas. Trial registration number NCT02179112; Pre-results. PMID:28588977

Incentive spirometry does not enhance recovery after thoracic surgery.

PubMed

Gosselink, R; Schrever, K; Cops, P; Witvrouwen, H; De Leyn, P; Troosters, T; Lerut, A; Deneffe, G; Decramer, M

2000-03-01

To investigate the additional effect of incentive spirometry to chest physiotherapy to prevent postoperative pulmonary complications after thoracic surgery for lung and esophageal resections. Randomized controlled trial. University hospital, intensive care unit, and surgical department. Sixty-seven patients (age, 59 +/- 13 yrs; forced expiratory volume in 1 sec, 93% +/- 22% predicted) undergoing elective thoracic surgery for lung (n = 40) or esophagus (n = 27) resection. Physiotherapy (breathing exercises, huffing, and coughing) (PT) plus incentive spirometry (IS) was compared with PT alone. Lung function, body temperature, chest radiograph, white blood cell count, and number of hospital and intensive care unit days were all measured. Pulmonary function was significantly reduced after surgery (55% of the initial value) and improved significantly in the postoperative period in both groups. However, no differences were observed in the recovery of pulmonary function between the groups. The overall score of the chest radiograph, based on the presence of atelectasis, was similar in both treatment groups. Eight patients (12%) (three patients with lobectomy and five with esophagus resection) developed a pulmonary complication (abnormal chest radiograph, elevated body temperature and white blood cell count), four in each treatment group. Adding IS to regular PT did not reduce hospital or intensive care unit stay. Pulmonary complications after lung and esophagus surgery were relatively low. The addition of IS to PT did not further reduce pulmonary complications or hospital stay. Although we cannot rule out beneficial effects in a subgroup of high-risk patients, routine use of IS after thoracic surgery seems to be ineffective.

Incidence of postoperative nausea and vomiting after paediatric strabismus surgery with sevoflurane or remifentanil-sevoflurane.

PubMed

Oh, A Y; Kim, J H; Hwang, J W; Do, S H; Jeon, Y T

2010-06-01

In this prospective, randomized, double-blind study, we evaluated and compared the incidence of postoperative nausea and vomiting (PONV) after paediatric strabismus surgery with two different anaesthetic methods, sevoflurane or remifentanil-sevoflurane. In total, 78 paediatric patients (aged 6-11 yr) undergoing strabismus surgery were enrolled and randomly assigned to two groups, sevoflurane (Group S) and remifentanil-sevoflurane (Group R). Anaesthesia was maintained with 2-3% sevoflurane in Group S (n=39) or with a continuous infusion of remifentanil combined with 1% sevoflurane in Group R (n=39), both using 50% N(2)O/O(2). Arterial pressure and heart rate before induction, after tracheal intubation, after skin incision, and at the end of surgery were recorded. The incidence of PONV in the post-anaesthesia care unit, the day surgery care unit, and at home 24 h after surgery was recorded. Arterial pressure and heart rate were stable throughout the surgery, but were significantly lower in Group R than in Group S after tracheal intubation and skin incision. The incidence of PONV and postoperative vomiting was 17.9%/17.9% and 12.8%/10.2% (Group S/Group R) at the respective time points; values were comparable between the groups. The incidence of PONV after paediatric strabismus surgery under sevoflurane anaesthesia was relatively low, and combining remifentanil with sevoflurane did not further increase the incidence.

Impact of an ultraviolet air sterilizer on cardiac surgery patients, a randomized clinical trial.

PubMed

Heredia-Rodríguez, María; Álvarez-Fuente, Elisa; Bustamante-Munguira, Juan; Poves-Alvarez, Rodrigo; Fierro, Inmaculada; Gómez-Sánchez, Esther; Gómez-Pesquera, Estefanía; Lorenzo-López, Mario; Eiros, José María; Álvarez, Francisco Javier; Tamayo, Eduardo

2018-05-25

Numerous studies have evaluated the use of ultraviolet-C devices for terminal disinfection in hospitals, however, to date there is little information about the device's final impact on patients. We investigated the effect of an ultraviolet air sterilizer (UVAS) on the clinical outcomes of cardiac surgery patients. This random, prospective and non-interventional study included 1097 adult patients undergoing elective cardiac surgery: 522 stayed in an ICU room with UVAS (Medixair ® ) and 575 patients ICU room without UVAS and were used as a control. The primary outcome measure was to evaluate the effect of a UVAS on the overall prevalence of nosocomial infections in postoperative cardiac patients in ICUs. No significant differences in ventilator-associated pneumonia (4.6% vs. 5.0%, p=0.77) and total infection (14.0% vs. 15.5%, p=0.45) rates were detected in patients with and without the UVAS. The length of stay in the intensive care unit and at the hospital was similar in both groups, UVAS (4.6 (8.2) days and 18.3 (5.5) days) and without UVAS (4.6 (7.3) days and 19.2 (18.6) days). The 30-day in-hospital mortality rate was 5.3%, no significant differences between groups were observed (p=0.053). Novel ultraviolet-C technology has not been shown to significantly reduce nosocomial infections or mortality rates in cardiac surgery patients. Copyright © 2018 Elsevier España, S.L.U. All rights reserved.

Comparative study of the Aristotle Comprehensive Complexity and the Risk Adjustment in Congenital Heart Surgery scores.

PubMed

Bojan, Mirela; Gerelli, Sébastien; Gioanni, Simone; Pouard, Philippe; Vouhé, Pascal

2011-09-01

The Aristotle Comprehensive Complexity (ACC) and the Risk Adjustment in Congenital Heart Surgery (RACHS-1) scores have been proposed for complexity adjustment in the analysis of outcome after congenital heart surgery. Previous studies found RACHS-1 to be a better predictor of outcome than the Aristotle Basic Complexity score. We compared the ability to predict operative mortality and morbidity between ACC, the latest update of the Aristotle method and RACHS-1. Morbidity was assessed by length of intensive care unit stay. We retrospectively enrolled patients undergoing congenital heart surgery. We modeled each score as a continuous variable, mortality as a binary variable, and length of stay as a censored variable. We compared performance between mortality and morbidity models using likelihood ratio tests for nested models and paired concordance statistics. Among all 1,384 patients enrolled, 30-day mortality rate was 3.5% and median length of intensive care unit stay was 3 days. Both scores strongly related to mortality, but ACC made better prediction than RACHS-1; c-indexes 0.87 (0.84, 0.91) vs 0.75 (0.65, 0.82). Both scores related to overall length of stay only during the first postoperative week, but ACC made better predictions than RACHS-1; U statistic=0.22, p<0.001. No significant difference was noted after adjusting RACHS-1 models on age, prematurity, and major extracardiac abnormalities. The ACC was a better predictor of operative mortality and length of intensive care unit stay than RACHS-1. In order to achieve similar performance, regression models including RACHS-1 need to be further adjusted on age, prematurity, and major extracardiac abnormalities. Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

The Black Dermatologist: 1990—A Viewpoint

PubMed Central

Pierce, Harold E.

1982-01-01

Despite equivalent training in dermatology and dermatologic surgery, in a traditional sense black dermatologists are overtrained in the area of cancer surgery by virtue of the nature of their black practices. I believe that the survival of black dermatologists in the United States will one day depend upon the adjunctive dermatoplastic skills that they must develop, not only to meet the increasing demand for these procedures by their patients, but to assure a broadening of their economic base to meet their white competition. PMID:7120483

Alterations in plasma phosphorus, red cell 2,3-diphosphoglycerate and P50 following open heart surgery.

PubMed

Hasan, R A; Sarnaik, A P; Meert, K L; Dabbagh, S; Simpson, P; Makimi, M

1994-12-01

To evaluate changes in and the correlation between plasma phosphorus, red cell 2,3-diphosphoglycerate (DPG) and adenosine triphosphate (ATP), and P50 in children following heart surgery. Prospective, observational study with factorial design. A pediatric intensive care unit in a university hospital. Twenty children undergoing open heart surgery for congenital heart defects. None. Red cell 2,3-DPG and ATP, P50, plasma phosphorus, and arterial lactate were obtained before and at 1, 8, 16, 24, 48, and 72 hours after surgery. The amount of intravenous fluid and glucose administered, and age of blood utilized were documented. Variables were analyzed by repeated measure analysis of variance followed by paired t-tests. To investigate the relationship between variables at each time point, scatterplot matrices and correlation coefficients were obtained. There was a reduction in plasma phosphorus, red cell 2,3-DPG, and P50 and an increase in arterial lactate at 1, 8, 16, 24, 48, and 72 hours after surgery. Red cell 2,3-DPG correlated with P50 at 1, 8 and 16 hours. The decrease in the plasma phosphorus correlated with the amounts of intravenous fluid and glucose administered on the day of surgery and on the first and second postoperative days. The age of the blood utilized correlated with the decrease in red cell 2,3-DPG on the day of surgery. Reduction in red cell 2,3-DPG, P50, and plasma phosphorus occurs after open heart surgery in children. These changes can potentially contribute to impaired oxygen utilization in the postoperative period, when adequacy of tissue oxygenation is critical.

Preoperative immobility significantly impacts the risk of postoperative complications in bariatric surgery patients.

PubMed

Higgins, Rana M; Helm, Melissa; Gould, Jon C; Kindel, Tammy L

2018-06-01

Preoperative immobility in general surgery patients has been associated with an increased risk of postoperative complications. It is unknown if immobility affects bariatric surgery outcomes. The aim of this study was to determine the impact of immobility on 30-day postoperative bariatric surgery outcomes. This study took place at a university hospital in the United States. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2015 data set was queried for primary minimally invasive bariatric procedures. Preoperative immobility was defined as limited ambulation most or all the time. Logistic regression analysis was performed to determine if immobile patients are at increased risk (odds ratio [OR]) for 30-day complications. There were 148,710 primary minimally invasive bariatric procedures in 2015. Immobile patients had an increased risk of mortality (OR 4.59, P<.001) and greater operative times, length of stay, reoperation rates, and readmissions. Immobile patients had a greater risk of multiple complications, including acute renal failure (OR 6.42, P<.001), pulmonary embolism (OR 2.44, P = .01), cardiac arrest (OR 2.81, P = .05), and septic shock (OR 2.78, P = .02). Regardless of procedure type, immobile patients had a higher incidence of perioperative morbidity compared with ambulatory patients. This study is the first to specifically assess the impact of immobility on 30-day bariatric surgery outcomes. Immobile patients have a significantly increased risk of morbidity and mortality. This study provides an opportunity for the development of multiple quality initiatives to improve the safety and perioperative complication profile for immobile patients undergoing bariatric surgery. Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.

Outlier identification in colorectal surgery should separate elective and nonelective service components.

PubMed

Byrne, Ben E; Mamidanna, Ravikrishna; Vincent, Charles A; Faiz, Omar D

2014-09-01

The identification of health care institutions with outlying outcomes is of great importance for reporting health care results and for quality improvement. Historically, elective surgical outcomes have received greater attention than nonelective results, although some studies have examined both. Differences in outlier identification between these patient groups have not been adequately explored. The aim of this study was to compare the identification of institutional outliers for mortality after elective and nonelective colorectal resection in England. This was a cohort study using routine administrative data. Ninety-day mortality was determined by using statutory records of death. Adjusted Trust-level mortality rates were calculated by using multiple logistic regression. High and low mortality outliers were identified and compared across funnel plots for elective and nonelective surgery. All English National Health Service Trusts providing colorectal surgery to an unrestricted patient population were studied. Adults admitted for colorectal surgery between April 2006 and March 2012 were included. Segmental colonic or rectal resection was performed. The primary outcome measured was 90-day mortality. Included were 195,118 patients, treated at 147 Trusts. Ninety-day mortality rates after elective and nonelective surgery were 4% and 18%. No unit with high outlying mortality for elective surgery was a high outlier for nonelective mortality and vice versa. Trust level, observed-to-expected mortality for elective and nonelective surgery, was moderately correlated (Spearman ρ = 0.50, p< 0.001). This study relied on administrative data and may be limited by potential flaws in the quality of coding of clinical information. Status as an institutional mortality outlier after elective and nonelective colorectal surgery was not closely related. Therefore, mortality rates should be reported for both patient cohorts separately. This would provide a broad picture of the state of colorectal services and help direct research and quality improvement activities.

Are “knife and fork” good enough for day case surgery of resistant tennis elbow?

PubMed Central

Govindaswamy, Raja; Elbouni, Tariq; Chambler, Andrew F. W.

2008-01-01

This observational retrospective study was performed on 22 consecutive patients treated surgically in a day surgery unit for resistant tennis elbow to ascertain the effectiveness of the “knife and fork” procedure. All patients had an unfavourable response to nonsurgical treatment lasting at least six months. A simple and inexpensive “knife and fork” technique yielded excellent results in 90.5% of patients and a high percentage (95.2%) of satisfied patients at an average follow-up of two years. There were no fair or poor results and no complications. We conclude that the “knife and fork” technique is a simple and dependable day case procedure. In the present National Health Service (NHS) era of tariff and “payment by results”, this approach is more cost effective than an arthroscopic alternative. PMID:19096844

Emetogenicity-risk procedures in same day surgery center of an academic university hospital in United States: a retrospective cost-audit of postoperative nausea vomiting management.

PubMed

Gupta, Deepak; Haber, Halim

2014-06-01

Despite the variable results of published studies, it is imperative for ambulatory surgery centers to self-audit local cost-implications for post-operative nausea and vomiting (PONV) management. Our retrospective cost-audit assessed if there were comparative peri-anesthesia care cost-trends among patients who had undergone Low-Emetogenicity-Risk Procedures (LERP), Moderate-Emetogenicity-Risk Procedures (MERP) and Severe-Emetogenicity-Risk Procedures (SERP). This study was a review of Same Day Surgery Center practices in an academic university hospital setting during a three-year period (2010-2012). The patient lists were accessed from CIS and CITRIX App Bar for time audit and OR (operating room) schedule reports. Subsequently, OR pharmacy department ran a search for peri-operative anti-emetics and opioids that were billed for the patients at Same Day Surgery Center for the review period. The primary outcomes were the comparative costs/charges of these medications and comparative durations/ charges for these patients' stay in the post-anesthesia care unit (PACU). Secondary outcomes analyzed in the study included peri-anesthesia durations. A total of 8,657 patient records were analyzed. Almost all analyzed variables revealed statistically significant inter-variable positive correlations. The patients' age was significantly (P < 0.001) different among LERP/MERP/SERP patients (LERP: 48.8 +/- 14.7 years; MERP: 61.8 +/- 14.6 years; SERP: 51.3 +/- 14.5 years). In regards to primary and secondary outcomes, the statistical significant differences among LERP/MERP/SERP patients (after correcting for both patients' age as well as patients' sex) were only achieved for preoperative times (P = 0.002; Power = 0.9), operating room recovery times (P = 0.003; Power = 0.9), PACU stay times (P < 0.001; Power = 1.0), and PACU charges (P < 0.001; Power = 1.0). PACU stay times and PACU charges were significantly higher in patients who had undergone SERP as compared to patients who had undergone LERP or MERP at our Same Day Surgery Center.

Bleeding impacting mortality after noncardiac surgery: a protocol to establish diagnostic criteria, estimate prognostic importance, and develop and validate a prediction guide in an international prospective cohort study

PubMed Central

Roshanov, Pavel S.; Eikelboom, John W.; Crowther, Mark; Tandon, Vikas; Borges, Flavia K.; Kearon, Clive; Lamy, Andre; Whitlock, Richard; Biccard, Bruce M.; Szczeklik, Wojciech; Guyatt, Gordon H.; Panju, Mohamed; Spence, Jessica; Garg, Amit X.; McGillion, Michael; VanHelder, Tomas; Kavsak, Peter A.; de Beer, Justin; Winemaker, Mitchell; Sessler, Daniel I.; Le Manach, Yannick; Sheth, Tej; Pinthus, Jehonathan H.; Thabane, Lehana; Simunovic, Marko R.I.; Mizera, Ryszard; Ribas, Sebastian; Devereaux, P.J.

2017-01-01

Introduction: Various definitions of bleeding have been used in perioperative studies without systematic assessment of the diagnostic criteria for their independent association with outcomes important to patients. Our proposed definition of bleeding impacting mortality after noncardiac surgery (BIMS) is bleeding that is independently associated with death during or within 30 days after noncardiac surgery. We describe our analysis plan to sequentially 1) establish the diagnostic criteria for BIMS, 2) estimate the independent contribution of BIMS to 30-day mortality and 3) develop and internally validate a clinical prediction guide to estimate patient-specific risk of BIMS. Methods: In the Vascular Events In Noncardiac Surgery Patients Cohort Evaluation (VISION) study, we prospectively collected bleeding data for 16 079 patients aged 45 years or more who had noncardiac inpatient surgery between 2007 and 2011 at 12 centres in 8 countries across 5 continents. We will include bleeding features independently associated with 30-day mortality in the diagnostic criteria for BIMS. Candidate features will include the need for reoperation due to bleeding, the number of units of erythrocytes transfused, the lowest postoperative hemoglobin concentration, and the absolute and relative decrements in hemoglobin concentration from the preoperative value. We will then estimate the incidence of BIMS and its independent association with 30-day mortality. Last, we will construct and internally validate a clinical prediction guide for BIMS. Interpretation: This study will address an important gap in our knowledge about perioperative bleeding, with implications for the 200 million patients who undergo noncardiac surgery globally every year. Trial registration: ClinicalTrials.gov, no NCT00512109. PMID:28943515

Source-case investigation of Mycobacterium wolinskyi cardiac surgical site infection.

PubMed

Dupont, C; Terru, D; Aguilhon, S; Frapier, J-M; Paquis, M-P; Morquin, D; Lamy, B; Godreuil, S; Parer, S; Lotthé, A; Jumas-Bilak, E; Romano-Bertrand, S

2016-07-01

The non-tuberculous mycobacteria (NTM) Mycobacterium wolinskyi caused bacteraemia and massive colonization of an aortic prosthesis in a patient 16 days after cardiac surgery, necessitating repeat surgery and targeted antimicrobial chemotherapy. The infection control team investigated the source and conditions of infection. Peri-operative management of the patient complied with recommendations. The environmental investigation showed that although M. wolinskyi was not recovered, diverse NTM species were present in water from point-of-use taps and heater-cooler units for extracorporeal circulation. This case and increasing evidence of emerging NTM infections in cardiac surgery led to the implementation of infection control procedures in cardiac surgery wards. Copyright © 2016 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

Predictive value of the model for end-stage liver disease score in patients undergoing left ventricular assist device implantation.

PubMed

Deo, Salil V; Daly, Richard C; Altarabsheh, Salah E; Hasin, Tal; Zhao, Yanjun; Shah, Ishan K; Stulak, John M; Boilson, Barry A; Schirger, John A; Joyce, Lyle D; Park, Soon J

2013-01-01

Axial flow left ventricular assist device (LVAD) implantation is an effective therapy for patients with advanced heart failure. As the preoperative hepatic and renal function play a critical role in determining adverse events after LVAD implantation, we analyzed the predictive role of the model for end-stage liver disease (MELD) score in determining in-hospital mortality after surgery. One hundred twenty-six patients underwent implant of an LVAD at our institution. Their individual preoperative MELD scores and perioperative total blood product usage (TBPU) were calculated. As LVAD implant as a reoperation is known to influence postoperative bleeding and mortality independently, the patients were divided into group I (first cardiac surgery) and group II (reoperative surgery). Group I: LVAD implantation was performed in 68/126 (54%) patients as their first cardiac surgery. The mean MELD score was 16.3 ± 6. Median TBPU for this group was 20.7 (0, 135) units. Inhospital mortality/30-day mortality was 4/68 (5.8%). Increasing MELD score (c-statistic = 0.88) and TBPU were found to be predictors of early mortality. An increasing MELD score was associated with more TBPU (p < 0.01) with a 10.9 ± 3 TBPU increase per a 10 unit rise in the MELD score. Group II: Of the 126 patients, 58 (46%) underwent LVAD implantation as a reoperation. Mean MELD score for these patients was 16 ± 5. Inhospital mortality/30-day mortality in this group was 12% and median TBPU was 30 (4,153) units. The MELD score was not predictive of inhospital mortality in these patients (p = 0.97). The MELD score is predictive of early mortality in patients undergoing LVAD implantation as their first cardiac surgery. Use of this score to select patients for LVAD implantation may be appropriate.

The use of enhanced recovery after surgery (ERAS) principles in Scottish orthopaedic units--an implementation and follow-up at 1 year, 2010-2011: a report from the Musculoskeletal Audit, Scotland.

PubMed

Scott, Nicholas B; McDonald, David; Campbell, Jane; Smith, Richard D; Carey, A Kate; Johnston, Ian G; James, Kate R; Breusch, Steffen J

2013-01-01

To establish whether a nationally guided programme can lead to more widespread implementation of enhanced recovery after surgery (ERAS), a well-established optimised care pathway for lower limb arthroplasty. In 2010, National Services Scotland's Musculoskeletal Audit was asked to perform a 'snapshot' audit of the current peri-operative management of patients undergoing total hip and knee arthroplasty in all 22 Scottish orthopaedic units with an identical follow-up audit in 2011 after input and support from the national steering group. Audit 1 and audit 2 involved 1,345 and 1,278 patients, respectively. The number of Scottish units that developed an ERAS programme increased from 8 (36 %) to 15 (68 %). Units that included more ERAS patients had earlier mobilisation rates (146/474, 36 % ERAS patients mobilised same day vs. 34/873, 4 % non-ERAS; n = 22 units, r = 0.55, p = 0.008) and shorter post-operative length of stay (median 4 days vs. ERAS, 5 days non-ERAS, n = 22 units, r = -0.64, p = 0.001). ERAS knee arthroplasty patients had lower blood transfusion rates (5/205, 2 % vs. 51/399, 13 %, n = 22 units, r = -0.62, p = 0.002). Units that restricted the use of IV fluids post-operatively had higher early mobilisation rates (n = 22 units, r = 0.48, p = 0.03) and shorter post-operative length of stay (n = 22 units, r = -0.56, p = 0.007). Reduced use of patient-controlled analgesia was also associated with earlier mobilisation (n = 22 units, r = 0.49, p = 0.02) and shorter length of stay (n = 22 units, r = -0.39, p = 0.07). Urinary catheterisation rates also dropped from 468/1,345 (35 %) in 2010 to 337/1,278 (26 %) in 2011 (n = 22 units, z = 2.19, p = 0.03). A clinically guided and nationally supported process has proven highly successful in achieving a further uptake of enhanced recovery principles after lower limb arthroplasty in Scotland, which has resulted in clinical benefits to patients and reduced length of hospital stay.

The day of your surgery - adult

MedlinePlus

Same-day surgery - adult; Ambulatory surgery - adult; Surgical procedure - adult; Preoperative care - day of surgery ... meet with them at an appointment before the day of surgery or on the same day of ...

Day case stapled anopexy for the treatment of haemorrhoids and rectal mucosal prolapse.

PubMed

Hidalgo Grau, L A; Heredia Budó, A; Llorca Cardeñosa, S; Carbonell Roure, J; Estrada Ferrer, O; García Torralbo, E; Suñol Sala, X

2012-06-01

Stapled anopexy (SA) gives better early postoperative results than classical haemorrhoidectomy. The aim of this study is to demonstrate that SA is a safe and effective procedure for the treatment of haemorrhoids and rectal mucose prolapse in a day-case surgery programme. From January 2000 to December 2008, 297 SA procedures were performed; 230 (77.4%) were performed in the Day Surgery Unit (DSU). Third- and fourth-degree haemorrhoids, second-degree haemorrhoids with no response to conservative treatment and several cases of rectal prolapse were included. The mean age of the patients in the series was 48.1 years (range 21-85). Preoperative preparation included phosphate enemas and antibiotic prophylaxis. Patients were operated on mainly under spinal anaesthesia. Day-case rate, postoperative pain (measured by a visual analogic scale, 1-10), admissions, re-admissions, early postoperative situation and recurrence were evaluated in the study. The overall DSU rate was 78%, with a progressive increase from 46% to 99% in 2008. One hundred and eighty-five patients (80%) had pain scores under 2; no patient had a pain score over 7. Eighteen (8%) patients required admission on the day of surgery. Late admission was needed for 3 (3%) patients. Thirty-three patients reported their situation as excellent, 174 as good, 20 as acceptable and three as bad when they answered a phone questionnaire 24 h after surgery. Overall, 20 (9%) patients had recurrence of symptoms. SA is a safe and effective procedure for prolapsing haemorrhoids in the day case setting. The recurrence rate is higher than that observed in classical haemorrhoidectomy. Most patients can be managed as day-cases. © 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland.

Preoperative Aspirin Does Not Increase Transfusion or Reoperation in Isolated Valve Surgery.

PubMed

Goldhammer, Jordan E; Herman, Corey R; Berguson, Mark W; Torjman, Marc C; Epstein, Richard H; Sun, Jian-Zhong

2017-10-01

Preoperative aspirin has been studied in patients undergoing isolated coronary artery bypass graft surgery. However, there is a paucity of clinical data available evaluating perioperative aspirin in other cardiac surgical procedures. This study was designed to investigate the effects of aspirin on bleeding and transfusion in patients undergoing non-emergent, isolated, heart valve repair or replacement. Retrospective, cohort study. Academic medical center. A total of 694 consecutive patients having non-emergent, isolated, valve repair or replacement surgery at an academic medical center were identified. Of the 488 patients who met inclusion criteria, 2 groups were defined based on their preoperative use of aspirin: those taking (n = 282), and those not taking (n = 206) aspirin within 5 days of surgery. Binary logistic regression was used to examine relationships among demographic and clinical variables. No significant difference was found between the aspirin and non-aspirin groups with respect to the percentage receiving red blood cell (RBC) transfusion, mean RBC units transfused in those who required transfusion, massive transfusion of RBC, or amounts of fresh frozen plasma, cryoprecipitate, or platelets. Aspirin was not associated with an increase in the rate of re-exploration for bleeding (5.3% v 6.3%, p = 0.478). Major adverse cardiocerebral events (MACE), 30-day mortality, and 30-day readmission rates were not statistically different between the aspirin-and non-aspirin-treated groups. Preoperative aspirin therapy in elective, isolated, valve surgery did not result in an increase in transfusion or reoperation for bleeding and was not associated with reduced readmission rate, MACE, or 30-day mortality. Copyright © 2017 Elsevier Inc. All rights reserved.

Minimising preoperative anxiety with music for day surgery patients - a randomised clinical trial.

PubMed

Ni, Cheng-Hua; Tsai, Wei-Her; Lee, Liang-Ming; Kao, Ching-Chiu; Chen, Yi-Chung

2012-03-01

The objective of this study was to evaluate the effects of musical intervention on preoperative anxiety and vital signs in patients undergoing day surgery. Studies and systematic meta-analyses have shown inconclusive results of the efficacy of music in reducing preoperative anxiety. We designed a study to provide additional evidence for its use in preoperative nursing care. Randomised, controlled study. Patients (n = 183) aged 18-65 admitted to our outpatient surgery department were randomly assigned to either the experimental group (music delivered by earphones) or control group (no music) for 20 minutes before surgery. Anxiety, measured by the State-Trait Anxiety Inventory, and vital signs were measured before and after the experimental protocol. A total of 172 patients (60 men and 112 women) with a mean age of 40·90 (SD 11·80) completed the study. The largest number (35·7%) was undergoing elective plastic surgery and 76·7% of the total reported previous experience with surgery. Even though there was only a low-moderate level of anxiety at the beginning of the study, both groups showed reduced anxiety and improved vital signs compared with baseline values; however, the intervention group reported significantly lower anxiety [mean change: -5·83 (SD 0·75) vs. -1·72 (SD 0·65), p < 0·001] on the State-Trait Anxiety Inventory compared with the control group. Patients undergoing day surgery may benefit significantly from musical intervention to reduce preoperative anxiety and improve physiological parameters. Finding multimodal approaches to ease discomfort and anxiety from unfamiliar unit surroundings and perceived risks of morbidity (e.g. disfigurement and long-term sequelae) is necessary to reduce preoperative anxiety and subsequent physiological complications. This is especially true in the day surgery setting, where surgical admission times are often subject to change and patients may have to accommodate on short notice or too long a wait that may provoke anxiety. Our results provide additional evidence that musical intervention may be incorporated into routine nursing care for patients undergoing minor surgery. © 2011 Blackwell Publishing Ltd.

The effect of blood transfusion on short-term, perioperative outcomes in elective spine surgery.

PubMed

Seicean, Andreea; Alan, Nima; Seicean, Sinziana; Neuhauser, Duncan; Weil, Robert J

2014-09-01

Studies in various surgical procedures have shown that transfusion of red blood cells (RBC) increases the risk of postoperative morbidity and mortality. Impact of blood transfusion in patients undergoing spine surgery is not well-described. We assessed the impact of intra and postoperative transfusion on postoperative morbidity and mortality in patients undergoing elective spine surgery. We used the American College of Surgeons' National Surgical Quality Improvement Program to identify a retrospective cohort of 36,901 adult patients who underwent elective spine surgery between 2006 and 2011. Patients who received intra or postoperative transfusion (n=3262) were matched to those who did not using propensity scores. Logistic regression predicted adverse postoperative outcomes. We conducted sensitivity analysis in a subset of patients in whom the number of intraoperatively transfused units of RBC or whole blood was known. Upon matching, preoperative hematocrit, length of surgery, and percentage of spinal fusion surgery were not significantly different between transfused and non-transfused patients. After matching, transfusion remained adversely associated with prolonged length of stay (LOS) in hospital (odds ratio [OR] 2.6, 95% confidence interval [CI] 2.3-2.9), postoperative complications (OR 1.6, 95% CI 1.4-1.9), and an increased 30 day return to operation room (OR 1.7, 95% CI 1.3-2.2). Transfusion of even one unit of blood intraoperatively was associated with prolonged LOS (OR 2.0, 95% CI 1.5-2.6) and minor complications (OR 2.4, 95% CI 1.3-4.3). Therefore, transfusion of RBC or whole blood, even a single unit, increased LOS and postoperative morbidity in patients undergoing elective spine surgery, independent of preoperative hematocrit level and patient comorbidities. Copyright © 2014 Elsevier Ltd. All rights reserved.

The Relationship Between Stressors and Anxiety Levels After CABG in Sari, Iran.

PubMed

Bagheri Nesami, Masoumeh; Shorofi, Seyed Afshin; Jafari, Azam; Khalilian, Ali Reza; Ziabakhsh Tabari, Shervin

2016-05-01

Hospitalization and surgery are crucial adverse life events that lead to considerable anxiety in patients. The present study aimed to investigate stressors after coronary artery bypass graft surgery and identify stressors that predict anxiety. This is a descriptive-analytical study that uses a non-random convenience sampling method on patients undergoing coronary artery bypass graft surgery at the cardiac surgery intensive care unit of Fatemeh Zahra Cardiac center in Sari, Iran. A total of 186 patients completed the post-surgical stressors questionnaire and the Spielberger State-Trait Anxiety Inventory on postoperative days 2 or 3 in the cardiac surgery intensive care unit. Data were analyzed using descriptive statistics including frequencies, means, and standard deviations. The Mann-Whitney U test was used to determine the relationship between the observed variables, and the logistic regression model was used to identify the relationship between stressors and anxiety after-surgery. Post-surgical anxiety predictors included insufficient sleep during hospitalization (Odds ratio [OR]: 5.42; 95% confidence interval [CI]: 1.46 - 20.00; P = 0.010), treatment not explained to the patient by the nurse (OR: 4.83; 95% CI: 1.82 - 12.84; P = 0.002), being away from family members (OR: 3.88; 95% CI: 1.46 - 10.26; P = 0.006), presence of a chest tube (OR: 3.27; 95% CI: 1.83 - 5.84; P = 0.000), and pain in any part of the body (OR: 1.95; 95% CI: 1.06 - 3.58; P = 0.031). Physical or physiological and psychological stressors impose greater stress and are predictors of anxiety. When preparing their nursing care plan, nurses should consider these stressors that affect anxiety levels in patients undergoing CABG surgery and those hospitalized in intensive care units.

The Contemporary Incidence and Sequelae of Rhabdomyolysis Following Extirpative Renal Surgery: A Population Based Analysis.

PubMed

Gelpi-Hammerschmidt, Francisco; Tinay, Ilker; Allard, Christopher B; Su, Li-Ming; Preston, Mark A; Trinh, Quoc-Dien; Kibel, Adam S; Wang, Ye; Chung, Benjamin I; Chang, Steven L

2016-02-01

We evaluate the contemporary incidence and consequences of postoperative rhabdomyolysis after extirpative renal surgery. We conducted a population based, retrospective cohort study of patients who underwent extirpative renal surgery with a diagnosis of a renal mass or renal cell carcinoma in the United States between 2004 and 2013. Regression analysis was performed to evaluate 90-day mortality (Clavien grade V), nonfatal major complications (Clavien grade III-IV), hospital readmission rates, direct costs and length of stay. The final weighted cohort included 310,880 open, 174,283 laparoscopic and 69,880 robotic extirpative renal surgery cases during the 10-year study period, with 745 (0.001%) experiencing postoperative rhabdomyolysis. The presence of postoperative rhabdomyolysis led to a significantly higher incidence of 90-day nonfatal major complications (34.7% vs 7.3%, p <0.05) and higher 90-day mortality (4.4% vs 1.02%, p <0.05). Length of stay was twice as long for patients with postoperative rhabdomyolysis (incidence risk ratio 1.83, 95% CI 1.56-2.15, p <0.001). The robotic approach was associated with a higher likelihood of postoperative rhabdomyolysis (vs laparoscopic approach, OR 2.43, p <0.05). Adjusted 90-day median direct hospital costs were USD 7,515 higher for patients with postoperative rhabdomyolysis (p <0.001). Our model revealed that the combination of obesity and prolonged surgery (more than 5 hours) was associated with a higher likelihood of postoperative rhabdomyolysis developing. Our study confirms that postoperative rhabdomyolysis is an uncommon complication among patients undergoing extirpative renal surgery, but has a potentially detrimental impact on surgical morbidity, mortality and costs. Male gender, comorbidities, obesity, prolonged surgery (more than 5 hours) and a robotic approach appear to place patients at higher risk for postoperative rhabdomyolysis. Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

The first national examination of outcomes and trends in robotic surgery in the United States.

PubMed

Anderson, Jamie E; Chang, David C; Parsons, J Kellogg; Talamini, Mark A

2012-07-01

There are few population-based data describing outcomes of robotic-assisted surgery. We compared outcomes of robotic-assisted, laparoscopic, and open surgery in a nationally representative population database. A retrospective analysis of the Nationwide Inpatient Sample database from October 2008 to December 2009 was performed. We identified the most common robotic procedures by ICD-9 procedure codes and grouped them into categories by procedure type. Multivariate analyses examined mortality, length of stay (LOS), and total hospital charges, adjusting for age, race, sex, Charlson comorbidity index, and teaching hospital status. A total of 368,239 patients were identified. On adjusted analysis, compared with open, robotic-assisted laparoscopic surgery was associated with decreased odds of mortality (odds ratio = 0.1; 95% CI, 0.0-0.2; p < 0.001), decreased mean LOS (-2.4 days; 95% CI, -2.5 to 2.3; p < 0.001), and increased mean total charges in all procedures (range $3,852 to $15,329) except coronary artery bypass grafting (-$17,318; 95% CI, -34,492 to -143; p = 0.048) and valvuloplasty (not statistically significant). Compared with laparoscopic, robotic-assisted laparoscopic surgery was associated with decreased odds of mortality (odds ratio = 0.1; 95% CI, 0.0-0.6; p = 0.008), decreased LOS overall (-0.6 days; 95% CI, -0.7 to -0.5; p < 0.001), but increased LOS in prostatectomy and other kidney/bladder procedures (0.3 days; 95% CI, 0.1-0.4; p = 0.006; 0.8 days; 95% CI, 0.0-1.6; p = 0.049), and increased total charges ($1,309; 95% CI, 519-2,099; p = 0.001). Data suggest that, compared with open surgery, robotic-assisted surgery results in decreased LOS and diminished likelihood of death. However, these benefits are not as apparent when comparing robotic-assisted laparoscopic with nonrobotic laparoscopic procedures. Copyright © 2012 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

New Zealand health reforms: effect on ophthalmic practice.

PubMed

Raynel, S; Reynolds, H

1999-01-01

Are specialized ophthalmic units with inpatient facilities going to disappear in the New Zealand public health system? We have entered the era of cost containment, business methodologies, bench marking, day case surgery, and technologic advances. The dilemma for nursing is maintenance of a skill base with dwindling clinical practice areas.

Does Changing Examiner Stations During UK Postgraduate Surgery Objective Structured Clinical Examinations Influence Examination Reliability and Candidates' Scores?

PubMed

Brennan, Peter A; Croke, David T; Reed, Malcolm; Smith, Lee; Munro, Euan; Foulkes, John; Arnett, Richard

2016-01-01

Objective structured clinical examinations (OSCE) are widely used for summative assessment in surgery. Despite standardizing these as much as possible, variation, including examiner scoring, can occur which may affect reliability. In study of a high-stakes UK postgraduate surgical OSCE, we investigated whether examiners changing stations once during a long examining day affected marking, reliability, and overall candidates' scores compared with examiners who examined the same scenario all day. An observational study of 18,262 examiner-candidate interactions from the UK Membership of the Royal College of Surgeons examination was carried at 3 Surgical Colleges across the United Kingdom. Scores between examiners were compared using analysis of variance. Examination reliability was assessed with Cronbach's alpha, and the comparative distribution of total candidates' scores for each day was evaluated using t-tests of unit-weighted z scores. A significant difference was found in absolute scores differences awarded in the morning and afternoon sessions between examiners who changed stations at lunchtime and those who did not (p < 0.001). No significant differences were found for the main effects of either broad content area (p = 0.290) or station content area (p = 0.450). The reliability of each day was not affected by examiner switching (p = 0.280). Overall, no difference was found in z-score distribution of total candidate scores and categories of examiner switching. This large study has found that although the range of marks awarded varied when examiners change OSCE stations, examination reliability and the likely candidate outcome were not affected. These results may have implications for examination design and examiner experience in surgical OSCEs and beyond. Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Levosimendan for Hemodynamic Support after Cardiac Surgery.

PubMed

Landoni, Giovanni; Lomivorotov, Vladimir V; Alvaro, Gabriele; Lobreglio, Rosetta; Pisano, Antonio; Guarracino, Fabio; Calabrò, Maria G; Grigoryev, Evgeny V; Likhvantsev, Valery V; Salgado-Filho, Marcello F; Bianchi, Alessandro; Pasyuga, Vadim V; Baiocchi, Massimo; Pappalardo, Federico; Monaco, Fabrizio; Boboshko, Vladimir A; Abubakirov, Marat N; Amantea, Bruno; Lembo, Rosalba; Brazzi, Luca; Verniero, Luigi; Bertini, Pietro; Scandroglio, Anna M; Bove, Tiziana; Belletti, Alessandro; Michienzi, Maria G; Shukevich, Dmitriy L; Zabelina, Tatiana S; Bellomo, Rinaldo; Zangrillo, Alberto

2017-05-25

Acute left ventricular dysfunction is a major complication of cardiac surgery and is associated with increased mortality. Meta-analyses of small trials suggest that levosimendan may result in a higher rate of survival among patients undergoing cardiac surgery. We conducted a multicenter, randomized, double-blind, placebo-controlled trial involving patients in whom perioperative hemodynamic support was indicated after cardiac surgery, according to prespecified criteria. Patients were randomly assigned to receive levosimendan (in a continuous infusion at a dose of 0.025 to 0.2 μg per kilogram of body weight per minute) or placebo, for up to 48 hours or until discharge from the intensive care unit (ICU), in addition to standard care. The primary outcome was 30-day mortality. The trial was stopped for futility after 506 patients were enrolled. A total of 248 patients were assigned to receive levosimendan and 258 to receive placebo. There was no significant difference in 30-day mortality between the levosimendan group and the placebo group (32 patients [12.9%] and 33 patients [12.8%], respectively; absolute risk difference, 0.1 percentage points; 95% confidence interval [CI], -5.7 to 5.9; P=0.97). There were no significant differences between the levosimendan group and the placebo group in the durations of mechanical ventilation (median, 19 hours and 21 hours, respectively; median difference, -2 hours; 95% CI, -5 to 1; P=0.48), ICU stay (median, 72 hours and 84 hours, respectively; median difference, -12 hours; 95% CI, -21 to 2; P=0.09), and hospital stay (median, 14 days and 14 days, respectively; median difference, 0 days; 95% CI, -1 to 2; P=0.39). There was no significant difference between the levosimendan group and the placebo group in rates of hypotension or cardiac arrhythmias. In patients who required perioperative hemodynamic support after cardiac surgery, low-dose levosimendan in addition to standard care did not result in lower 30-day mortality than placebo. (Funded by the Italian Ministry of Health; CHEETAH ClinicalTrials.gov number, NCT00994825 .).

Weekend Hospitalizations and Post-operative Complications following urgent surgery for Ulcerative Colitis and Crohn’s Disease

PubMed Central

Ananthakrishnan, Ashwin N; McGinley, Emily L

2013-01-01

Background There is increasing complexity in the management of patients with acute severe exacerbation of inflammatory bowel disease (IBD; Crohn’s disease (CD), ulcerative colitis (UC)) with frequent requirement for urgent surgery. Aim To determine whether a weekend effect exists for IBD care in the United States. Methods We used data from the Nationwide Inpatient Sample (NIS) 2007, the largest all-payer hospitalization database in the United States. Discharges with a diagnosis of CD or UC who underwent urgent intestinal surgery within 2 days of hospitalization were identified using the appropriate ICD-9 codes. The independent effect of admission on a weekend was examined using multivariate logistic regression adjusting for potential confounders. Results Our study included 7,112 urgent intestinal surgeries in IBD patients, 21% of which occurred following weekend admissions. There was no difference in disease severity between weekend and weekday admissions. Post-operative complications were more common following weekend than weekday hospitalizations in UC (odds ratio (OR) 1.71, 95% confidence interval (CI) 1.01–2.90). The most common post-operative complication was post-operative infections (Weekend 30% vs. weekday 20%, p=0.04). The most striking difference between weekend and weekday hospitalizations was for need for repeat laparotomy (OR 11.5), mechanical wound complications (OR 10.03) and pulmonary complications (OR 2.22). In contrast, occurrence of any post-operative complication in CD was similar between weekday and weekend admissions. Conclusion Patients with UC hospitalized on a weekend undergoing urgent surgery within 2 days have an increased risk for post-operative complications, in particular mechanical wound complications, need for repeat laparotomy, and post-operative infections. PMID:23451882

Impact of First Eye versus Second Eye Cataract Surgery on Visual Function and Quality of Life.

PubMed

Shekhawat, Nakul S; Stock, Michael V; Baze, Elizabeth F; Daly, Mary K; Vollman, David E; Lawrence, Mary G; Chomsky, Amy S

2017-10-01

To compare the impact of first eye versus second eye cataract surgery on visual function and quality of life. Cohort study. A total of 328 patients undergoing separate first eye and second eye phacoemulsification cataract surgeries at 5 veterans affairs centers in the United States. Patients with previous ocular surgery, postoperative endophthalmitis, postoperative retinal detachment, reoperation within 30 days, dementia, anxiety disorder, hearing difficulty, or history of drug abuse were excluded. Patients received complete preoperative and postoperative ophthalmic examinations for first eye and second eye cataract surgeries. Best-corrected visual acuity (BCVA) was measured 30 to 90 days preoperatively and postoperatively. Patients completed the National Eye Institute Visual Functioning Questionnaire (NEI-VFQ) 30 to 90 days preoperatively and postoperatively. The NEI-VFQ scores were calculated using a traditional subscale scoring algorithm and a Rasch-refined approach producing visual function and socioemotional subscale scores. Postoperative NEI-VFQ scores and improvement in NEI-VFQ scores comparing first eye versus second eye cataract surgery. Mean age was 70.4 years (±9.6 standard deviation [SD]). Compared with second eyes, first eyes had worse mean preoperative BCVA (0.55 vs. 0.36 logarithm of the minimum angle of resolution (logMAR), P < 0.001), greater mean BCVA improvement after surgery (-0.50 vs. -0.32 logMAR, P < 0.001), and slightly worse postoperative BCVA (0.06 vs. 0.03 logMAR, P = 0.039). Compared with first eye surgery, second eye surgery resulted in higher postoperative NEI-VFQ scores for nearly all traditional subscales (P < 0.001), visual function subscale (-3.85 vs. -2.91 logits, P < 0.001), and socioemotional subscale (-2.63 vs. -2.10 logits, P < 0.001). First eye surgery improved visual function scores more than second eye surgery (-2.99 vs. -2.67 logits, P = 0.021), but both first and second eye surgeries resulted in similar improvements in socioemotional scores (-1.62 vs. -1.51 logits, P = 0.255). Second eye cataract surgery improves visual function and quality of life well beyond levels achieved after first eye cataract surgery alone. For certain socioemotional aspects of quality of life, second eye cataract surgery results in comparable improvement to first eye cataract surgery. Copyright © 2017 American Academy of Ophthalmology. All rights reserved.

The structure, organisation and perioperative management of ambulatory surgery and anaesthesia in France: Methodology of the SFAR-OPERA study.

PubMed

Albaladejo, Pierre; Aubrun, Frédéric; Samama, Charles-Marc; Jouffroy, Laurent; Beaussier, Marc; Benhamou, Dan; Romegoux, Pauline; Skaare, Kristina; Bosson, Jean-Luc; Ecoffey, Claude

2017-10-01

The organization of health care establishments and perioperative care are essential for ensuring the quality of care and safety of patients undergoing outpatient surgery. In order to correctly inventory these organizations and practices, in 2013-2014, the French society of anaesthesia and intensive care organized an extensive practical survey in French ambulatory surgery units entitled the "OPERA" study (Organisation periopératoire de l'anesthésie en chirurgie ambulatoire). From among all of the ambulatory surgery centres listed by the Agences régionales de santé (Regional health agencies, France), 206 public and private centres were randomly selected. A structural (typology, organization) survey and a medical-practice survey (focusing on the management of postoperative pain, nausea and vomiting as well as the prevention of venous thromboembolism) were collected and managed by a prospective audit of practices occurring on two randomly selected days. The latter was further accompanied by an additional audit specifically focussing on ten representative procedures: (1) stomatology surgery (third molar removal); (2) knee arthroscopy; (3) surgery of the abdominal wall (including inguinal hernia); (4) perianal surgery; (5) varicose vein surgery; (6) digestive laparoscopy-cholecystectomy; (7) breast surgery (tumourectomy); (8) uterine surgery; (9) hallux valgus and (10) hand surgery (excluding carpal tunnel). Over the 2 days of observation, 7382 patients were included comprising 2174 patients who underwent one of the procedures from the above list. The analysis of these data will provide an overview of the organization of health establishments, the modalities thus supported and compliance with standards. Copyright © 2016 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.

Delayed Sternal Closure in Infant Heart Surgery-The Importance of Where and When: An Analysis of the STS Congenital Heart Surgery Database.

PubMed

Nelson-McMillan, Kristen; Hornik, Christoph P; He, Xia; Vricella, Luca A; Jacobs, Jeffrey P; Hill, Kevin D; Pasquali, Sara K; Alejo, Diane E; Cameron, Duke E; Jacobs, Marshall L

2016-11-01

Delayed sternal closure (DSC) is commonly used to optimize hemodynamic stability after neonatal and infant heart surgery. We hypothesized that duration of sternum left open (SLO) was associated with rate of infection complications, and that location of sternal closure may mitigate infection risk. Infants (age ≤365 days) undergoing index operations with cardiopulmonary bypass and DSC at STS Congenital Heart Surgery Database centers (from 2007 to 2013) with adequate data quality were included. Primary outcome was occurrence of infection complication, defined as one or more of the following: endocarditis, pneumonia, wound infection, wound dehiscence, sepsis, or mediastinitis. Multivariable regression models were fit to assess association of infection complication with: duration of SLO (days), location of DSC procedure (operating room versus elsewhere), and patient and procedural factors. Of 6,127 index operations with SLO at 100 centers, median age and weight were 8 days (IQR, 5-24) and 3.3 kg (IQR, 2.9-3.8); 66% of operations were STAT morbidity category 4 or 5. At least one infection complication occurred in 18.7%, compared with 6.6% among potentially eligible neonates and infants without SLO. Duration of SLO (median, 3 days; IQR, 2-5) was associated with an increased rate of infection complications (p < 0.001). Location of DSC procedure was operating room (16%), intensive care unit (67%), or other (17%). Location of DSC was not associated with rate of infection complications (p = 0.45). Rate of occurrence of infectious complications is high among infants with sternum left open following cardiac surgery. Longer duration of SLO is associated with increased infection complications. Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Orthognathic Surgery in Patients With Congenital Myopathies and Congenital Muscular Dystrophies: Case Series and Review of the Literature.

PubMed

Bezak, Brett J; Arce, Kevin A; Jacob, Adam; Van Ess, James

2016-03-01

This case series examined preoperative findings and the surgical, anesthetic, and postoperative management of 6 patients with congenital myopathies (CMs) and congenital muscular dystrophies (CMDs) treated at a tertiary medical institution with orthognathic surgery over 15 years to describe pertinent considerations for performing orthognathic surgery in these complex patients. According to the institutional review board-approved protocol, chart records were reviewed for all orthognathic surgical patients with a clinical, genetic, or muscle biopsy-proved diagnosis of CM or CMD. Six patients (5 male, 1 female) qualified, and they were treated by 4 surgeons in the division of oral and maxillofacial surgery from 1992 through 2007. Average age was 19.5 years at the time of orthognathic surgery. Five patients had Class III malocclusions and 1 patient had Class II malocclusion. All 6 patients had apertognathia with lip incompetence. Nasoendotracheal intubation with a difficulty of 0/3 (0=easiest, 3=most difficult) was performed in all cases. Routine induction and maintenance anesthetics, including halogenated agents and nondepolarizing muscle relaxants, were administered without malignant hyperthermia. All 6 patients underwent Le Fort level osteotomies; 4 also had mandibular setback surgery with or without balancing mandibular inferior border osteotomies. Five patients required planned intensive care unit care postoperatively (average, 18.4 days; range, 4 to 65 days). Postoperative respiratory complications resulting in major blood oxygen desaturations occurred in 5 patients; 4 of these patients required reintubation during emergency code response. Five patients required extended postoperative intubation (average, 4.2 days; range, 3 to 6 days) and ventilatory support. Average hospital length of stay was 21.8 days (range, 6 to 75 days). Average postoperative follow-up interval was 29.8 weeks (range, 6 to 128 weeks). Patients with CMs or CMDs often have characteristic dentofacial malocclusions that contribute to functional problems with feeding and drooling and psychosocial problems. Orthognathic surgery, usually bimaxillary, can be judiciously considered in these patients; these procedures typically require multidisciplinary pre- and postoperative evaluation and care over lengthy hospital stays with a high risk of respiratory complications that bear consideration in treatment planning. Copyright © 2016 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Intensive care unit versus hospital floor: a comparative study of postoperative management of patients with adolescent idiopathic scoliosis.

PubMed

Shan, Le-Qun; Skaggs, David L; Lee, Christopher; Kissinger, Catherine; Myung, Karen S

2013-04-03

Patients undergoing posterior spinal instrumentation and fusion surgery for adolescent idiopathic scoliosis were admitted to the intensive care unit until two years ago, at which time we changed our protocol to admit these patients to the general hospital floor following a brief stay in a postanesthesia care unit. This study compared postoperative management on a hospital floor with that in the intensive care unit for patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion. A retrospective review of 124 consecutive patients with adolescent idiopathic scoliosis treated with spinal fusion from August 2007 to August 2010 was performed. Inclusion criteria were a diagnosis of adolescent idiopathic scoliosis and posterior spinal instrumentation and fusion surgery. Of 124 patients, sixty-six were managed postoperatively in the intensive care unit and fifty-eight, on the hospital floor. The mean age at the time of surgery was fourteen years. A mean of eleven vertebral levels (range, six to fifteen levels) were fused. No significant difference between the groups was found with respect to the mean age at the time of surgery, mean weight, mean preoperative and postoperative Cobb angles, and mean number of levels fused (p ≥ 0.12). However, the use of analgesic and antianxiety medication, number of postoperative blood tests, days of hospital stay, and number of physical therapy sessions were significantly decreased in the floor group compared with the intensive care unit group (p ≤ 0.05). No patient from the floor group had to be admitted to the intensive care unit. The mean charge was $33,121 for the floor group and $39,252 for the intensive care unit group (p < 0.001). Initial postoperative management of patients with adolescent idiopathic scoliosis following a posterior spinal instrumentation and fusion surgery on a general hospital floor, rather than in an intensive care unit, was associated with a shorter hospital stay, fewer blood tests, less analgesic and antianxiety medication usage, and fewer physical therapy sessions at this high-volume, academic, tertiary-care children's hospital. In addition to improved patient outcomes, there was a significant decrease of 16% in hospital charges for the group that did not go to the intensive care unit.

Is bariatric surgery safe in patients who refuse blood transfusion?

PubMed

Kitahama, Seiichi; Smith, Mark D; Rosencrantz, David R; Patterson, Emma J

2013-01-01

A small, but significant, number of patients undergoing bariatric surgery refuse blood transfusion for religious or other personal reasons. Jehovah's Witnesses number more than 1 million members in the United States alone. The reported rates of hemorrhage vary from .5% to 4% after bariatric surgery, with transfusion required in one half of these cases. Pharmacologic prophylaxis against venous thromboembolism could further increase the perioperative bleeding risk. Our objective was to report the perioperative outcomes of bariatric surgery who refuse blood transfusion at a bariatric center of excellence, private practice in the United States. A retrospective review of all patients who refused blood transfusion when undergoing bariatric surgery during a 10-year period was conducted. Patients were identified from a prospectively maintained database by the bloodless surgery program at Legacy Good Samaritan Hospital. Data were collected on demographics, co-morbidities, laboratory values, medication use, blood loss, and 30-day complications. Thirty-five bloodless surgery patients underwent bariatric surgery from 2000 to 2009. Of these 35 patients, 21 underwent laparoscopic adjustable gastric banding and 14 Roux-en-Y gastric bypass. Before 2006, only pneumatic compression devices were applied for venous thromboembolism prophylaxis (n = 6). Subsequently, combination venous thromboembolism prophylaxis was performed with fondaparinux sodium 2.5 mg for RYGB or enoxaparin 40 mg for LAGB (n = 29). One RYGB patient developed postoperative hemorrhage requiring reoperation. No venous thromboembolisms or deaths occurred. Bariatric surgery can be performed in patients who refuse blood transfusion with acceptable postoperative morbidity. Larger studies are necessary to confirm the safety of this approach and to examine the effect of pharmacologic thromboprophylaxis in this patient group. Copyright © 2013 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.

Does intraoperative fluid management in spine surgery predict intensive care unit length of stay?

PubMed

Nahtomi-Shick, O; Kostuik, J P; Winters, B D; Breder, C D; Sieber, A N; Sieber, F E

2001-05-01

To determine whether intraoperative fluid management in spine surgery predicts postoperative intensive care unit length of stay (ICU LOS). Retrospective case series. University-affiliated medical center. 103 adult ASA physical status I, II, and III patients undergoing spine surgery. Patients were divided into three LOS groups: no ICU stay (LOS0) (n = 26), 1 day ICU stay (LOS1) (n = 48), and ICU stay > 1 day (LOS2) (n = 29). Measurements were analyzed by groups using the Kruskal-Wallis and Mann-Whitney tests, and linear regression. Demographics, comorbidity, length of surgery, surgical procedure, and intraoperative fluids were recorded. The important differences in perioperative fluid management among the three groups included estimated blood loss (612 +/- 480 mL, 1853 +/- 1175 mL, 2702 +/- 1771 mL, means +/- SD); total crystalloid administration (2715 +/- 1396 mL, 5717 +/- 2574 mL, 7281 +/- 3417 mL); and total blood administration (92 +/- 279 mL, 935 +/- 757 mL, 1542 +/- 1230 mL) in LOS0, LOS1, and LOS2, respectively. The mixture of surgical procedures was similar in LOS1 and LOS2; and differed from LOS0. Predictors of ICU LOS included age, ASA physical status, surgical procedure, total crystalloid administration, and platelet administration. Surgical procedure and total crystalloid administration correlated (Pearson correlation coefficient = 0.441; p = 0.000) and were not related to age or ASA physical status. Total crystalloid administration during spine surgery does predict ICU LOS. In addition, total crystalloid administration is closely related to the surgical procedure. Given that the mixture of surgical procedures was similar in LOS1 and LOS2, but differed in estimated blood loss, total crystalloid administration, and total blood administration; intraoperative fluid management during spine surgery only predicts ICU LOS insofar as total crystalloid administration is related to the surgical procedure.

Feasibility and safety of minimized cardiopulmonary bypass in major aortic surgery

PubMed Central

Momin, Aziz U.; Sharabiani, Mansour T. A.; Kidher, Emadin; Najefi, Ali; Mulholland, John W.; Reeves, Barnaby C.; Angelini, Gianni D.; Anderson, Jon R.

2013-01-01

OBJECTIVES Conventional cardiopulmonary bypass causes haemodilution and is a trigger of systemic inflammatory reactions, coagulopathy and organ failure. Miniaturized cardiopulmonary bypass has been proposed as a way to reduce these deleterious effects of conventional cardiopulmonary bypass and to promote a more physiological state. The use of miniaturized cardiopulmonary bypass has been reported in low-risk patients undergoing valve and coronary artery bypass graft (CABG) surgery. However, little is known about its application in major aortic surgery. METHODS From February 2007 to September 2010, 49 patients underwent major aortic surgery using the Hammersmith miniaturized cardiopulmonary bypass (ECCO, Sorin). Data were extracted from medical records to characterize preoperative comorbidities (EuroSCORE), perioperative complications and the use of blood products. The same data were collected and described for 328 consecutive patients having similar surgery with conventional cardiopulmonary bypass at the Bristol Heart Institute, our twinned centre, during the same period. RESULTS The miniaturized cardiopulmonary bypass group had a median EuroSCORE of 8 [inter-quartile range (IQR): 5–11], 13% had preoperative renal dysfunction and 20% of operations were classified as emergency or salvage. Thirty-day mortalities were 6.4; and 69, 67 and 74% had ≥1 unit of red cells, fresh frozen plasma (FFP) and platelets transfused, respectively. Eight percent of patients experienced a renal complication, and 8% a neurological complication. The conventional cardiopulmonary bypass group was similar, with a EuroSCORE of 8 (IQR: 6–10); 30-day mortalities were 9.4; and 68, 62 and 74% had ≥1 unit of red cells, FFP and platelets transfused, respectively. The proportions experiencing renal and neurological complications were 14 and 5%. CONCLUSIONS Our experience suggests that miniaturized cardiopulmonary bypass is safe and feasible for use in major aortic cardiac surgery. A randomized trial is needed to evaluate miniaturized cardiopulmonary bypass formally. PMID:23814138

Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

PubMed

2016-10-31

As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. ISRCTN51817007 © The Author 2016. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.

Incidence of cerebrovascular accidents in patients undergoing minimally invasive valve surgery.

PubMed

LaPietra, Angelo; Santana, Orlando; Mihos, Christos G; DeBeer, Steven; Rosen, Gerald P; Lamas, Gervasio A; Lamelas, Joseph

2014-07-01

Minimally invasive valve surgery has been associated with increased cerebrovascular complications. Our objective was to evaluate the incidence of cerebrovascular accidents in patients undergoing minimally invasive valve surgery. We retrospectively reviewed all the minimally invasive valve surgery performed at our institution from January 2009 to June 2012. The operative times, lengths of stay, postoperative complications, and mortality were analyzed. A total of 1501 consecutive patients were identified. The mean age was 73 ± 13 years, and 808 patients (54%) were male. Of the 1501 patients, 206 (13.7%) had a history of a cerebrovascular accident, and 225 (15%) had undergone previous heart surgery. The procedures performed were 617 isolated aortic valve replacements (41.1%), 658 isolated mitral valve operations (43.8%), 6 tricuspid valve repairs (0.4%), 216 double valve surgery (14.4%), and 4 triple valve surgery (0.3%). Femoral cannulation was used in 1359 patients (90.5%) and central cannulation in 142 (9.5%). In 1392 patients (92.7%), the aorta was clamped, and in 109 (7.3%), the surgery was performed with the heart fibrillating. The median aortic crossclamp and cardiopulmonary bypass times were 86 minutes (interquartile range [IQR], 70-107) minutes and 116 minutes (IQR, 96-143), respectively. The median intensive care unit length of stay was 47 hours (IQR, 29-74), and the median postoperative hospital length of stay was 7 days (IQR, 5-10). A total of 23 cerebrovascular accidents (1.53%) and 38 deaths (2.53%) had occurred at 30 days postoperatively. Minimally invasive valve surgery was associated with an acceptable stroke rate, regardless of the cannulation technique. Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Psychoeducational preparation of children for surgery: the importance of parental involvement.

PubMed

Li, Ho Cheung William; Lopez, Violeta; Lee, Tin Loi Isabel

2007-01-01

To examine the effects of therapeutic play intervention on outcomes of children undergoing day surgery, and to highlight the importance of parental involvement in the psychoeducational preparation of children for surgery. A randomized controlled trial, two group pre-test and repeated post-test, between subjects design was employed. Hong Kong Chinese children (7-12 years of age; n=203) admitted for elective surgery in a day surgery unit, along with their parents during a 13-month period, were invited to participate in the study. By using a simple complete randomization method, 97 of children with their parents were assigned to the experimental group receiving therapeutic play intervention, and 106 children with their parents were assigned to the control group receiving routine information preparation. The results showed that both children and their parents in the experimental group reported lower state anxiety scores in pre- and post-operative periods. Children in the experimental group exhibited fewer instances of negative emotional behaviors and parents in the experimental group reported greater satisfaction. The results, however, find no differences in children's post-operative pain between the two groups. The study provides empirical evidence to support the effectiveness of using therapeutic play intervention and the importance of parental involvement in the psychoeducational preparation of children for surgery. The findings heighten the awareness of the importance of integrating therapeutic play and parental involvement as essential components of holistic and quality nursing care to prepare children for surgery.

Incision integrity and postoperative outcomes after microcoaxial phacoemulsification performed using 2 incision-dependent systems.

PubMed

Vasavada, Vaishali; Vasavada, Abhay R; Vasavada, Viraj A; Srivastava, Samaresh; Gajjar, Devarshi U; Mehta, Siddharth

2013-04-01

To compare incision integrity and clinical outcomes of 2 microcoaxial phacoemulsification systems. Iladevi Cataract & IOL Research Centre, Ahmedabad, India. Prospective randomized clinical trial. Eyes were randomized to have phacoemulsification using a 1.8 mm clear corneal incision (CCI) system (Group 1, Stellaris system) or a 2.2 mm CCI system (Group 2, Intrepid Infiniti system). Incision enlargement at end of surgery was measured. At the conclusion of surgery, trypan blue was applied over the conjunctival surface, anterior chamber aspirate withdrawn, and ingress into anterior chamber measured. Postoperative observations included evaluation of the CCI using anterior segment optical coherence tomography (AS-OCT), change in central corneal thickness (CCT), and anterior segment inflammation at 1 day, 1 week, and 1 month and endothelial cell loss and surgically induced astigmatism (SIA) at 3 months. Incision enlargement (P<.001) and trypan blue ingress in the anterior chamber (mean 1.7 log units ± 0.6 [SD] versus 3.8 ± 0.6 log units, P<.001) was significantly greater in Group 1 (n = 50) than in Group 2 (n = 50). On AS-OCT, endothelial misalignment and gaping were more frequent in Group 1 at 1 day (P=.001) and 1 week (P=.018). There were no significant differences in SIA, change in CCT, endothelial cell loss, or anterior segment inflammation (P>.05). At the end of surgery, it is not the initial incision size alone but also the distortion of the incision during subsequent stages of surgery that determine the integrity of the CCI. Copyright © 2013 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.

Application of total care time and payment per unit time model for physician reimbursement for common general surgery operations.

PubMed

Chatterjee, Abhishek; Holubar, Stefan D; Figy, Sean; Chen, Lilian; Montagne, Shirley A; Rosen, Joseph M; Desimone, Joseph P

2012-06-01

The relative value unit system relies on subjective measures of physician input in the care of patients. A payment per unit time model incorporates surgeon reimbursement to the total care time spent in the operating room, postoperative in-house, and clinic time to define payment per unit time. We aimed to compare common general surgery operations by using the total care time and payment per unit time method in order to demonstrate a more objective measurement for physician reimbursement. Average total physician payment per case was obtained for 5 outpatient operations and 4 inpatient operations in general surgery. Total care time was defined as the sum of operative time, 30 minutes per hospital day, and 30 minutes per office visit for each operation. Payment per unit time was calculated by dividing the physician reimbursement per case by the total care time. Total care time, physician payment per case, and payment per unit time for each type of operation demonstrated that an average payment per time spent for inpatient operations was $455.73 and slightly more at $467.51 for outpatient operations. Partial colectomy with primary anastomosis had the longest total care time (8.98 hours) and the least payment per unit time ($188.52). Laparoscopic gastric bypass had the highest payment per time ($707.30). The total care time and payment per unit time method can be used as an adjunct to compare reimbursement among different operations on an institutional level as well as on a national level. Although many operations have similar payment trends based on time spent by the surgeon, payment differences using this methodology are seen and may be in need of further review. Copyright © 2012 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Cost comparison between surgical treatments and endoscopic submucosal dissection in patients with early gastric cancer in Korea.

PubMed

Kim, Younhee; Kim, Young Woo; Choi, Il Ju; Cho, Joo Young; Kim, Jong Hee; Kwon, Jin Won; Lee, Ja Youn; Lee, Na Rae; Seol, Sang Yong

2015-03-01

This study was conducted to evaluate whether medical costs can be reduced using endoscopic submucosal dissection (ESD) instead of conventional surger-ies in patients with early gastric cancer (EGC). Pa-tients who underwent open gastrectomy (OG), laparoscopy-assisted gastrectomy (LAG), and ESD for EGC were recruited from three medical institutions in 2009. For macro-costing, the medical costs for each patient were derived from the ex-penses incurred during the patient's hospital stay and 1-year follow-up. The overall costs in micro-costing were determined by multiplying the unit cost with the resources used during the patients' hospitalization. A total of 194 patients were included in this study. The hospital stay for ESD was 5 to 8 days and was significantly shorter than the 12-day hospital stay for OG or the 11- to 17-day stay for LAG. Using macro-costing, the average medical costs for ESD during the hospital stay ranged from 2.1 to 3.4 million Korean Won (KRW) per patient, and the medical costs for conventional surgeries were estimated to be between 5.1 million and 8.2 million KRW. There were no significant differences in the 1-year follow-up costs between ESD and conventional surger-ies. ESD patients had lower medical costs than those patients who had conventional surgeries for EGC with conservative indications. (Gut Liver, 2015;9174-180).

Do prices reflect the costs of cardiac surgery in the elderly?

PubMed

Coelho, Pedro; Rodrigues, Vanessa; Miranda, Luís; Fragata, José; Pita Barros, Pedro

2017-01-01

Payment for cardiac surgery in Portugal is based on a contract agreement between hospitals and the health ministry. Our aim was to compare the prices paid according to this contract agreement with calculated costs in a population of patients aged ≥65 years undergoing cardiac surgery in one hospital department. Data on 250 patients operated between September 2011 and September 2012 were prospectively collected. The procedures studied were coronary artery bypass graft surgery (CABG) (n=67), valve surgery (n=156) and combined CABG and valve surgery (n=27). Costs were calculated by two methods: micro-costing when feasible and mean length of stay otherwise. Price information was provided by the hospital administration and calculated using the hospital's mean case-mix. Thirty-day mortality was 3.2%. Mean EuroSCORE I was 5.97 (standard deviation [SD] 4.5%), significantly lower for CABG (p<0.01). Mean intensive care unit stay was 3.27 days (SD 4.7) and mean hospital stay was 9.92 days (SD 6.30), both significantly shorter for CABG. Calculated costs for CABG were €6539.17 (SD 3990.26), for valve surgery €8289.72 (SD 3319.93) and for combined CABG and valve surgery €11 498.24 (SD 10 470.57). The payment for each patient was €4732.38 in 2011 and €4678.66 in 2012 based on the case-mix index of the hospital group, which was 2.06 in 2011 and 2.21 in 2012; however, the case-mix in our sample was 6.48 in 2011 and 6.26 in 2012. The price paid for each patient was lower than the calculated costs. Prices would be higher than costs if the case-mix of the sample had been used. Costs were significantly lower for CABG. Copyright © 2016 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.

Anesthetic and Perioperative Management of Nontransplant Surgery in Patients After Liver Transplant.

PubMed

Ersoy, Zeynep; Ayhan, Asude; Ozdemirkan, Aycan; Polat, Gulsi Gulsah; Zeyneloglu, Pinar; Arslan, Gulnaz; Haberal, Mehmet

2017-02-01

We aimed to document the anesthetic management and metabolic, hemodynamic, and clinical outcomes of liver-graft recipients who subsequently undergo nontransplant surgical procedures. We retrospectively analyzed the data of 96 liver-graft recipients who underwent 144 nontransplant surgeries between October 1998 and April 2016 at Başkent University Hospital. The median patient age at the time of nontransplant surgery was 32 years, and 35% were female (n = 33). The median time between transplant and nontransplant surgery was 1231 days. The most frequent types of nontransplant surgery were abdominal (22%), orthopedic (16%), and urologic (13%). Seventy patients had an American Society of Anesthesiologists status of 2 (49%); the status was 3 in 71 patients (49%) and 4 in 3 patients (2%). Of the 144 procedures, 23 were emergent (16%) and 48% were abdominal. General anesthesia was used in 69%, regional anesthesia in 19%, and sedoanalgesia in 11%. Twenty-five patients required intraoperative blood-product transfusion (17%). Intraoperative hemodynamic instability developed in 17% of patients, and hypoxemia developed in 2%. Eleven patients remained intubated at the end of surgery (8%). Of the 144 procedures, 19 (13%) required transfer to the intensive care unit, 108 (75%) transferred to the ward, and the remaining 17 (12%) were discharged on the same day. Eight patients developed respiratory failure (6%), 7 had renal dysfunction (5%), 4 had coagulation abnormalities (3%), and 10 had infectious complications (7%) in the early postoperative period. The median hospital stay was 4 days, and 5 patients (4%) developed rejection during hospitalization. Five patients died of respiratory or infectious complications (4%). Most liver-graft recipients who undergo nontransplant surgery are given general anesthesia, transferred to the ward after the procedure, and discharged without major complications. We suggest that orthotopic liver transplant recipients may undergo nontransplant surgery without any postoperative graft dysfunction.

Extracranial-intracranial bypass surgery for stroke prevention in hemodynamic cerebral ischemia: the Carotid Occlusion Surgery Study randomized trial.

PubMed

Powers, William J; Clarke, William R; Grubb, Robert L; Videen, Tom O; Adams, Harold P; Derdeyn, Colin P

2011-11-09

Patients with symptomatic atherosclerotic internal carotid artery occlusion (AICAO) and hemodynamic cerebral ischemia are at high risk for subsequent stroke when treated medically. To test the hypothesis that extracranial-intracranial (EC-IC) bypass surgery, added to best medical therapy, reduces subsequent ipsilateral ischemic stroke in patients with recently symptomatic AICAO and hemodynamic cerebral ischemia. Parallel-group, randomized, open-label, blinded-adjudication clinical treatment trial conducted from 2002 to 2010. Forty-nine clinical centers and 18 positron emission tomography (PET) centers in the United States and Canada. The majority were academic medical centers. Patients with arteriographically confirmed AICAO causing hemispheric symptoms within 120 days and hemodynamic cerebral ischemia identified by ipsilateral increased oxygen extraction fraction measured by PET. Of 195 patients who were randomized, 97 were randomized to receive surgery and 98 to no surgery. Follow-up for the primary end point until occurrence, 2 years, or termination of trial was 99% complete. No participant withdrew because of adverse events. Anastomosis of superficial temporal artery branch to a middle cerebral artery cortical branch for the surgical group. Antithrombotic therapy and risk factor intervention were recommended for all participants. For all participants who were assigned to surgery and received surgery, the combination of (1) all stroke and death from surgery through 30 days after surgery and (2) ipsilateral ischemic stroke within 2 years of randomization. For the nonsurgical group and participants assigned to surgery who did not receive surgery, the combination of (1) all stroke and death from randomization to randomization plus 30 days and (2) ipsilateral ischemic stroke within 2 years of randomization. The trial was terminated early for futility. Two-year rates for the primary end point were 21.0% (95% CI, 12.8% to 29.2%; 20 events) for the surgical group and 22.7% (95% CI, 13.9% to 31.6%; 20 events) for the nonsurgical group (P = .78, Z test), a difference of 1.7% (95% CI, -10.4% to 13.8%). Thirty-day rates for ipsilateral ischemic stroke were 14.4% (14/97) in the surgical group and 2.0% (2/98) in the nonsurgical group, a difference of 12.4% (95% CI, 4.9% to 19.9%). Among participants with recently symptomatic AICAO and hemodynamic cerebral ischemia, EC-IC bypass surgery plus medical therapy compared with medical therapy alone did not reduce the risk of recurrent ipsilateral ischemic stroke at 2 years. clinicaltrials.gov Identifier: NCT00029146.

Cost of treating ventilator-associated pneumonia post cardiac surgery in the National Health Service: Results from a propensity-matched cohort study.

PubMed

Luckraz, Heyman; Manga, Na'ngono; Senanayake, Eshan L; Abdelaziz, Mahmoud; Gopal, Shameer; Charman, Susan C; Giri, Ramesh; Oppong, Raymond; Andronis, Lazaros

2018-05-01

Ventilator-associated pneumonia is associated with significant morbidity, mortality and healthcare costs. Most of the cost data that are available relate to general intensive care patients in privately remunerated institutions. This study assessed the cost of managing ventilator-associated pneumonia in a cardiac intensive care unit in the National Health Service in the United Kingdom. Propensity-matched study of prospectively collected data from the cardiac surgical database between April 2011 and December 2014 in all patients undergoing cardiac surgery (n = 3416). Patients who were diagnosed as developing ventilator-associated pneumonia, as per the surveillance definition for ventilator-associated pneumonia (n = 338), were propensity score matched with those who did not (n = 338). Costs of treating post-op cardiac surgery patients in intensive care and cost difference if ventilator-associated pneumonia occurred based on Healthcare Resource Group categories were assessed. Secondary outcomes included differences in morbidity, mortality and cardiac intensive care unit and in-hospital length of stay. There were no significant differences in the pre-operative characteristics or procedures between the groups. Ventilator-associated pneumonia developed in 10% of post-cardiac surgery patients. Post-operatively, the ventilator-associated pneumonia group required longer ventilation (p < 0.01), more respiratory support, longer cardiac intensive care unit (8 vs 3, p < 0.001) and in-hospital stay (16 vs 9) days. The overall cost for post-operative recovery after cardiac surgery for ventilator-associated pneumonia patients was £15,124 compared to £6295 for non-ventilator-associated pneumonia (p < 0.01). The additional cost of treating patients with ventilator-associated pneumonia was £8829. Ventilator-associated pneumonia was associated with significant morbidity to the patients, generating significant costs. This cost was nearer to the lower end for the cost for general intensive care unit patients in privately reimbursed systems.

Readmission Rates, Reasons, and Risk Factors Following Anterior Cervical Fusion for Cervical Spondylosis in Patients Above 65 Years of Age.

PubMed

Puvanesarajah, Varun; Hassanzadeh, Hamid; Shimer, Adam L; Shen, Francis H; Singla, Anuj

2017-01-15

A retrospective database review. The aim of this study was to determine readmission reasons and rates following primary, elective anterior cervical spinal fusion surgery for cervical spondylosis and determine risk factors predicting increased risk of 30-day readmission in an exclusively elderly population. In the United States, there were almost 190,000 cervical spine procedures in 2009. Many cervical spine surgery patients are elderly, a demographic increasingly requiring surgery for degenerative cervical spine pathology. Unfortunately, this patient population is poorly studied, particularly concerning readmission rates. Medicare data from 2005 to 2012 were queried for elderly patients (65-84 years) who underwent primary one to two and ≥three-level anterior cervical spine fusion surgeries for cervical spondylosis. Forty-five thousand two hundred eighty-four patients treated with one to two-level and 12,103 patients with ≥three-level anterior cervical fusion (ACF) were identified and included in two study cohorts. Reasons for and rates of readmission were determined within 30 days, 90 days, and one-year postoperatively. Risk factors for medical, surgical, and all 30-day readmissions were also determined, selecting from various comorbidities, demographics, and surgical variables. Readmission rates of 1.0% to 1.4%, 2.7% to 3.6%, and 13.2% to 14.1% were observed within 30 days, 90 days, and one year. Within 30 days, over 30% of patients from both study cohorts were readmitted for surgical reasons. Of surgical reasons for 30-day readmission, hematoma/seroma diagnoses were the most frequent (11.4%-15.4% of all readmissions). Male gender, diabetes mellitus, chronic pulmonary disease, obesity, and smoking history were all found to be predictive of all-cause readmissions. Unplanned 30-day readmission rates following primary, elective ACF in elderly patients is low and often due to medical reasons. Frequent surgical reasons for 30-day readmission include hematoma/seroma formation. Male gender and various comorbid diagnoses are significant predictors of all-cause readmissions within 30 days. 3.

A diabetic foot service established by a department of vascular surgery: an observational study.

PubMed

Williams, Dean T; Majeed, Muhammad U; Shingler, Guy; Akbar, Mohammed J; Adamson, Diane G; Whitaker, Christopher J

2012-07-01

The mechanism by which the multidisciplinary approach to diabetic foot disease reduces amputation rates is unclear. Ischemia, sepsis, and necrosis represent aspects of severe diabetic foot disease amenable to intervention. In 2006, a vascular unit introduced a rapid access service for severe foot disease, augmenting the established community provision. This study aimed to determine whether concurrent changes in amputation rates were observed, and to identify areas that may have influenced outcomes. Unit data prospectively collected during 4 years for patients with lower-limb disease were compared with data retrieved over 2 years before the foot service. Outcome measurements were major amputations, foot surgery, vascular interventions, admissions, and length of stay. Major amputation rates associated with diabetes peaked in 2005 at 24.7/10,000 vs. 1.07/10,000 in 2009; (relative risk = 0.043, 95% confidence interval = 0.006-0.322). The proportion of diabetic to nondiabetic amputations decreased; foot surgery rates also dropped (53.7/10,000 in 2006 vs. 7.5/10,000 in 2009). The number of open revascularization procedures decreased, but the rates of endovascular procedures remained generally constant. Hospital admission rates decreased after initially peaking, and the length of stay was unchanged (16 vs. 15.5 days in 2004 and 2009, respectively). The integration of a vascular unit with community care has been associated with improved outcomes for patients with diabetic foot disease. Improvements were not related to the increased number of vascular procedures or hospitalizations, but did coincide with a greater proportion of patients attending the foot unit. The referral of patients to the unit facilitates the rapid management of severe disease, reducing delays deleterious to outcomes. Copyright © 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.

Patterns and determinants of functional and absolute iron deficiency in patients undergoing cardiac rehabilitation following heart surgery.

PubMed

Tramarin, Roberto; Pistuddi, Valeria; Maresca, Luigi; Pavesi, Marco; Castelvecchio, Serenella; Menicanti, Lorenzo; de Vincentiis, Carlo; Ranucci, Marco

2017-05-01

Background Anaemia and iron deficiency are frequent following major surgery. The present study aims to identify the iron deficiency patterns in cardiac surgery patients at their admission to a cardiac rehabilitation programme, and to determine which perioperative risk factor(s) may be associated with functional and absolute iron deficiency. Design This was a retrospective study on prospectively collected data. Methods The patient population included 339 patients. Functional iron deficiency was defined in the presence of transferrin saturation <20% and serum ferritin ≥100 µg/l. Absolute iron deficiency was defined in the presence of serum ferritin values <100 µg/l. Results Functional iron deficiency was found in 62.9% of patients and absolute iron deficiency in 10% of the patients. At a multivariable analysis, absolute iron deficiency was significantly ( p = 0.001) associated with mechanical prosthesis mitral valve replacement (odds ratio 5.4, 95% confidence interval 1.9-15) and tissue valve aortic valve replacement (odds ratio 4.5, 95% confidence interval 1.9-11). In mitral valve surgery, mitral repair carried a significant ( p = 0.013) lower risk of absolute iron deficiency (4.4%) than mitral valve replacement with tissue valves (8.3%) or mechanical prostheses (22.5%). Postoperative outcome did not differ between patients with functional iron deficiency and patients without iron deficiency; patients with absolute iron deficiency had a significantly ( p = 0.017) longer postoperative hospital stay (median 11 days) than patients without iron deficiency (median nine days) or with functional iron deficiency (median eight days). Conclusions Absolute iron deficiency following cardiac surgery is more frequent in heart valve surgery and is associated with a prolonged hospital stay. Routine screening for iron deficiency at admission in the cardiac rehabilitation unit is suggested.

Associated with Health Care-Associated Infections in Cardiac Surgery

PubMed Central

Greco, Giampaolo; Shi, Wei; Michler, Robert E.; Meltzer, David O.; Ailawadi, Gorav; Hohmann, Samuel F.; Thourani, Vinod; Argenziano, Michael; Alexander, John; Sankovic, Kathy; Gupta, Lopa; Blackstone, Eugene H.; Acker, Michael A.; Russo, Mark J.; Lee, Albert; Burks, Sandra G.; Gelijns, Annetine C.; Bagiella, Emilia; Moskowitz, Alan J.; Gardner, Timothy J.

2014-01-01

BACKGROUND Health care-associated infections (HAIs) are the most common noncardiac complications after cardiac surgery and are associated with increased morbidity and mortality. Current information about their economic burden is limited. OBJECTIVES To determine the cost associated with major types of HAIs during the first 2 months after cardiac surgery. METHODS Prospectively collected data from a multicenter observational study of the Cardiothoracic Surgery Clinical Trials Network, in which patients were monitored for infections for 65 days after surgery, were merged with related financial data, routinely collected by the University HealthSystem Consortium. Incremental length of stay (LOS) and cost associated with HAIs were estimated using generalized linear models, adjusting for patient demographics, clinical history, baseline laboratory values, and surgery type. RESULTS Among 4,320 cardiac surgery patients, mean age of 64 ± 13 years, 119 (2.8%) experienced a major HAI during the index hospitalization. The most common HAIs were pneumonia (48%), sepsis (20%) and C. Difficile colitis (18%). On average, the estimated incremental cost associated with a major HAI was nearly $38,000, of which 47% was related to intensive care unit services. The incremental LOS was 14 days. Overall, there were 849 readmissions, among these, 8.7% were attributed to major HAIs. The cost of readmissions due to major HAI was on average nearly three times as much as readmissions not related to HAI. CONCLUSIONS Hospital cost, length of stay, and readmissions are strongly associated with HAIs. These associations suggest the potential for large reductions in costs if HAIs following cardiac surgery can be reduced. PMID:25572505

Postoperative nausea and vomiting after unrestricted clear fluids before day surgery: A retrospective analysis.

PubMed

McCracken, Graham C; Montgomery, Jane

2018-05-01

Guidance on pre-operative fluids fasting policy continues to evolve. Current European guidelines encourage the intake of oral fluids up to 2 h before the induction of general anaesthesia. From October 2014, Torbay Hospital Day Surgery Unit commenced an unrestricted fluid policy, encouraging patients to drink clear fluids up until the time of transfer to theatre. The aim of this study was to assess the incidence of postoperative nausea and vomiting before and after the change to the unrestricted pre-operative clear oral fluids. Retrospective, before and after study. Single district general hospital between November 2013 and February 2016. A total of 11 500 patients on the day case pathway who were receiving either sedation, general anaesthesia, regional anaesthesia or their combination. The data from these patients were collected routinely. This number of patients represents approximately 78% of all patients before the change in fluids policy and 74% after the change. Exclusions were patients undergoing a termination of pregnancy, or patients undergoing community dental procedures, from whom patient experience data are not collected. Introduction of a change to the day surgery pathway policy permitting unrestricted clear oral fluids preoperatively until transfer to theatre (from October 2014). Incidence of postoperative nausea and vomiting. The rates of nausea within 24 h postoperatively were 270/5192 (5.2%) when patients could not drink within 2 h of surgery, and 179/4724 (3.8%) when patients could drink up until surgery, a relative rate (95% confidence interval) of 0.73 (0.61 to 0.88), P = 0.00074. The corresponding rates of vomiting were 146/5186 (2.8%) and 104/4716 (2.2%), a relative rate (95% confidence interval) of 0.78 (0.61 to 1.00), P = 0.053. Our data suggest that the liberal consumption of clear fluids before the induction of scheduled day case anaesthesia reduced the rates of postoperative nausea and vomiting.

Surgical injury: comparing open surgery and laparoscopy by markers of tissue damage.

PubMed

Máca, Jan; Peteja, Matúš; Reimer, Petr; Jor, Ondřej; Šeděnková, Věra; Panáčková, Lucie; Ihnát, Peter; Burda, Michal; Ševčík, Pavel

2018-01-01

Major abdominal surgery (MAS) is high-risk intervention usually accompanied by tissue injury leading to a release of signaling danger molecules called alarmins. This study evaluates the surgical injury caused by two fundamental types of gastrointestinal surgical procedures (open surgery and laparoscopy) in relation to the inflammation elicited by alarmins. Patients undergoing MAS were divided into a mixed laparoscopy group (LPS) and an open surgery group (LPT). Serum levels of alarmins (S100A8, S100A12, HMGB1, and HSP70) and biomarkers (leukocytes, C-reactive protein [CRP], and interleukin-6 [IL-6]) were analyzed between the groups. The secondary objectives were to compare LPT and LPS cancer subgroups and to find the relationship between procedure and outcome (intensive care unit length of stay [ICU-LOS] and hospital length of stay [H-LOS]). A total of 82 patients were analyzed. No significant difference was found in alarmin levels between the mixed LPS and LPT groups. IL-6 was higher in the LPS group on day 2 ( p =0.03) and day 3 ( p =0.04). Significantly higher S100A8 protein levels on day 1 ( p =0.02) and day 2 ( p =0.01) and higher S100A12 protein levels on day 2 ( p =0.03) were obtained in the LPS cancer subgroup. ICU-LOS and H-LOS were longer in the LPS cancer subgroup. The degree of surgical injury elicited by open MAS as reflected by alarmins is similar to that of laparoscopic procedures. Nevertheless, an early biomarker of inflammation (IL-6) was higher in the laparoscopy group, suggesting a greater inflammatory response. Moreover, the levels of S100A8 and S100A12 were higher with a longer ICU-LOS and H-LOS in the LPS cancer subgroup.

Economic impact of laparoscopic instrumentation: a company perspective.

PubMed

Swem, T; Fazzalari, R

1995-01-01

This report represents findings concerning the economic impact of laparoscopic surgery. Specifically, the study addresses hospital costs, and not the hospital charges often given attention by studies in the literature. Hospital expenditures for the equipment and instrumentation required for laparoscopic surgery are important cost factors in laparoscopic surgery. Data for determining hospital costs was obtained from nine hospitals throughout the United States. At each hospital, a research team spent four to five days interviewing surgeons, OR staff, hospital administrators and other personnel as well as gathering data. Analysis of operating room equipment and supplies indicates that single-use laparoscopic instruments are a cost-effective alternative to reusable instruments. In addition, single-use instruments have many benefits that were not possible to quantify accurately in this study.

Association of time-to-surgery with outcomes in clinical stage I-II pancreatic adenocarcinoma treated with upfront surgery.

PubMed

Swords, Douglas S; Zhang, Chong; Presson, Angela P; Firpo, Matthew A; Mulvihill, Sean J; Scaife, Courtney L

2018-04-01

Time-to-surgery from cancer diagnosis has increased in the United States. We aimed to determine the association between time-to-surgery and oncologic outcomes in patients with resectable pancreatic ductal adenocarcinoma undergoing upfront surgery. The 2004-2012 National Cancer Database was reviewed for patients undergoing curative-intent surgery without neoadjuvant therapy for clinical stage I-II pancreatic ductal adenocarcinoma. A multivariable Cox model with restricted cubic splines was used to define time-to-surgery as short (1-14 days), medium (15-42), and long (43-120). Overall survival was examined using Cox shared frailty models. Secondary outcomes were examined using mixed-effects logistic regression models. Of 16,763 patients, time-to-surgery was short in 34.4%, medium in 51.6%, and long in 14.0%. More short time-to-surgery patients were young, privately insured, healthy, and treated at low-volume hospitals. Adjusted hazards of mortality were lower for medium (hazard ratio 0.94, 95% confidence interval, .90, 0.97) and long time-to-surgery (hazard ratio 0.91, 95% confidence interval, 0.86, 0.96) than short. There were no differences in adjusted odds of node positivity, clinical to pathologic upstaging, being unresectable or stage IV at exploration, and positive margins. Medium time-to-surgery patients had higher adjusted odds (odds ratio 1.11, 95% confidence interval, 1.03, 1.20) of receiving an adequate lymphadenectomy than short. Ninety-day mortality was lower in medium (odds ratio 0.75, 95% confidence interval, 0.65, 0.85) and long time-to-surgery (odds ratio 0.72, 95% confidence interval, 0.60, 0.88) than short. In this observational analysis, short time-to-surgery was associated with slightly shorter OS and higher perioperative mortality. These results may suggest that delays for medical optimization and referral to high volume surgeons are safe. Published by Elsevier Inc.

Does a thrombin-based topical haemostatic agent reduce blood loss and transfusion requirements after total knee revision surgery? A randomized, controlled trial.

PubMed

Romanò, Carlo L; Monti, Lorenzo; Logoluso, Nicola; Romanò, Delia; Drago, Lorenzo

2015-11-01

The aim of the present study was to assess the efficacy of a thrombin-based topical haemostatic in reducing blood requirements after total knee replacement (TKR) revision surgery. This prospective, randomized, controlled study was designed to evaluate the haemostatic efficacy and safety of a thrombin-based topical haemostatic (Floseal) versus standard treatment in patients receiving total knee revision arthroplasty. The decrease in haemoglobin values postsurgery and the blood units transfused were recorded. The decision to transfuse was made by a surgeon blinded to the patient's group allocation. Forty-eight patients were enroled in the study; twenty-four patients each were randomized to the treatment and control groups, respectively. The median decrease in haemoglobin concentration on the first postoperative day was 2.2 g/dL in the treatment group and 2.7 g/dL in the control group. A significant reduction in units of blood transfused was also observed in the treatment group compared with the control group [1.1 ± 1.13 (range 0-4) vs. 1.9 ± 1.41 (range 0-5) blood units; P = 0.04]. No major treatment-related adverse events were recorded in the study. This study shows that a thrombin-based topical haemostatic reduces the need for blood transfusion in TKR revision surgery. A thrombin-based topical haemostatic agent can be an appropriate solution to enhance haemostasis and vessel sealing at the operative site in TKR revision surgery, in order to reduce the need for blood transfusion after surgery. II.

Suction on chest drains following lung resection: evidence and practice are not aligned.

PubMed

Lang, Peter; Manickavasagar, Menaka; Burdett, Clare; Treasure, Tom; Fiorentino, Francesca

2016-02-01

A best evidence topic in Interactive CardioVascular and Thoracic Surgery (2006) looked at application of suction to chest drains following pulmonary lobectomy. After screening 391 papers, the authors analysed six studies (five randomized controlled trials [RCTs]) and found no evidence in favour of postoperative suction in terms of air leak duration, time to chest drain removal or length of stay. Indeed, suction was found to be detrimental in four studies. We sought to determine whether clinical practice is consistent with published evidence by surveying thoracic units nationally and performing a meta-analysis of current best evidence. We systematically searched MEDLINE, EMBASE and CENTRAL for RCTs, comparing outcomes with and without application of suction to chest drains after lung surgery. A meta-analysis was performed using RevMan(©) software. A questionnaire concerning chest drain management and suction use was emailed to a clinical representative in every thoracic unit. Eight RCTs, published 2001-13, with 31-500 participants, were suitable for meta-analysis. Suction prolonged length of stay (weighted mean difference [WMD] 1.74 days; 95% confidence interval [CI] 1.17-2.30), chest tube duration (WMD 1.77 days; 95% CI 1.47-2.07) and air leak duration (WMD 1.47 days; 95% CI 1.45-2.03). There was no difference in occurrence of prolonged air leak. Suction was associated with fewer instances of postoperative pneumothorax. Twenty-five of 39 thoracic units responded to the national survey. Suction is routinely used by all surgeons in 11 units, not by any surgeon in 5 and by some surgeons in 9. Of the 91 surgeons represented, 62 (68%) routinely used suction. Electronic drains are used in 15 units, 10 of which use them routinely. Application of suction to chest drains following non-pneumonectomy lung resection is common practice. Suction has an effect in hastening the removal of air and fluid in clinical experience but a policy of suction after lung resection has not been shown to offer improved clinical outcomes. Clinical practice is not aligned with Level 1a evidence. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Initial experience using a femtosecond laser cataract surgery system at a UK National Health Service cataract surgery day care centre

PubMed Central

Dhallu, Sandeep K; Maurino, Vincenzo; Wilkins, Mark R

2016-01-01

Objectives To describe the initial outcomes following installation of a cataract surgery laser system. Setting National Health Service cataract surgery day care unit in North London, UK. Participants 158 eyes of 150 patients undergoing laser-assisted cataract surgery. Interventions Laser cataract surgery using the AMO Catalys femtosecond laser platform. Primary and secondary outcome measures Primary outcome measure: intraoperative complications including anterior and posterior capsule tears. Secondary outcome measures: docking to the laser platform, successful treatment delivery, postoperative visual acuities. Results Mean case age was 67.7±10.8 years (range 29–88 years). Docking was successful in 94% (148/158 cases), and in 4% (6/148 cases) of these, the laser delivery was aborted part way during delivery due to patient movement. A total of 32 surgeons, of grades from junior trainee to consultant, performed the surgeries. Median case number per surgeon was 3 (range from 1–20). The anterior capsulotomy was complete in 99.3% of cases, there were no anterior capsule tears (0%). There were 3 cases with posterior capsule rupture requiring anterior vitrectomy, and 1 with zonular dialysis requiring anterior vitrectomy (4/148 eyes, 2.7%). These 4 cases were performed by trainee surgeons, and were either their first laser cataract surgery (2 surgeons) or their first and second laser cataract surgeries (1 surgeon). Conclusions Despite the learning curve, docking and laser delivery were successfully performed in almost all cases, and surgical complication rates and visual outcomes were similar to those expected based on national data. Complications were predominately confined to trainee surgeons, and with the exception of intraoperative pupil constriction appeared unrelated to the laser-performed steps. PMID:27466243

Impact of Spanish-language information sessions on Spanish-speaking patients seeking bariatric surgery.

PubMed

Martin, Allison N; Marino, Miguel; Killerby, Marie; Rosselli-Risal, Liliana; Isom, Kellene A; Robinson, Malcolm K

2017-06-01

Bariatric centers frequently provide preoperative educational programs to inform patients about the risks and benefits of weight loss surgery. However, most programs are conducted in English, which may create barriers to effective treatment and access to care for non-English speaking populations. To address this concern, we instituted a comprehensive Spanish-language education program consisting of preoperative information and group nutrition classes conducted entirely in, and supported with Spanish-language materials. The primary aim was to examine the effect of this intervention on Spanish-speaking patients' decision to undergo surgery in a pilot study. University Hospital/Community Health Center, United States. Three cohorts of patients seeking bariatric surgery between January 1, 2011 and March 31, 2012 were identified: 1) primary English speakers attending English-language programs ("English-English"); 2) primary Spanish speakers attending Spanish-language programs ("Spanish-Spanish"); and 3) primary Spanish speakers attending English-speaking programs with the assistance of a Spanish-to-English translator ("Spanish-English"). 26% of the English-English cohort ultimately underwent surgery compared with only 12% of the Spanish-Spanish cohort (P = .009). Compared with the English-English group, time to surgery was 35 days longer for the Spanish-Spanish and 185 days longer for the Spanish-English group (both P< .001). Spanish-speaking patients were less likely to undergo bariatric surgery regardless of the language in which educational sessions are provided. For those choosing surgery, providing Spanish-language sessions can shorten time to surgery. A barrier to effective obesity treatment may exist for Spanish speakers, which may be only partially overcome by providing support in Spanish. Copyright © 2017. Published by Elsevier Inc.

The Auckland Cataract Study: co-morbidity, surgical techniques, and clinical outcomes in a public hospital service

PubMed Central

Riley, Andrew F; Malik, Tahira Y; Grupcheva, Christina N; Fisk, Michael J; Craig, Jennifer P; McGhee, Charles N

2002-01-01

Aim: To prospectively assess cataract surgery in a major New Zealand public hospital by defining presenting clinical parameters and surgical and clinical outcomes in a cohort of subjects just below threshold for treatment, based upon a points based prioritisation system. Methods: The prospective observational study comprised 488 eyes of 480 subjects undergoing consecutive cataract operations at Auckland Hospital. All subjects underwent extensive ophthalmic examination before and after surgery. Details of the surgical procedure, including any intraoperative difficulties or complications, were documented. Postoperative review was performed at 1 day and 4 weeks after surgery. Demographic data, clinical outcomes, and adverse events were correlated by an independent assessor. Results: The mean age at surgery was 74.9 (SD 9.6) years with a female predominance (62%). Significant systemic disease affected 80% of subjects, with 20% of the overall cohort exhibiting diabetes mellitus. 26% of eyes exhibited coexisting ocular disease and in 7.6% this affected best spectacle corrected visual acuity (BSCVA). A mean spherical equivalent of −0.49 (1.03) D and mean BSCVA of 0.9 (0.6) log MAR units (Snellen equivalent approximately 6/48) was noted preoperatively. Local anaesthesia was employed in 99.8% of subjects (94.9% sub-Tenon's). The majority of procedures (97.3%) were small incision phacoemulsification with foldable lens implant. Complications included: 4.9% posterior capsule tears, 3.8% cystoid macular oedema, and one case (0.2%) of endophthalmitis. Mean BSCVA after surgery was 0.1 (0.2) log MAR units (6/7.5 Snellen equivalent), with a mean spherical equivalent of −0.46 (0.89) D, and was 6/12 or better in 88% of all eyes. A drop in BSCVA, thought to be directly attributable to the surgical intervention, was recorded in a small percentage of eyes (1.5%) after surgery. Conclusion: This study provides a representative assessment of the management of cataract in the New Zealand public hospital system. A predominantly elderly, female population, frequently exhibiting significant systemic illness and coexisting ocular disease, relatively advanced cataracts, and poor BSCVA, presented for cataract surgery. The majority of subjects underwent small incision, phacoemulsification, day case surgery. While almost 90% achieved at least 6/12 BSCVA post-surgery, approximately 5% sustained an adverse intraoperative event and 1.5% of eyes exhibited a reduction in BSCVA postoperatively. PMID:11815345

Effect of magnesium on arrhythmia incidence in patients undergoing coronary artery bypass grafting.

PubMed

Mohammadzadeh, Alireza; Towfighi, Farshad; Jafari, Naser

2018-06-01

Cardiac arrhythmia after coronary artery bypass grafting (CABG) surgery is a common complication of cardiac surgery. The effect of serum magnesium, hypomagnesaemia treatment and prophylactic administration of magnesium in the development and prevention of arrhythmias is controversial and there are many different ideas. This study evaluates the therapeutic effects of magnesium in cardiac arrhythmia after CABG surgery. The clinical trial enrolled 250 patients who underwent CABG. Based on the initial serum levels of magnesium, patients were divided into two groups: hypomagnesium and normomagnesium. Based on bioethics committee requirements, patients in the hypo-magnesium group received magnesium treatments until they attained normal magnesium blood levels. Both groups underwent CABG with normal blood levels of magnesium. After surgery, each group was randomly divided into two subgroups: one subgroup received a bolus dose of magnesium sulphate (30 mg/kg in 5 min) and the other subgroup received a placebo. Subgroups were under observation in the intensive care unit for 3 days and arrhythmias were recorded. Data from all four subgroups were analysed statistically and interpreted. The results of this study showed that the occurrence of arrhythmia was not significantly different among subgroups (P > 0.05). There was no significant relationship between blood levels of magnesium and arrhythmia during the 3 days post-surgery (P > 0.05). The results of this study showed that magnesium sulphate administration did not significantly improve the incidence of arrhythmias in hypo- and normo-magnesium patients after CABG. There was no significant correlation between post-operative serum levels of magnesium and arrhythmia during 3 days. © 2017 Royal Australasian College of Surgeons.

The association between pre-operative sepsis and 30-day mortality in hip fracture patients-A cohort study.

PubMed

Mørch, S S; Tantholdt-Hansen, S; Pedersen, N E; Duus, C L; Petersen, J A; Andersen, C Ø; Jarløv, J O; Meyhoff, C S

2018-05-24

Post-operative sepsis considerably increases mortality, but the extent of pre-operative sepsis in hip fracture patients and its consequences are sparsely elucidated. The aim of this study was to assess the association between pre-operative sepsis and 30-day mortality after hip fracture surgery. We conducted a retrospective analysis of data collected among 1894 patients who underwent hip fracture surgery in the Capital Region of Denmark in 2014 (NCT03201679). Data on vital signs, cultures and laboratory data were obtained. Sepsis was defined as a positive culture of any kind and presence of systemic inflammatory response syndrome within 24 hours and was assessed within 72 hours before surgery and 30 days post-operatively. Primary outcome was 30-day mortality. Secondary outcomes included length of hospital stay and admission to intensive care unit. A total of 144 (7.6%) of the hip fracture patients met the criteria for pre-operative sepsis. The 30-day mortality was 13.9% in patients with pre-operative sepsis as compared to 9.0% in those without (OR 1.69, 95% CI [1.00; 2.85], P = .08). Patients with pre-operative sepsis had longer hospital stays (median 10 days vs 9 days, mean difference 2.1 [SD 9.4] days, P = .03), and higher frequency of ICU admission (11.1% vs 2.7%, OR 4.15, 95% CI [2.19; 7.87], P < .0001). Pre-operative sepsis in hip fracture patients was associated with an increased length of hospital stay and tended to increase mortality. Pre-operative sepsis in hip fracture patients merits more intensive surveillance and increased attention to timely treatment. © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

Spine Surgery Outcomes in Elderly Patients Versus General Adult Patients in the United States: A MarketScan Analysis.

PubMed

Lagman, Carlito; Ugiliweneza, Beatrice; Boakye, Maxwell; Drazin, Doniel

2017-07-01

To compare spine surgery outcomes in elderly patients (80-103 years old) versus general adult patients (18-79 years-old) in the United States. Truven Health Analytics MarketScan Research Databases (2000-2012) were queried. Patients with a diagnosis of degenerative disease of the spine without concurrent spinal stenosis, spinal stenosis without concurrent degenerative disease, or degenerative disease with concurrent spinal stenosis and who had undergone decompression without fusion, fusion without decompression, or decompression with fusion procedures were included. Indirect outcome measures included length of stay, in-hospital mortality, in-hospital and 30-day complications, and discharge disposition. Patients (N = 155,720) were divided into elderly (n = 10,232; 6.57%) and general adult (n = 145,488; 93.4%) populations. Mean length of stay was longer in elderly patients versus general adult patients (3.62 days vs. 3.11 days; P < 0.0001). In-hospital mortality was more common in elderly patients versus general adult patients (0.31% vs. 0.06%; P < 0.0001). In-hospital and 30-day complications were more common in elderly patients versus general adult patients (11.3% vs. 7.15% and 17.8% vs. 12.6%; P < 0.0001). Nonroutine discharge was more common in elderly patients versus general adult patients (33.7% vs. 16.2%; P < 0.0001). Our results revealed significantly longer hospital stays, more in-hospital mortalities, and more in-hospital and 30-day complications after decompression without fusion, fusion without decompression, or decompression with fusion procedures in elderly patients. Copyright © 2017 Elsevier Inc. All rights reserved.

Potential cost saving of Epoetin alfa in elective hip or knee surgery due to reduction in blood transfusions and their side effects: a discrete-event simulation model.

PubMed

Tomeczkowski, Jörg; Stern, Sean; Müller, Alfred; von Heymann, Christian

2013-01-01

Transfusion of allogeneic blood is still common in orthopedic surgery. This analysis evaluates from the perspective of a German hospital the potential cost savings of Epoetin alfa (EPO) compared to predonated autologous blood transfusions or to a nobloodconservationstrategy (allogeneic blood transfusion strategy)during elective hip and knee replacement surgery. Individual patients (N = 50,000) were simulated based on data from controlled trials, the German DRG institute (InEK) and various publications and entered into a stochastic model (Monte-Carlo) of three treatment arms: EPO, preoperative autologous donation and nobloodconservationstrategy. All three strategies lead to a different risk for an allogeneic blood transfusion. The model focused on the costs and events of the three different procedures. The costs were obtained from clinical trial databases, the German DRG system, patient records and medical publications: transfusion (allogeneic red blood cells: €320/unit and autologous red blood cells: €250/unit), pneumonia treatment (€5,000), and length of stay (€300/day). Probabilistic sensitivity analyses were performed to determine which factors had an influence on the model's clinical and cost outcomes. At acquisition costs of €200/40,000 IU EPO is cost saving compared to autologous blood donation, and cost-effective compared to a nobloodconservationstrategy. The results were most sensitive to the cost of EPO, blood units and hospital days. EPO might become an attractive blood conservation strategy for anemic patients at reasonable costs due to the reduction in allogeneic blood transfusions, in the modeled incidence of transfusion-associated pneumonia andthe prolongedlength of stay.

90-day postoperative mortality is a legitimate measure of hepatopancreatobiliary surgical quality

PubMed Central

Mise, Yoshihiro; Vauthey, Jean-Nicolas; Zimmitti, Giuseppe; Parker, Nathan H.; Conrad, Claudius; Aloia, Thomas A.; Lee, Jeffery E.; Fleming, Jason B.; Katz, Matthew H. G.

2015-01-01

Objective To investigate the legitimacy of 90-day mortality as a measure of hepatopancreatobiliary quality. Summary Background Data The 90-day mortality rate has been increasingly but not universally reported after hepatopancreatobiliary surgery. The legitimacy of this definition as a measure of surgical quality has not been evaluated. Methods We retrospectively reviewed the causes of all deaths that occurred within 365 postoperative days in patients undergoing hepatectomy (n = 2811) and/or pancreatectomy (n = 1092) from January 1997 through December 2012. The rates of surgery-related, disease-related, and overall mortality within 30 days, within 30 days or during the index hospitalization, within 90 days, and within 180 days following surgery were calculated. Results Seventy-nine (3%) surgery-related deaths and 92 (3%) disease-related deaths occurred within 365 days after hepatectomy. Twenty (2%) surgery-related deaths and 112 (10%) disease-related deaths occurred within 365 days after pancreatectomy. The overall mortality rates at 99 day and 118 days optimally reflected surgery-related mortality following hepatobiliary and pancreatic operations, respectively. The 90-day overall mortality rate was a less sensitive but equivalently specific measure of surgery-related death. Conclusions and Relevance The 99-day and 118-day definitions of postoperative mortality optimally reflected surgery-related mortality following hepatobiliary and pancreatic operations, respectively. However, among commonly reported metrics, the 90-day overall mortality rate represents a legitimate measure of surgical quality. PMID:25590497

Continuous Positive Airway Pressure Versus Oxygen Therapy in the Cardiac Surgical Ward: A Randomized Trial.

PubMed

Olper, Luigi; Bignami, Elena; Di Prima, Ambra L; Albini, Santina; Nascimbene, Simona; Cabrini, Luca; Landoni, Giovanni; Alfieri, Ottavio

2017-02-01

Noninvasive ventilation (NIV) is a common technique to manage patients with acute respiratory failure in the intensive care unit. However, use of NIV in general wards is less well described. The authors' aim was to demonstrate efficacy of NIV, applied in a cardiac surgery ward, in improving oxygenation in patients who developed hypoxemic acute respiratory failure after being discharged from the intensive care unit. Randomized, open-label trial. University hospital. Sixty-four patients with hypoxemia (PaO 2 /F I O 2 ratio between 100 and 250) admitted to the main ward after cardiac surgery. Patients were randomized to receive standard treatment (oxygen, early mobilization, a program of breathing exercises and diuretics) or continuous positive airway pressure in addition to standard treatment. Continuous positive airway pressure was administered 3 times a day for 2 consecutive days. Every cycle lasted 1 to 3 hours. All patients completed their 1-year follow-up. Data were analyzed according to the intention-to-treat principle. The primary endpoint was the number of patients with PaO 2 /F I O 2 <200 48 hours after randomization. Continuous positive airway pressure use was associated with a statistically significant reduction in the number of patients with PaO 2 /F I O 2 <200 (4/33 [12%] v 14/31 [45%], p = 0.003). One patient in the control group died at the 30-day follow-up. Among patients with acute respiratory failure following cardiac surgery, administration of continuous positive airway pressure in the main ward was associated with improved respiratory outcome. This was the first study that was performed in the main ward of post-surgical patients with acute respiratory failure. Copyright © 2017 Elsevier Inc. All rights reserved.

Sustained relief of pain from osteosynthesis surgery of rib fracture by using biodegradable lidocaine-eluting nanofibrous membranes.

PubMed

Yu, Yi-Hsun; Hsu, Yung-Heng; Chou, Ying-Chao; Fan, Chin-Lung; Ueng, Steve W N; Kau, Yi-Chuan; Liu, Shih-Jung

2016-10-01

Various effective methods are available for perioperative pain control in osteosynthesis surgery, but they are seldom applied intraoperatively. The aim of this study was to evaluate a biodegradable poly([d,l]-lactide-co-glycolide) (PLGA)/lidocaine nanofibrous membrane for perioperative pain control in rib fracture surgery. Scanning electron microscopy showed high porosity of the membrane, and an ex vivo high-performance liquid chromatography study revealed an excellent release profile for both burst and controlled release of lidocaine within 30days. Additionally, the PLGA/lidocaine nanofibrous membrane was applied in an experimental rabbit rib osteotomy model. Implantation of the membrane around the osteotomized rib during osteosynthesis surgery resulted in a significant increase in weight gain, food and water consumption, and daily activity compared to the study group without the membrane. In addition, all osteotomized ribs were united. Thus, application of the PLGA/lidocaine nanofibrous membrane may be effective for sustained relief of pain in oeteosynthesis surgery. Copyright © 2016 Elsevier Inc. All rights reserved.

Ambulatory surgery in orthopedics: experience of over 10,000 patients.

PubMed

Martín-Ferrero, M A; Faour-Martín, O; Simon-Perez, C; Pérez-Herrero, M; de Pedro-Moro, J A

2014-03-01

The concept of day surgery is becoming an increasingly important part of elective surgery worldwide. Relentless pressure to cut costs may constrain clinical judgment regarding the most appropriate location for a patient's surgical care. The aim of this study was to determine clinical and quality indicators relating to our experience in orthopedic day durgery, mainly in relation to unplanned overnight admission and readmission rates. Additionally, we focused on describing the main characteristics of the patients that experienced complications, and compared the patient satisfaction rates following ambulatory and non-ambulatory procedures. We evaluated 10,032 patients who underwent surgical orthopedic procedures according to the protocols of our Ambulatory Surgery Unit. All complications that occurred were noted. A quality-of-life assessment (SF-36 test) was carried out both pre- and postoperatively. Ambulatory substitution rates and quality indicators for orthopedic procedures were also determined. The major complication rate was minimal, with no mortal cases, and there was a high rate of ambulatory substitution for the procedures studied. Outcomes of the SF-36 questionnaire showed significant improvement postoperatively. An unplanned overnight admission rate of 0.14 % was achieved. Our institution has shown that it is possible to provide good-quality ambulatory orthopedic surgery. There still appears to be the potential to increase the proportion of these procedures. Surgeons and anesthesiologists must strongly adhere to strict patient selection criteria for ambulatory orthopedic surgery in order to reduce complications in the immediate postoperative term.

A randomized controlled trial of levosimendan to reduce mortality in high-risk cardiac surgery patients (CHEETAH): Rationale and design.

PubMed

Zangrillo, Alberto; Alvaro, Gabriele; Pisano, Antonio; Guarracino, Fabio; Lobreglio, Rosetta; Bradic, Nikola; Lembo, Rosalba; Gianni, Stefano; Calabrò, Maria Grazia; Likhvantsev, Valery; Grigoryev, Evgeny; Buscaglia, Giuseppe; Pala, Giovanni; Auci, Elisabetta; Amantea, Bruno; Monaco, Fabrizio; De Vuono, Giovanni; Corcione, Antonio; Galdieri, Nicola; Cariello, Claudia; Bove, Tiziana; Fominskiy, Evgeny; Auriemma, Stefano; Baiocchi, Massimo; Bianchi, Alessandro; Frontini, Mario; Paternoster, Gianluca; Sangalli, Fabio; Wang, Chew-Yin; Zucchetti, Maria Chiara; Biondi-Zoccai, Giuseppe; Gemma, Marco; Lipinski, Michael J; Lomivorotov, Vladimir V; Landoni, Giovanni

2016-07-01

Patients undergoing cardiac surgery are at risk of perioperative low cardiac output syndrome due to postoperative myocardial dysfunction. Myocardial dysfunction in patients undergoing cardiac surgery is a potential indication for the use of levosimendan, a calcium sensitizer with 3 beneficial cardiovascular effects (inotropic, vasodilatory, and anti-inflammatory), which appears effective in improving clinically relevant outcomes. Double-blind, placebo-controlled, multicenter randomized trial. Tertiary care hospitals. Cardiac surgery patients (n = 1,000) with postoperative myocardial dysfunction (defined as patients with intraaortic balloon pump and/or high-dose standard inotropic support) will be randomized to receive a continuous infusion of either levosimendan (0.05-0.2 μg/[kg min]) or placebo for 24-48 hours. The primary end point will be 30-day mortality. Secondary end points will be mortality at 1 year, time on mechanical ventilation, acute kidney injury, decision to stop the study drug due to adverse events or to start open-label levosimendan, and length of intensive care unit and hospital stay. We will test the hypothesis that levosimendan reduces 30-day mortality in cardiac surgery patients with postoperative myocardial dysfunction. This trial is planned to determine whether levosimendan could improve survival in patients with postoperative low cardiac output syndrome. The results of this double-blind, placebo-controlled randomized trial may provide important insights into the management of low cardiac output in cardiac surgery. Copyright © 2016 Elsevier Inc. All rights reserved.

Mortality and need of surgical treatment in acute upper gastrointestinal bleeding: a one year study in a tertiary center with a 24 hours / day-7 days / week endoscopy call. Has anything changed?

PubMed

Botianu, Am; Matei, D; Tantau, M; Acalovschi, M

2013-01-01

Acute upper gastrointestinal bleeding, previously often a surgical problem, is now the most common gastroenterological emergency. To evaluate the current situation in terms of mortality and need of surgery. Retrospective non-randomised clinical study performed between 1st January-31st December 2011, at "Professor Dr. Octavian Fodor" Regional Institute of Gastroenterology and Hepatology in Cluj Napoca. 757 patients with upper gastrointestinal bleeding were endoscopically examined within 24 hours from presentation in the emergency unit. Data were collected from admission charts and Hospital Manager programme. Statistical analysis was performed with GraphPad 2004, using the following tests: chi square, Spearman, Kruskall-Wallis, Mann-Whitney, area under receiver operating curve. Non-variceal etiology was predominant, the main cause was bleeding being peptic ulcer. In hospital global mortality was of 10.43%, global rebleeding rate was 12.02%, surgery was performed in 7.66% of patients. Urgent haemostatic surgery was needed in 3.68% of patients with nonvariceal bleeding. The need for surgery correlated with the postendoscopic Rockall score (p=0.0425). In peptic ulcer, the need for surgery was not influenced by time to endoscopy or type of treatment (p=0.1452). Weekend (p=0.996) or night (p=0.5414) admission were not correlated with a higher need for surgery. Over the last decade, the need for urgent surgery in upper gastrointestinal bleeding has decreased by half, but mortality has remained unchanged. Celsius.

Relative influence on total cancelled operating room time from patients who are inpatients or outpatients preoperatively.

PubMed

Dexter, Franklin; Maxbauer, Tina; Stout, Carole; Archbold, Laura; Epstein, Richard H

2014-05-01

In previous studies, hospitals' operating room (OR) schedules were influenced markedly by decisions made within a few days of surgery. At least half of ORs had their last case scheduled or changed within 2 working days of surgery. In the current investigation, we studied whether many of these changes were due to patients who were admitted before surgery. We differentiated these "inpatients" from "outpatients" having ambulatory surgery or admitted on the day of surgery. From 21 facilities of a nonacademic health system throughout the United States, N = 5 eight-week periods of cancellation data were obtained. From an academic hospital, N = 8 thirteen-week periods of cancellation data were obtained, including detailed audit data with timestamps of the entire scheduling/rescheduling/cancellation history for each case. (1) In the non-academic health system, outpatients accounted for 1.6% ± 0.1% (SEM) of the scheduled minutes that were cancelled, whereas inpatients accounted for 8.1% ± 0.4%. Consequently, even though inpatients represented much less than half the total scheduled minutes of surgery (16.2% ± 0.5%, P < 0.0001), they accounted for approximately half of the total cancelled minutes (overall P = 0.55, 49% ± 2%; hospitals only P = 0.062, 57% ± 3%). (2) In the nonacademic health system, each 10% increase in a facility's percentage of outpatients making a physical visit to a preoperative clinic (versus only a preoperative phone call) was associated with a 0.0% ± 0.1% absolute decrease in cancelled minutes (P = 0.58). (3) In the academic hospital, inpatients accounted for 22.3% ± 0.4% of the scheduled minutes but most of the total cancelled minutes (70% ± 2%, P < 0.0001). Slightly more than half the total inpatient cancelled minutes (54% ± 1%, P = 0.006) were due to cases scheduled within 1 workday prior to the day of surgery (e.g., Friday for Monday, Monday for Tuesday). During this period, inpatient cancellation rates, measured in minutes, were several-fold larger than outpatient rates (P < 0.0001). Facilities can achieve a ≤2% cancellation rate for patients who are outpatient preoperatively with very few attending a preoperative clinic, when a virtual evaluation is carried out by phone. At least half of the cancelled time at health systems and hospitals is attributable to inpatients, and these patients principally are scheduled within 1 workday of the day of surgery. This is why there are so many changes to the OR schedule within 1 workday before the day of surgery. Hospitals should evaluate the cost-effectiveness of earlier assessments of inpatients. In addition, scheduling office decision-making within 1 workday before surgery should be based on statistical forecasts that include the risks of cancellation and of inpatient add-on cases being scheduled. Hospitals should monitor the performance of their perioperative managers with respect to such behavior.

Robot-assisted surgery: the future is here.

PubMed

Gerhardus, Diana

2003-01-01

According to L. Wiley Nifong, director of robotic surgery at East Carolina University's Brody School of Medicine, "Nationally, only one-fourth of the 15 million surgeries performed each year are done with small incisions or what doctors call 'minimally invasive surgery'." Robots could raise that number substantially (Stark 2002). Currently, healthcare organizations use robot technology for thoracic, abdominal, pelvic, and neurological surgical procedures. Minimally invasive surgery reduces the amount of inpatient hospital days, and the computer in the system filters any hand tremors a physician may have during the surgery. The use of robot-assisted surgery improves quality of care because the patient experiences less pain after the surgery. Robot-assisted surgery demonstrates definite advantages for the patient, physician, and hospital; however, healthcare organizations in the United States have yet to acquire the technology because of implementation costs and the lack of FDA (Food and Drug Administration) approval for using the technology for certain types of heart procedures. This article focuses on robot-assisted surgery advantages to patients, physicians, and hospitals as well as on the disadvantages to physicians. In addition, the article addresses implementation costs, which creates financial hurdles for most healthcare organizations; offers recommendations for administrators to embrace this technology for strategic positioning; and enumerates possible roles for robots in medicine.

Inspiratory Muscle Training and Functional Capacity in Patients Undergoing Cardiac Surgery.

PubMed

Cordeiro, André Luiz Lisboa; de Melo, Thiago Araújo; Neves, Daniela; Luna, Julianne; Esquivel, Mateus Souza; Guimarães, André Raimundo França; Borges, Daniel Lago; Petto, Jefferson

2016-04-01

Cardiac surgery is a highly complex procedure which generates worsening of lung function and decreased inspiratory muscle strength. The inspiratory muscle training becomes effective for muscle strengthening and can improve functional capacity. To investigate the effect of inspiratory muscle training on functional capacity submaximal and inspiratory muscle strength in patients undergoing cardiac surgery. This is a clinical randomized controlled trial with patients undergoing cardiac surgery at Instituto Nobre de Cardiologia. Patients were divided into two groups: control group and training. Preoperatively, were assessed the maximum inspiratory pressure and the distance covered in a 6-minute walk test. From the third postoperative day, the control group was managed according to the routine of the unit while the training group underwent daily protocol of respiratory muscle training until the day of discharge. 50 patients, 27 (54%) males were included, with a mean age of 56.7±13.9 years. After the analysis, the training group had significant increase in maximum inspiratory pressure (69.5±14.9 vs. 83.1±19.1 cmH2O, P=0.0073) and 6-minute walk test (422.4±102.8 vs. 502.4±112.8 m, P=0.0031). We conclude that inspiratory muscle training was effective in improving functional capacity submaximal and inspiratory muscle strength in this sample of patients undergoing cardiac surgery.

A comparison of efficacy of endovascular versus surgical repair for the treatment of arteriovenous fistula stenosis in Taiwan.

PubMed

Fan, Szu-Shan; Chen, Chien-Wen; Lu, Kuo-Cheng; Mao, Hung-Chung; Chen, Miao-Pei; Chou, Chu-Lin

2017-05-15

Percutaneous transluminal angioplasty (PTA) and fistula reconstruction surgery are therapeutic options for vascular access occlusion in hemodialysis patients. However, owing to its convenience, PTA has gradually become the preferred therapeutic option for fistula stenosis or occlusion. This study investigated the effects of the two therapeutic methods on the vascular access maintenance duration (number of days) and maintenance costs of fistula in dialysis patients from different dialysis units. In this study, 544 hemodialysis patients from 2 dialysis units in a teaching hospital in the southern area of Taiwan were included in the analysis of the frequency of PTA or revascularization surgery and the use of related medical resources by conducting a retrospective chart review. The frequency of PTA in the patients undergoing long-term hemodialysis was not significantly associated with their demographic characteristics. The efficacy of PTA has declined with shorter maintenance duration with increasing PTA frequency. The cost profile of PTA was more expensive than that of fistula revascularization surgery. In this study, PTA was found to be just a temporary solution for fistula thrombosis, whereas fistula reconstruction surgery is inexpensive and improves survival time. Therefore, dialysis units should establish an appropriate standard of care to avoid over-reliance on PTA in order to reduce the fistula failure rate, improve the dialysis efficacy, and reduce the psychological stress in patients, as well as to reduce the maintenance costs and rationalize the medical expenses.

A comparison between minimized extracorporeal circuits and conventional extracorporeal circuits in patients undergoing aortic valve surgery: is 'minimally invasive extracorporeal circulation' just low prime or closed loop perfusion ?

PubMed

Starinieri, Pascal; Declercq, Peter E; Robic, Boris; Yilmaz, Alaaddin; Van Tornout, Michiel; Dubois, Jasperina; Mees, Urbain; Hendrikx, Marc

2017-07-01

Even though results have been encouraging, an unequivocal conclusion on the beneficial effect of minimally invasive extracorporeal circulation (MiECC) in patients undergoing aortic valve surgery cannot be derived from previous publications. Long-term outcomes are rarely reported and a significant decrease in operative mortality has not been shown. Most studies have a limited number of patients and are underpowered. They merely report on short-term results of a heterogeneous intraoperative group using different types of ECC system in aortic valve surgery. The aim of the present study was to determine whether MiECC systems are more beneficial than conventional extracorporeal systems (CECC) with regard to mortality, hospital stay and inflammation and with only haemodilution and blood-air interface as differences. We retrospectively analysed data regarding mortality, hospital stay and inflammation in patients undergoing isolated aortic valve surgery. Forty patients were divided into two groups based on the type of extracorporeal system used; conventional (n=20) or MiECC (n=20). Perioperative blood product requirements were significantly lower in the MiECC group (MiECC: 0.2±0.5 units vs CECC: 0.9±1.2 units, p=0.004). No differences were seen postoperatively regarding mortality (5% vs 5%, p=0.99), total length of hospital stay (10.6±7.2 days (MiECC) vs 12.1±5.9 days (CECC), p=0.39) or inflammation markers (CRP: MiECC: 7.09±13.62 mg/L vs CECC: 3.4±3.2 mg/L, p=0.89). MiECC provides circulatory support that is equally safe and feasible as conventional extracorporeal circuits. No differences in mortality, hospital stay or inflammation markers were observed.

Management of open tibial fractures – a regional experience

PubMed Central

Townley, WA; Nguyen, DQA; Rooker, JC; Dickson, JK; Goroszeniuk, DZ; Khan, MS; Camp, D

2010-01-01

INTRODUCTION The treatment of soft-tissue injuries associated with tibial diaphyseal fractures presents a clinical challenge that is best managed by a combined plastic and orthopaedic surgery approach. The current study was undertaken to assess early treatment outcomes and burden of service provision across five regional plastic surgery units in the South-West of England. SUBJECTS AND METHODS We conducted a prospective 6-month audit of open tibial diaphyseal fracture management in five plastic surgery units (Bristol, Exeter, Plymouth, Salisbury, Swansea) with a collective catchment of 9.2 million people. Detailed data were collected on patient demographics, injury pattern, surgical management and outcome followed to discharge. RESULTS The study group consisted of 55 patients (40 male, 15 female). Twenty-two patients presented directly to the emergency department at the specialist hospital (primary group), 33 patients were initially managed at a local hospital (tertiary group). The mean time from injury to soft tissue cover was significantly less (P < 0.001) in the primary group (3.6 ± 0.8 days) than the tertiary group (10.8 ± 2.2 days), principally due to a delay in referral in the latter group (5.4 ±1.7 days). Cover was achieved with 39 flaps (19 free, 20 local), eight split skin grafts. Nine wounds closed directly or by secondary intention. There were 11 early complications (20%) including one flap failure and four infections. The overall mean length of stay was 17.5 ± 2.8 days. CONCLUSIONS Multidisciplinary management of severe open tibial diaphyseal may not be feasible at presentation of injury depending on local hospital specialist services available. Our results highlight the need for robust assessment, triage and senior orthopaedic review in the early post-injury phase. However, broader improvements in the management of lower limb trauma will additionally require further development of combined specialist trauma centres. PMID:21047449

EARLY POSTOPERATIVE COMPLICATIONS IN ROUX-EN-Y GASTRIC BYPASS

PubMed Central

STOLL, Aluisio; ROSIN, Leandro; DIAS, Mariana Fernandes; MARQUIOTTI, Bruna; GUGELMIN, Giovana; STOLL, Gabriela Fanezzi

2016-01-01

ABSTRACT Background: Roux-en-Y gastric bypass is one of the most common bariatric surgery and leads to considerable weight loss in the first months. Aim: To quantify the main early postoperative complications in patients submitted to the gastric bypass. Method: Observational retrospective cohort. Data of 1051 patients with class II obesity associated with comorbidities or class III obesity submitted to the gastric bypass with 30 days of follow-up starting from the date of the surgery. Results: The age average was 36 years with a predominance of females (81.1%). The mean preoperative body mass index was 43 kg/m². The major complication was fistula (2.3%), followed by intestinal obstruction (0.5%) and pulmonary embolism (0.5%). Death occurred in 0.6% of the cases. Conclusion: In the period of 30 days after surgery the overall complication rate was 3.8%; reoperation was necessary in 2.6% and death occurred in 0.6%. Fistula was the main complication and the leading cause of hospitalization in intensive care unit, reoperation and death. PMID:27683781

Ninety-day Postoperative Mortality Is a Legitimate Measure of Hepatopancreatobiliary Surgical Quality.

PubMed

Mise, Yoshihiro; Vauthey, Jean-Nicolas; Zimmitti, Giuseppe; Parker, Nathan H; Conrad, Claudius; Aloia, Thomas A; Lee, Jeffrey E; Fleming, Jason B; Katz, Matthew Harold G

2015-12-01

To investigate the legitimacy of 90-day mortality as a measure of hepatopancreatobiliary quality. The 90-day mortality rate has been increasingly but not universally reported after hepatopancreatobiliary surgery. The legitimacy of this definition as a measure of surgical quality has not been evaluated. We retrospectively reviewed the causes of all deaths that occurred within 365 postoperative days in patients undergoing hepatectomy (n = 2811) and/or pancreatectomy (n = 1092) from January 1997 to December 2012. The rates of surgery-related, disease-related, and overall mortality within 30 days, within 30 days or during the index hospitalization, within 90 days, and within 180 days after surgery were calculated. Seventy-nine (3%) surgery-related deaths and 92 (3%) disease-related deaths occurred within 365 days after hepatectomy. Twenty (2%) surgery-related deaths and 112 (10%) disease-related deaths occurred within 365 days after pancreatectomy. The overall mortality rates at 99 and 118 days optimally reflected surgery-related mortality after hepatobiliary and pancreatic operations, respectively. The 90-day overall mortality rate was a less sensitive but equivalently specific measure of surgery-related death. The 99- and 118-day definitions of postoperative mortality optimally reflected surgery-related mortality after hepatobiliary and pancreatic operations, respectively. However, among commonly reported metrics, the 90-day overall mortality rate represents a legitimate measure of surgical quality.

Incentive spirometry decreases respiratory complications following major abdominal surgery.

PubMed

Westwood, K; Griffin, M; Roberts, K; Williams, M; Yoong, K; Digger, T

2007-12-01

Pulmonary complications are the leading cause of morbidity and mortality following major abdominal surgery. Chest physiotherapy aims to decrease the likelihood of these complications and hasten recovery. Exercises aimed at maximising inspiratory effort are the most beneficial for the patients. The incentive spirometer is a handheld device that patients use to achieve effective inspiration. In a nonrandomised pilot study of 263 patients we have found that the addition of the incentive spirometer, as part of an intensive post-operative physiotherapy programme, decreased the occurrence of pulmonary complications (6 vs 17%, p = 0.01) and length of stay on the surgical high dependency unit (3.1 vs 4 days p = 0.03). The two groups were comparable when age, sex, smoking history, the need for emergency surgery and post-operative analgesia were compared.

General paediatric surgery for patients aged under 5 years: a 5-year experience at a district general hospital.

PubMed

Kwok, C-S; Gordon, A C

2016-09-01

Introduction The gradual shift of general paediatric surgery (GPS) provision from district general hospitals (DGH) to specialised units is well recognised in the UK. The consequences of centralisation include a reduction in exposure to GPS for current surgical trainees. The GPS practice of a DGH is examined here. Methods All operations performed on children aged under 5 years over a 5-year period were identified using the local electronic operation database. Electronic hospital records and clinic letters were accessed to collect data on demographics, operations performed and outcome measures. Results 472 GPS operations were performed on children between the age of 22 days and 5 years between 2009 and 2014, of which 43 were on an emergency basis and 105 were performed on patients aged less than 1 year. Three patients were admitted following day case surgery. Six patients were readmitted within 30 days. Complication rates for all procedures and the four most common procedures were similar to those found in published literature. Conclusions GPS for patients aged less than 5 years is comparatively safe in the DGH setting. The training opportunities available at DGHs are invaluable to surgical trainees and vital for sustaining the future provision of GPS by such hospitals.

Patent ductus arteriosus in preterm infants: benefits of early surgical closure.

PubMed

Fonseca, Elizabeth; Georgiev, Stanimir G; Gorenflo, Matthias; Loukanov, Tsvetomir S

2014-05-01

Patent ductus arteriosus in preterm neonates leads to significant morbidity. Surgery is indicated when pharmacological treatment fails or is contraindicated, but the optimal timing remains unclear. We retrospectively studied all 41 preterm neonates with symptomatic ductus arteriosus who underwent ligation between 1988 and 2009. We compared early complications rates and late neurological outcomes of patients operated on before 21 days of age with these operated on later. The median gestational age at birth was 26 weeks (range 23-31 weeks) and median weight at birth was 930 g (range 510-1500 g); 34 (82.9%) received pharmacological treatment before surgery. Fourteen (34.1%) patients underwent surgical closure before 21 days of age and 27 (65.9%) after 21 days. The 2 groups did not differ significantly in gestational age and weight at birth, but those operated on after 21 days received significantly more pharmacological treatment cycles. Patients in the early closure group had shorter intubation times: median 23 days (range 13-35 days) vs. 43 days (range 27-84 days; p < 0.001) and shorter neonatal intensive care unit stay: median 44 days (range 31-66 days) vs. 76 days (range 41-97 days; p < 0.001), with significantly lower rates of bronchopulmonary dysplasia, intraventricular hemorrhage, and acute renal failure, and significantly better neurological outcomes. Performing early ligation of symptomatic ductus arteriosus after unsuccessful pharmacological therapy in preterm neonates might lower complication rates and improve neurological outcome. Prospective randomized studies are needed to determine the optimal treatment.

The Impact of Patient Safety Training on Oral and Maxillofacial Surgery Residents' Attitudes and Knowledge: A Mixed Method Case Study

ERIC Educational Resources Information Center

Buhrow, Suzanne

2013-01-01

It is estimated that in the United States, more than 40,000 patients are injured each day because of preventable medical errors. Patient safety experts and graduate medical education accreditation leaders recognize that medical education reform must include the integration of safety training focused on error causation, system engineering, and…

Day of surgery urine cultures identify urogynecologic patients at increased risk for postoperative urinary tract infection.

PubMed

Fok, Cynthia S; McKinley, Kathleen; Mueller, Elizabeth R; Kenton, Kimberly; Schreckenberger, Paul; Wolfe, Alan; Brubaker, Linda

2013-05-01

Despite preoperative screening and treatment for urinary tract infections, a postoperative urinary tract infection develops in approximately 1 in 5 urogynecologic patients. In this study we assess the proportion of urogynecologic patients with a positive day of surgery urine culture, the clinical consequences of a positive day of surgery culture and differences in postoperative urinary tract infection risks based on day of surgery culture. After institutional review board approval, patients undergoing urogynecologic surgery at Loyola University Medical Center were recruited for the study. Catheterized urine samples were collected in the operating room before intravenous antibiotic administration. Clinical cultures were considered positive if 1,000 colonies per ml or more bacteria were found on routine culture. For analysis we matched each woman with a positive culture with 2 women with negative culture by age within 10 years and within surgical groups (ie prolapse and/or incontinence). Data were analyzed using SPSS® version 19. Nearly a tenth (9.5%) of participants had positive day of surgery cultures. The clinical and demographic characteristics were similar in women with negative vs positive day of surgery cultures. However, women with positive day of surgery cultures were more likely to experience a postoperative urinary tract infection despite standard perioperative antibiotic administration (29.6% vs 5.6%, p = 0.005, odds ratio 7.2). Regardless of day of surgery culture status no participant experienced postoperative systemic urinary complications. Nearly a tenth of urogynecologic patients had positive day of surgery cultures. Patients with a positive day of surgery culture had an increased risk (29.6%) of postoperative urinary tract infection within 6 weeks of surgery. These findings highlight an opportunity to identify and treat patients with positive day of surgery cultures and reduce the incidence of postoperative urinary tract infections. Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

A Prospective Multicenter Evaluation of the Value of the On-Call Orthopedic Resident.

PubMed

Jackson, J Benjamin; Vincent, Scott; Davies, James; Phelps, Kevin; Cornett, Chris; Grabowski, Greg; Scannell, Brian; Stotts, Alan; Bice, Miranda

2018-02-01

Funding for graduate medical education is at risk despite the services provided by residents. We quantified the potential monetary value of services provided by on-call orthopedic surgery residents. We conducted a prospective, cross-sectional, multicenter cohort study design. Over a 90-day period in 2014, we collected data on consults by on-call orthopedic surgery residents at 4 tertiary academic medical centers in the United States. All inpatient and emergency department consults evaluated by first-call residents during the study period were eligible for inclusion. Based on their current procedural terminology codes, procedures and evaluations for each consult were assigned a relative value unit and converted into a monetary value to determine the value of services provided by residents. The primary outcome measures were the total dollar value of each consult and the percentage of resident salaries that could be funded by the generated value of the resident consult services. In total, 2644 consults seen by 33 residents from the 4 institutions were included for analysis. These yielded an average value of $81,868 per center for the 90-day study period, that is, $327,471 annually. With a median resident stipend of $53,992, the extrapolated average percentage of resident stipends that could be funded by these consult revenues was 73% of the stipends of the residents who took call or 36% of the stipends of the overall resident cohort. The potential monetary value generated by on-call orthopedic surgery residents is substantial.

Implementation Costs of an Enhanced Recovery After Surgery Program in the United States: A Financial Model and Sensitivity Analysis Based on Experiences at a Quaternary Academic Medical Center.

PubMed

Stone, Alexander B; Grant, Michael C; Pio Roda, Claro; Hobson, Deborah; Pawlik, Timothy; Wu, Christopher L; Wick, Elizabeth C

2016-03-01

Despite positive results from several international Enhanced Recovery After Surgery (ERAS) protocols, the United States has been slow to adopt ERAS protocols, in part due to concern regarding the expenses of such a program. We sought to evaluate the potential annual net cost savings of implementing a US-based ERAS program. Using data from existing publications and experience with an ERAS program, a model of net financial costs was developed for surgical groups of escalating numbers of annual cases. Our example scenario provided a financial analysis of the implementation of an ERAS program at a United States academic institution based on data from the ERAS Program for Colorectal Surgery at The Johns Hopkins Hospital. Based on available data from the United States, ERAS programs lead to reductions in lengths of hospital stay that range from 0.7 to 2.7 days and substantial direct cost savings. Using example data from a quaternary hospital, the considerable cost of $552,783 associated with implementation of an ERAS program was offset by even greater savings in the first year of nearly $948,500, yielding a net savings of $395,717. Sensitivity analysis across several caseload and direct cost scenarios yielded similar savings in 20 of the 27 projections. Enhanced Recovery After Surgery protocols have repeatedly led to reduction in length of hospital stay and improved surgical outcomes. A financial model, based on published data and experience, projects that investment in an ERAS program can also lead to net financial savings for US hospitals. Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Vocal Cord Paralysis After Thoracic Aortic Surgery: Incidence and Impact on Clinical Outcomes.

PubMed

Lodewyks, Carly L; White, Christopher W; Bay, Graham; Hiebert, Brett; Wu, Bella; Barker, Mark; Kirkpatrick, Iain; Arora, Rakesh C; Moon, Michael; Pascoe, Edward

2015-07-01

Vocal cord paralysis (VCP) is a serious complication associated with thoracic aortic surgery; however, there is a paucity of literature regarding the incidence and impact of VCP on postoperative outcomes. We sought to determine the incidence of VCP and its impact on clinical outcomes in patients who underwent thoracic aortic repair at our center. A retrospective chart review was conducted on all patients who underwent thoracic aortic surgery between January 2009 and September 2012. A total of 259 patients underwent a thoracic aortic procedure during the study period. Vocal cord paralysis was diagnosed in 12 (5%) patients, a median of 6 [3 to 21] days after extubation. The incidence was 1%, 0%, 20%, and 25% in those undergoing an open ascending, hemiarch, total arch, or descending aortic procedure, respectively. Patients with VCP had an increased incidence of pneumonia (58% vs 17%, p = 0.003), readmission to the intensive care unit for respiratory failure (17% vs 2%, p = 0.047), and longer hospital length of stay (18 [11 to 43] days versus 9 [6 to 15] days, p = 0.002). A propensity-matched analysis confirmed a higher incidence of pneumonia (58% vs 17%, p = 0.020) and longer hospital length of stay (18 [11 to 43] vs 10 [7 to 14] days, p = 0.015) in patients suffering VCP. Vocal cord paralysis is a common complication in patients undergoing open surgery of the aortic arch and descending aorta, and is associated with significant morbidity. Further research may be warranted to determine if early fiberoptic examination and consideration of a vocal cord medialization procedure may mitigate the morbidity associated with VCP. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Down syndrome and postoperative complications after paediatric cardiac surgery: a propensity-matched analysis.

PubMed

Tóth, Roland; Szántó, Péter; Prodán, Zsolt; Lex, Daniel J; Sápi, Erzsébet; Szatmári, András; Gál, János; Szántó, Tamás; Székely, Andrea

2013-10-01

The incidence of congenital heart disease is ~50%, mostly related to endocardial cushion defects. The aim of our study was to investigate the postoperative complications that occur after paediatric cardiac surgery. Our perioperative data were analysed in paediatric patients with Down syndrome undergoing cardiac surgery. We retrospectively analysed the data from 2063 consecutive paediatric patients between January 2003 and December 2008. After excluding the patients who died or had missing data, the analysed database (before propensity matching) contained 129 Down patients and 1667 non-Down patients. After propensity matching, the study population comprised 222 patients and 111 patients had Down syndrome. Before propensity matching, the occurrences of low output syndrome (21.2 vs 32.6%, P = 0.003), pulmonary complication (14 vs 28.7%, P < 0.001) and severe infection (11.9 vs 22.5%, P = 0.001) were higher in the Down group. Down patients were more likely to have prolonged mechanical ventilation [median (interquartile range) 22 (9-72) h vs 49 (24-117) h, P = 0.007]. The total intensive care unit length of stay [6.9 (4.2-12.4) days vs 8.3 (5.3-13.2) days, P = 0.04] and the total hospital length of stay [17.3 (13.3-23.2) days vs 18.3 (15.1-23.6) days, P = 0.05] of the Down patients were also longer. Mortality was similar in the two groups before (3.58 vs 3.88%, P = 0.86) and after (5.4 vs 4.5%, P = 1.00) propensity matching. After propensity matching, there was no difference in the occurrence of adverse events. After propensity matching Down syndrome was not associated with increased mortality or complication rate following congenital cardiac surgery.

Burden of blood transfusion in knee and hip surgery in the US and Belgium.

PubMed

Blanchette, Christopher M; Joshi, Ashish V; Szpalski, Marek; Gunzburg, Robert; Du Bois, Mark; Donceel, Peter; Saunders, William B

2009-09-01

Transfusion services in orthopaedic surgery can lead to unnecessary complications and increased healthcare costs. The objective of this study was to assess treatments and costs associated with blood and blood product transfusions in a historical cohort of 189,457 inpatients in the US and 34,987 inpatients in Belgium undergoing knee or hip surgery. Descriptive analysis, logistic regression and ordinary least squares regression were used to describe the factors associated with the use and cost of allogeneic blood transfusion. Hospitalisation costs for joint replacement surgery totalled $12,718 (SD=6,356) and averaged 4.33 days in the US, while costs in Belgium were $6,526 (SD=3,192) and averaged 17.1 days. The use of low molecular weight heparin and tranexamic acid was much higher in Belgium than the US (36% and 99% compared to 0% and 40%, respectively). Patients in the US spent 12.7 (p<0.0001) fewer days in the hospital, 0.3 (p<0.0001) fewer days in the intensive care unit and were 88% less likely to have allogeneic blood transfusions (OR=0.22, 95% CI 0.22-0.23), but incurred $6,483 (p<0.0001) more costs per hospitalisation than patients in Belgium. While hospital costs for patients were greater in the US, length of stay was shorter and patients were less likely to have transfusion services than those patients in Belgium. While this study is limited by factors inherent to observational studies, such as omitted variable bias, misclassification, and disease comorbidity, there are substantial differences in the use of blood products between Belgium and the US.

Definitive surgical closure of enterocutaneous fistula: outcome and factors predictive of increased postoperative morbidity.

PubMed

Ravindran, P; Ansari, N; Young, C J; Solomon, M J

2014-03-01

Enterocutaneous fistula (ECF) presents a complex management problem with significant mortality and morbidity. The aim of this study was to assess the outcome of patients undergoing surgical cure for ECF and to predict factors that might relate to increased postoperative morbidity. Medical records of all patients who underwent definitive surgery for cure of an ECF within our colorectal surgery unit between 2000 and 2010 were reviewed. Forty-one patients (18 male) were identified, in whom 44 definitive procedures were performed. The median age was 54 (17-81) years. The median postoperative length of stay in hospital was 14 (2-213) days. Half (50%) of the ECFs occurred as a postoperative complication followed by spontaneous fistulation in Crohn's disease (36%). The interval to definitive surgery was influenced by the aetiology of the fistula. The median time to surgery after formation of postoperative fistula was 240 days (7.9 months). There was no 30-day postoperative mortality. There were two (4.5%) recurrences at 3 months. Thirty-eight (86%) patients suffered postoperative morbidity as defined by the Clavien-Dindo classification. High-grade morbidity occurred in 32% of patients. On univariate analysis, factors identified as being significantly associated with high-grade morbidity included a fistula output of > 500 ml/day (P = 0.004) in patients with postoperative ECF, malnutrition at presentation (P = 0.04) and a serum albumin value of < 30 g/l (P = 0.02) in patients with spontaneous ECF due to Crohn's disease. The majority of persistent complex ECFs can be cured surgically with low mortality and recurrence in a multidisciplinary setting. Postoperative morbidity, however, remains a significant burden. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland.

The Aristotle Comprehensive Complexity score predicts mortality and morbidity after congenital heart surgery.

PubMed

Bojan, Mirela; Gerelli, Sébastien; Gioanni, Simone; Pouard, Philippe; Vouhé, Pascal

2011-04-01

The Aristotle Comprehensive Complexity (ACC) score has been proposed for complexity adjustment in the analysis of outcome after congenital heart surgery. The score is the sum of the Aristotle Basic Complexity score, largely used but poorly related to mortality and morbidity, and of the Comprehensive Complexity items accounting for comorbidities and procedure-specific and anatomic variability. This study aims to demonstrate the ability of the ACC score to predict 30-day mortality and morbidity assessed by the length of the intensive care unit (ICU) stay. We retrospectively enrolled patients undergoing congenital heart surgery in our institution. We modeled the ACC score as a continuous variable, mortality as a binary variable, and length of ICU stay as a censored variable. For each mortality and morbidity model we performed internal validation by bootstrapping and assessed overall performance by R(2), calibration by the calibration slope, and discrimination by the c index. Among all 1,454 patients enrolled, 30-day mortality rate was 3.4% and median length of ICU stay was 3 days. The ACC score strongly related to mortality, but related to length of ICU stay only during the first postoperative week. For the mortality model, R(2) = 0.24, calibration slope = 0.98, c index = 0.86, and 95% confidence interval was 0.82 to 0.91. For the morbidity model, R(2) = 0.094, calibration slope = 0.94, c index = 0.64, and 95% confidence interval was 0.62 to 0.66. The ACC score predicts 30-day mortality and length of ICU stay during the first postoperative week. The score is an adequate tool for complexity adjustment in the analysis of outcome after congenital heart surgery. Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Fluid Overload is Associated with Late Poor Outcomes in Neonates Following Cardiac Surgery

PubMed Central

Wilder, Nicole S; Yu, Sunkyung; Donohue, Janet E; Goldberg, Caren S; Blatt, Neal B

2016-01-01

Objective Acute kidney injury (AKI) is a severe complication of cardiac surgery associated with increased morbidity and mortality, yet AKI classification for neonates remains challenging. We characterized patterns of post-operative fluid overload (FO) as a surrogate marker for AKI and as a risk factor of poor post-operative outcomes in neonates undergoing cardiac surgery. Design Retrospective cohort study. Setting Single, congenital heart center destination program. Patients 435 neonates undergoing cardiac surgery with cardiopulmonary bypass from January 2006 through December 2010. Interventions None Measurements and Main Results Demographics, diagnosis, and perioperative clinical variables were collected, including daily weights and serum creatinine (SCr) levels. A composite poor clinical outcome (death, need for renal replacement therapy (RRT), or extracorporeal life support (ECLS) within 30 post-operative days) was considered the primary outcome measure. Twenty-one neonates (5%) had a composite poor outcome with 7 (2%) requiring RRT, 8 (2%) requiring ECLS, and 14 (3%) dying between 3 and 30 days post-surgery. Neonates with a composite poor outcome had significantly higher maximum FO (>20%) and were slower to diurese. A receiver-operating characteristic curve determined that FO ≥ 16% and SCr ≥ 0.9 on post-operative day 3 were the optimal cutoffs for significant discrimination on the primary outcome (area under the curve = 0.71 and 0.76, respectively). In multivariable analysis, FO ≥ 16% (adjusted odds ratio [AOR] = 3.7) and SCr ≥ 0.9 (AOR = 6.6) on post-operative day 3 remained an independent risk factor for poor outcome. FO ≥ 16% was also significantly associated with cardiac arrest requiring cardiopulmonary resuscitation, prolonged intensive care unit stay, and chest re-exploration. Conclusions This study highlights the importance of monitoring fluid balance in the neonatal cardiac surgical population, and suggests that daily FO, a readily-available, non-invasive marker of renal function, may be a sensitive and specific predictor of adverse outcomes. PMID:27028790

Same-day breast cancer surgery: a qualitative study of women's lived experiences.

PubMed

Greenslade, M Victoria; Elliott, Barbara; Mandville-Anstey, Sue Ann

2010-03-01

To understand the experiences of women having same-day breast cancer surgery and make recommendations to assist healthcare professionals effect change to enhance quality of care. Thematic analysis of audiotaped interviews. Outpatient departments of two city hospitals on the east coast of Canada. Purposive sample of 13 women who had undergone same-day breast cancer surgery. A constructivist approach with in-depth interviews and comparative analysis to develop and systemically organize data into four major interrelated themes and a connecting essential thread. Women's experiences with same-day breast cancer surgery. The themes of preparation, timing, supports, and community health nursing intervention were of paramount importance for effective coping and recovery. Women who had a positive experience with same-day breast cancer surgery also reported having adequate preparation, appropriate timing of preparation, strong support systems, and sufficient community health nursing intervention. Those reporting a negative experience encountered challenges in one or more of the identified theme areas. Same-day surgery is a sign of the times, and the approach to it is changing. Healthcare systems need to be responsive to such changes. Although same-day surgery for breast cancer is not suitable for every patient, women undergoing this type of surgery should be assessed individually to determine whether it is appropriate for them. Women undergoing breast cancer surgery should be screened for same-day surgery suitability. Those having same-day breast cancer surgery should be prepared adequately with timely education. Most importantly, such women should receive community health nursing follow-up for assessment, continuing education, and psychosocial support.

A Tale of Two Health-Care Systems: Cost-Utility Analysis of Open Carpal Tunnel Release in Canada and the United States

PubMed Central

Kaur, Manraj N.; Tolliver, Tyson; Longo, Christopher J.; Naam, Nash H.; Thoma, Achilles

2017-01-01

Purpose: Canadian health care is often criticized for extended wait times, whereas the United States suffers from increased costs. The purpose of this pilot study was to determine the cost-utility of open carpal tunnel release in Canada versus the United States. Methods: A prospective cohort study evaluated patients undergoing open carpal tunnel release at an institution in Canada and the United States. All costs from a societal perspective were captured. Utility was measured using validated health-related quality of life (HRQOL) scales—the EuroQol-5D and the Michigan Hand Outcome Questionnaire. Results: Twenty-one patients at the Canadian site and 8 patients at the US site participated. Mean total costs were US $1581 ± $1965 and $2179 (range: $1421-$2741) at the Canadian and US sites, respectively. Health-related quality of life demonstrated significant improvements following surgery (P < .05). Patient utilities preoperatively and at 6 weeks and 3 months postoperatively were 0.72 ± 0.20, 0.86 ± 0.11, and 0.83 ± 0.16 at the Canadian site and 0.81 ± 0.09, 0.86 ± 0.10, and 0.86 ± 0.12 at the US site. Improvements in HRQOL directly related to surgery were not significantly different between patients in Canada and the United States. American patients, however, attained improved HRQOL sooner due to shorter wait times (27 ± 10 vs 214 ± 119 days; P < .001). The incremental cost-utility of the US system was $7758/quality-adjusted life year gained compared to the Canadian system. Sensitivity analyses confirmed that these results were robust. Conclusion: This pilot study suggests that carpal tunnel surgery is more cost-effective in the United States due to prolonged wait times in Canada. PMID:29026806

Analysis of Quality Indicators for Colorectal Cancer Surgery in Units Accredited by the Spanish Association of Coloproctology.

PubMed

de la Portilla, Fernando; Builes, Sergio; García-Novoa, Alejandra; Espín, Eloy; Kreisler, Esther; Enríquez-Navascues, José María; Biondo, Sebastiano; Codina, Antonio

2018-04-01

Currently, there is growing interest in analyzing the results from surgical units and the implementation of quality standards in order to identify good healthcare practices. Due to this fact, the Spanish Association of Coloproctology (AECP) has developed a unit accreditation program that contemplates basic standards. The aim of this article is to evaluate and analyze the specific quality indicators for the surgical treatment of colorectal cancer, established by the program. Data were collected from colorectal units during the accreditation process. We analyzed prospectively collected data from elective colorectal surgeries at 18 Spanish coloproctology units during the period 2013-2017. Three main and four secondary quality indicators were considered. Colon and rectal surgeries were analyzed independently; furthermore, results were compared according to surgical approach. A total of 3090 patients were included in the analysis. The global anastomotic leak rate was 7.8% (6.6% colon vs 10.6% rectum), while the surgical site infection rate was 12.6% (11.4% colon vs 14.8% rectum). Overall 30-day mortality was 2.3%, and anastomotic leak-related mortality was 10.2%. There were higher surgical site infection and mortality rates in the patients operated by open approach, however there was no difference in the anastomotic leak rate when compared with minimally invasive approaches. The evaluation of these results has determined optimal quality indices for the units accredited in the treatment of colorectal cancer. Furthermore, it allows us to establish realistic references in our country, thereby providing a better understanding and comparison of outcomes. Copyright © 2018 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.

Predicted shortage of vascular surgeons in the United Kingdom: A matter for debate?

PubMed

Harkin, D W; Beard, J D; Shearman, C P; Wyatt, M G

2016-10-01

Vascular surgery became a new independent surgical specialty in the United Kingdom (UK) in 2013. In this matter for debate we discuss the question, is there a "shortage of vascular surgeons in the United Kingdom?" We used data derived from the "Vascular Surgery United Kingdom Workforce Survey 2014", NHS Employers Electronic Staff Records (ESR), and the National Vascular Registry (NVR) surgeon-level public report to estimate current and predict future workforce requirements. We estimate there are approximately 458 Consultant Vascular Surgeons for the current UK population of 63 million, or 1 per 137,000 population. In several UK Regions there are a large number of relatively small teams (3 or less) of vascular surgeons working in separate NHS Trusts in close geographical proximity. In developed countries, both the number and complexity of vascular surgery procedures (open and endovascular) per capita population is increasing, and concerns have been raised that demand cannot be met without a significant expansion in numbers of vascular surgeons. Additional workforce demand arises from the impact of population growth and changes in surgical work-patterns with respect to gender, working-life-balance and 7-day services. We predict a future shortage of Consultant Vascular Surgeons in the UK and recommend an increase in training numbers and an expansion in the UK Consultant Vascular Surgeon workforce to accommodate population growth, facilitate changes in work-patterns and to create safe sustainable services. Crown Copyright © 2015. Published by Elsevier Ltd. All rights reserved.

Adequacy of Fixed-Dose Heparin Infusions for Venous Thromboembolism Prevention after Microsurgical Procedures.

PubMed

Bertolaccini, Corinne M; Prazak, Ann Marie B; Agarwal, Jayant; Goodwin, Isak A; Rockwell, W Bradford; Pannucci, Christopher J

2018-05-22

 In microvascular surgery, patients often receive unfractionated heparin infusions to minimize risk for microvascular thrombosis. Patients who receive intravenous (IV) heparin are believed to have adequate prophylaxis against venous thromboembolism (VTE). Whether a fixed dose of IV heparin provides detectable levels of anticoagulation, or whether the "one size fits all" approach provides adequate prophylaxis against VTE remains unknown. This study examined the pharmacodynamics of fixed-dose heparin infusions and the effects of real-time, anti-factor Xa (aFXa) level driven heparin dose adjustments.  This prospective clinical trial recruited adult microvascular surgery patients placed on a fixed-dose (500 units/h) unfractionated heparin infusion during their initial microsurgical procedure. Steady-state aFXa levels, a marker of unfractionated heparin efficacy and safety, were monitored. Patients with out-of-range aFXa levels received protocol-driven real-time dose adjustments. Outcomes of interest included aFXa levels in response to heparin 500 units/h, number of dose adjustments required to achieve goal aFXa levels, time to reach goal aFXa level, and 90-day clinically relevant bleeding and VTE.  Twenty patients were recruited prospectively. None of 20 patients had any detectable level of anticoagulation in response to heparin infusions at 500 units/h. The median number of dose adjustments required to reach goal level was five, and median weight-based dose to reach goal level was 11.8 units/kg/h. Real-time dose adjustments significantly increased the proportion of patients with in-range levels (60 vs. 0%, p  = 0.0001). The 90-day VTE rate was 5% and 90-day clinically relevant bleeding rate was 5%.  Fixed-dose heparin infusions at a rate of 500 units/h do not provide a detectable level of anticoagulation after microsurgical procedures and are insufficient for the majority of patients who require VTE prophylaxis. Weight-based heparin infusions at 10 to 12 units/kg/h deserve future study in patients undergoing microsurgical procedures to increase the proportion of patients receiving adequate VTE prophylaxis. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Postsurgical consequences in lower third molar surgical extraction using micromotor and piezosurgery.

PubMed

Mistry, Freddy Kersi; Hegde, Nidarsh Diwakar; Hegde, Mithra Nidarsh

2016-01-01

One of the most critical and crucial steps in surgical extraction is cutting the bone or osteotomy, for which many techniques are used, e.g., chisels and mallet, rotary instruments, and ultrasound bone-cutting instruments. If they are not used judiciously, they can be hazardous. To assess the efficiency of piezosurgery unit over micromotor while performing surgical extraction of lower third molars by assessing the time taken for the surgery and measuring postoperative parameters such as pain, trismus, and swelling. Thirty patients having bilateral impacted third molars with the same difficulty index were selected for the study. One side surgical removal was done using micromotor and other side by piezosurgery with an interval of 15 days. After each surgery, time taken to finish was measured and patients were followed up on postoperative days 1, 3, 5, 7, and 15 for assessing pain, trismus, and swelling. Data obtained were statistically analyzed. The mean time taken for the micromotor group is 37.90 min whereas by the piezosurgery group is 54.63 min, showing a statistically significant difference ( P < 0.001). Furthermore, there is statistically significant difference ( P < 0.001) in the level of pain, trismus, and swelling on postoperative days 1, 3, 5, and 7. Even the intragroup comparison of piezosurgical group for trismus and swelling showed no statistically significant difference on postoperative day 7, indicating faster recovery of trismus and swelling. On postoperative day 15, there was no difference in any parameter in both groups indicating complete symptom-free recovery in both groups. It takes more time to perform surgical extraction of third molars when piezosurgical unit is used. Despite that, it causes less pain postoperatively with faster improvement in trismus and quicker reduction in swelling.

Postsurgical consequences in lower third molar surgical extraction using micromotor and piezosurgery

PubMed Central

Mistry, Freddy Kersi; Hegde, Nidarsh Diwakar; Hegde, Mithra Nidarsh

2016-01-01

Background: One of the most critical and crucial steps in surgical extraction is cutting the bone or osteotomy, for which many techniques are used, e.g., chisels and mallet, rotary instruments, and ultrasound bone-cutting instruments. If they are not used judiciously, they can be hazardous. Objectives: To assess the efficiency of piezosurgery unit over micromotor while performing surgical extraction of lower third molars by assessing the time taken for the surgery and measuring postoperative parameters such as pain, trismus, and swelling. Materials and Methods: Thirty patients having bilateral impacted third molars with the same difficulty index were selected for the study. One side surgical removal was done using micromotor and other side by piezosurgery with an interval of 15 days. After each surgery, time taken to finish was measured and patients were followed up on postoperative days 1, 3, 5, 7, and 15 for assessing pain, trismus, and swelling. Data obtained were statistically analyzed. Results: The mean time taken for the micromotor group is 37.90 min whereas by the piezosurgery group is 54.63 min, showing a statistically significant difference (P < 0.001). Furthermore, there is statistically significant difference (P < 0.001) in the level of pain, trismus, and swelling on postoperative days 1, 3, 5, and 7. Even the intragroup comparison of piezosurgical group for trismus and swelling showed no statistically significant difference on postoperative day 7, indicating faster recovery of trismus and swelling. On postoperative day 15, there was no difference in any parameter in both groups indicating complete symptom-free recovery in both groups. Conclusion: It takes more time to perform surgical extraction of third molars when piezosurgical unit is used. Despite that, it causes less pain postoperatively with faster improvement in trismus and quicker reduction in swelling. PMID:28299267

[Adverse events of anesthesia in pediatric surgery scheduled at Gabriel Toure hospital].

PubMed

Samaké, B; Keita, M; Magalie, I M C; Diallo, G; Diallo, A

2010-01-01

The occurrence of an event planned or unplanned during anesthesia is a concern for staff. This event may jeopardize the success of surgery gesture. Pediatric Surgery therefore has its own specific complications that it requires anesthesia. To evaluate the incidence of adverse events during anesthesia in pediatric surgery scheduled. Descriptive non-randomized study. Descriptive non-randomized study on adverse events related to anesthesia in children over a period of seven months. It took place in the anesthesia and intensive care unit and the pediatric surgery unit of Gabriel Toure hospital in Bamako. It focused on patients aged 0 to 12 years scheduled for surgery under general anesthesia during the study period. Sixty six percent of patients selected was male gender with a sex ratio of 3 in favor of males. The average age was 2 years with extremes of 16 days and 12 years and a standard deviation of 2.93. The old history of premature was found in 36% of patients and 2% of asthmatic. The number of patients experiencing an adverse event is 42 on a total of 107 patients collected either 39.25%. When the children were younger than one year adverse events occurred with 30, 76%. The occurrence of adverse events was more frequent when the child was not intubated with P < 0.05. All adverse events have received support except tachycardia, late revival but all developed positively. This study estimates the incidence of adverse events in anesthesia during pediatric surgery. The overall rate of patients experiencing an adverse event is relatively high. Children age less than or equal to one year are most vulnerable.

Vaginal hysterectomy, an outpatient procedure.

PubMed

Engh, Marie Ellström; Hauso, Wenche

2012-11-01

To report our experience of treating women undergoing vaginal hysterectomy in an outpatient setting and to identify risk factors for hospital admission and women dissatisfied with care. Prospective observational report. department of obstetrics and gynecology, university hospital in Norway. 150 women who underwent vaginal hysterectomy at the outpatient clinic from February 2009 to April 2010. Perioperative data were collected prospectively and case notes were searched for complications. On the first postoperative day all women were contacted by telephone by a nurse. A visual analogue scale (VAS) was used to monitor pain and nausea during the stay at the outpatient clinic and the day after surgery. VAS was also used to specify the women's degree of satisfaction with care the day after surgery. The number of women who could be discharged from the outpatient unit and had a satisfaction score of ≥7 the day after surgery. Of the 150 women, 84% could be discharged after a mean observation period of 276 min (SD ± 80 min). The mean satisfaction score was 9.0, SD ± 1.4, and 92.6% of the women reported ≥7 points in the satisfaction score. No women with serious complications were sent home. Using a multivariable logistic regression model only pain at discharge was found as significant (p= 0.009) for admittance to hospital. Vaginal hysterectomy is a feasible outpatient procedure and the majority of women were satisfied with the care they received. © 2012 The Authors Acta Obstetricia et Gynecologica Scandinavica© 2012 Nordic Federation of Societies of Obstetrics and Gynecology.

Outcome of video-assisted translumbar retroperitoneal necrosectomy and closed lavage for severe necrotizing pancreatitis.

PubMed

Ulagendra Perumal, Srinivasan; Pillai, Sastha Ahanatha; Perumal, Senthilkumar; Sathyanesan, Jeswanth; Palaniappan, Ravichandran

2014-04-01

Surgery for necrotizing pancreatitis is associated with a high rate of morbidity and mortality. We present a series of 26 patients who underwent video-assisted translumbar retroperitoneal necrosectomy and analyse their outcomes. Records of 26 patients who underwent video-assisted translumbar retroperitoneal necrosectomy and closed drainage for infected pancreatitic necrosis between January 2008 and March 2012 were reviewed, retrospectively. Twenty-three out of 26 patients were males, with a mean age of 38.6 (±9.9) years. Alcohol was the aetiology in 18 patients, gall stones in 7, and in 1 it was idiopathic. The mean duration of symptoms before patients were taken up for surgery was 47.2 (±34.8) days. The mean computed tomography severity index was 7.7 (±1.2). All patients had undergone video-assisted retroperitoneal necrosectomy through a limited left lumbar incision. Post-operative lavage was given through drains placed in the retroperitoneum. Three patients required re-exploration. Eleven patients developed complications and there were two mortalities. The median intensive care unit (ICU) stay was 4 days (range 2-14 days). The mean post-operative hospital stay was 22.5 (±6.6) days. Video-assisted translumbar retroperitoneal necrosectomy followed by closed lavage of infected pancreatic necrosis in select cases of infected pancreatic necrosis was associated with a low rate of ICU stay, hospital stay and need for re-entry. © 2013 The Authors. ANZ Journal of Surgery © 2013 Royal Australasian College of Surgeons.

Thoracic duct lesions in thyroid surgery: An update on diagnosis, treatment and prevention based on a cohort study.

PubMed

Polistena, Andrea; Vannucci, Jacopo; Monacelli, Massimo; Lucchini, Roberta; Sanguinetti, Alessandro; Avenia, Stefano; Santoprete, Stefano; Triola, Roberta; Cirocchi, Roberto; Puma, Francesco; Avenia, Nicola

2016-04-01

Thoracic duct fistula at the cervical level is a severe but rare complication following thyroid surgery, particularly associated to lateral dissection of the neck and to mediastinal goiter. we retrospectively analyzed chylous fistulas observed in a cohort of 13.224 patients underwent surgery for thyroid disease since 1986 to 2014, in the Unit of Endocrine Surgery, S. Maria University Hospital, Terni, Italy. We observed 20 cases of chylous fistula. Thirteen patients underwent primary surgery in our institution while the remaining 7 cases had been referred to our Department from other hospitals for an already diagnosed lymphatic leak. Surgical procedures carried out included total thyroidectomy for mediastinal goiter in 4 patients, total thyroidectomy for cancer in 2 patients, unilateral functional lymphadenectomy in 11 patients and bilateral in 3. Intraoperative repair was carried out in 4 cases. Of the remaining 16 cases, 4 of the 6 fistulas with low flow leakage healed in about 30 days of conservative treatment, 2 cases instead required surgical repair. All 10 patients with "high-flow" fistula underwent surgery. Despite surgery was performed later, postoperative course in patients with late surgical repair is similar to what observed in those patients with early surgical repair. Both groups underwent cervical drainage removal in post-operative day 4. Healing of a cervical chylous fistula can be achieved by conservative medical therapy (nutritional and pharmacological) but in case of therapeutic failure with rapid decrease of general condition, the surgical approach is necessary. In our experience, duct ligation after unsuccessful conservative treatment, is the only resolutive treatment. Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.

Homeopathic arnica therapy in patients receiving knee surgery: results of three randomised double-blind trials.

PubMed

Brinkhaus, B; Wilkens, J M; Lüdtke, R; Hunger, J; Witt, C M; Willich, S N

2006-12-01

We investigated the effectiveness of homeopathic Arnica montana on postoperative swelling and pain after arthroscopy (ART), artificial knee joint implantation (AKJ), and cruciate ligament reconstruction (CLR). Three randomised, placebo-controlled, double-blind, sequential clinical trials. Single primary care unit specialised in arthroscopic knee surgery. Patients suffering from a knee disease that necessitated arthroscopic surgery. Prior to surgery, patients were given 1 x 5 globules of the homeopathic dilution 30x (a homeopathic dilution of 1:10(30)) of arnica or placebo. Following surgery, 3 x 5 globules were administered daily. The primary outcome parameter was difference in knee circumference, defined as the ratio of circumference on day 1 (ART) or day 2 (CLR and AKJ) after surgery to baseline circumference. A total of 227 patients were enrolled in the ART (33% female, mean age 43.2 years;), 35 in the AKJ (71% female, 67.0 years), and 57 in the CLR trial (26% female; 33.4 years). The percentage of change in knee circumference was similar between the treatment groups for ART (group difference Delta=-0.25%, 95% CI: -0.85 to 0.41, p=0.204) and AKJ (Delta=-1.68%, -4.24 to 0.77, p=0.184) and showed homeopathic arnica to have a beneficial effect compared to placebo in CLR (Delta=-1.80%, -3.30 to -0.30, p=0.019). In all three trials, patients receiving homeopathic arnica showed a trend towards less postoperative swelling compared to patients receiving placebo. However, a significant difference in favour of homeopathic arnica was only found in the CLR trial.

Preoperative and intraoperative predictors of cardiac adverse events after general, vascular, and urological surgery.

PubMed

Kheterpal, Sachin; O'Reilly, Michael; Englesbe, Michael J; Rosenberg, Andrew L; Shanks, Amy M; Zhang, Lingling; Rothman, Edward D; Campbell, Darrell A; Tremper, Kevin K

2009-01-01

The authors sought to determine the incidence and risk factors for perioperative cardiac adverse events (CAEs) after noncardiac surgery using detailed preoperative and intraoperative hemodynamic data. The authors conducted a prospective observational study at a single university hospital from 2002 to 2006. All American College of Surgeons-National Surgical Quality Improvement Program patients undergoing general, vascular, and urological surgery were included. The CAE outcome definition included cardiac arrest, non-ST elevation myocardial infarction, Q-wave myocardial infarction, and new clinically significant cardiac dysrhythmia within the first 30 postoperative days. Four years of data demonstrated that of 7,740 noncardiac operations, 83 patients (1.1%) experienced a CAE within 30 days. Nine independent predictors were identified (P < or = 0.05): age > or = 68, body mass index > or = 30, emergent surgery, previous coronary intervention or cardiac surgery, active congestive heart failure, cerebrovascular disease, hypertension, operative duration > or = 3.8 h, and the administration of 1 or more units of packed red blood cells intraoperatively. The c-statistic of this model was 0.81 +/- 0.02. Univariate analysis demonstrated that high-risk patients experiencing a CAE were more likely to experience an episode of mean arterial pressure < 50 mmHg (6% vs. 24%, P = 0.02), experience an episode of 40% decrease in mean arterial pressure (26% vs. 53%, P = 0.01), and an episode of heart rate > 100 (22% vs. 34%, P = 0.05). In comparison with current risk stratification indices, the inclusion of intraoperative elements improves the ability to predict a perioperative CAE after noncardiac surgery.

The use of rifaximin in pre-operative period of patients with tumors of the gastrointestinal tract - a retrospective study (2013-2016).

PubMed

Moroz, Nina; Sitarz, Robert; Mruk, Andrzej; Bakalarz, Robert; Maciąg, Ewa; Litwiński, Jakub; Wierzbicki, Ryszard

2018-02-28

ntroduction: One of the most important goals of preparing a patient for elective gastrointestinal cancer surgery is prevention of postoperative complications. The literature gives many ways to prepare for surgery, but only a few suggests that pre-operative use of rifaximin provides benefits in the form of fewer perioperative complications and reduces the severity of pain during this period. O bjective: The presented project is a retrospective analysis of the effectiveness of rifaximin in the prevention of perioperative complications in patients treated in the Unit of General Surgery with the Orthopedic and Urology in the Hospital of the Ministry of the Interior and Administration in Lublin, and a review of international literature in this subject. A retrospective analysis of the results of pre-operative use of rifaximin was performed in 181 patients scheduled for rectal and colorectal cancer between 2013 and 2016 in the General Surgery Unit with the Orthopedic and Urology in the Hospital of the Ministry of Interior and Administration in Lublin. Patients undergoing urgent surgery were excluded from the study. Patients were divided into 2 groups. The first group of 139 patients - patients operated on for rectal and colorectal cancer in 2013 until 2015, in whom rifaximine was not used in the preoperative period. The second group is 42 patients, operated on in 2016, in which the rifaximin was used in the pre-operative period at a dose of 2x2 tablets (400 mg) per day, 12-hour interval, for 7 days before the planned operation. Additionally, a probiotic was administered for 7 days. Drugs were ordained at the Oncological Outpatient Clinic as part of the pre-hospitalization check. R esults: The use of rifaximin in the preoperative period in patients with colorectal cancer had an effect on shortening the time of post-operative hospitalization and reduced post-surgical pain in comparison with the control group. The analysis of the cynumber and intensity of surgical complications in both groups did not differ. C onclusions: Large studies on the influence of rifaximin on the development of colorectal cancer have not been published so far. Only single reports suggest that its use has a positive effect on the perioperative period of patients treated for colorectal cancer including rectum and our retrospective analysis confirms these observations.

Management of unstable angina pectoris and non-Q-wave acute myocardial infarction in the United States and Canada (the TIMI III Registry).

PubMed

Anderson, H V; Gibson, R S; Stone, P H; Cannon, C P; Aguirre, F; Thompson, B; Knatterud, G L; Braunwald, E

1997-06-01

Management of Q-wave acute myocardial infarction (AMI) has been shown to differ between the United States and Canada, with more catheterization and revascularization procedures performed in the United States, but with little or no apparent difference in clinical outcomes. No previous studies have evaluated management differences for the acute coronary syndromes of unstable angina pectoris and non-Q-wave AMI. We therefore compared treatments and outcomes between 14 United States and 4 Canadian tertiary care centers participating in an observational registry of all consecutive admissions for unstable angina or non-Q-wave AMI between 1990 and 1993. A random, stratified sample was selected for detailed assessment and follow-up. There were 1,733 patients enrolled in United States centers and 642 in Canadian ones. In United States centers patients were less likely to receive intravenous nitroglycerin, heparin, beta blockers, calcium antagonists, or > or = 2 anti-ischemic agents. Coronary arteriography during index hospitalization was equally frequent in both countries (63.4% vs 66.9%, p = 0.781), but at 6 weeks and 1 year coronary arteriography was slightly less frequent in the United States patients. Revascularization by coronary angioplasty or bypass surgery was equivalent at 6 weeks and 1 year; however, there were trends toward less angioplasty and more bypass surgery in the United States than in Canada. Patients at United States centers stayed in the hospital fewer days than patients at Canadian centers (mean 8.2 vs 12.1 days, p <0.001). Death or AMI by 6 weeks was not different (4.8% vs 4.4%, p = 0.633), nor was it different at 1 year (10.0% vs 10.2%, p = 0.836). The combined outcome of death, AMI, or recurrent ischemia was more common in United States than in Canadian patients at 6 weeks (18.4% vs 13.9%, p = 0.004). Our findings indicate that United States physicians and hospitals did not consistently utilize more resources and were not more aggressive than their Canadian counterparts when treating acute coronary syndromes during this period.

Day of Surgery Impacts Outcome: Rehabilitation Utilization on Hospital Length of Stay in Patients Undergoing Elective Meningioma Resection.

PubMed

Sarkiss, Christopher A; Papin, Joseph A; Yao, Amy; Lee, James; Sefcik, Roberta K; Oermann, Eric K; Gordon, Errol L; Post, Kalmon D; Bederson, Joshua B; Shrivastava, Raj K

2016-09-01

Meningiomas account for approximately one third of all brain tumors in the United States. In high-volume medical centers, the average length of stay (LOS) for a patient is 6.8 days compared with 8.8 days in low-volume centers with median total admission charges equaling approximately $55,000. To our knowledge, few studies have evaluated day of surgery and its effect on hospital LOS. Our primary goal was to analyze patient outcome as a direct result of surgical date, as well as to characterize the individual variables that may impact their hospital course, early access to rehabilitation, and long-term functional status. A retrospective database was generated for cranial meningioma patients who underwent elective surgical resection at our institution over a 3-year study period (2011-2014). Inclusion criteria included any patient who underwent elective meningioma resection and was discharged either home or to a rehabilitation facility with at least 6 months of follow-up. Exclusion criteria included any patient who was not discharged after resection (i.e., expired). Each patient's medical record was evaluated for a subset of demographics and clinical variables. Given that patients who undergo surgical resection of meningiomas have a national median LOS of 6 days, we subdivided the patients into 2 cohorts: early discharge (LOS < 3) and late discharge (LOS ≥ 3). Statistical analysis was performed using SPSS 21.0 to assess the significance of the results. We identified 139 (25 male, 114 female) meningioma patients who underwent surgical resection. Seventy of these patients had surgery during the early week (defined as Monday-Wednesday), and 69 had surgery in the later week (Thursday-Friday). The median age for both early and late groups was 58, and the median diameter of the tumor was 3.1 cm and 3.3 cm, respectively. Overall, 55% of the patients had public insurance and 43% had private insurance, with no significant variation between the early and late groups. The median LOS for the early and late populations was 3 and 4 days, respectively. Physical therapy recommendations for rehabilitation facility were made in 26% of early-week patients and in 42% of late-week patients. Additionally, we found a statistically significant decreased LOS (<3 days) in those patients who underwent surgery during the early week (Monday-Wednesday), as opposed to those who received surgery in the later week (Thursday, Friday) (P = 0.045, Mann-Whitney test). Day of surgery may play a significant role in LOS for meningioma patients. Clinicians should remain aware of those factors that may delay optimal patient discharge and early access to rehabilitation facilities. Further studies will need to be performed to assess the social variables that may affect LOS, as well as the financial implications for such extended hospital courses. Copyright © 2016 Elsevier Inc. All rights reserved.

The Pulmonary Thromboembolism as a Risk of Surgical Treatments and the Role of Anticoagulant Prophylaxiss

PubMed Central

Cukic, Vesna

2014-01-01

Objective: Our objective is to show the number of patients with postoperative pulmonary thromboembolism (PPTE) treated in Intensive care unit of Clinic for pulmonary diseases an TB “Podhrastovi” in three-year period : from June 1, 2011 - June 1, 2014 and to indicate the importance of various surgical operations in the development of pulmonary thromboembolism (PTE). Material and methods: This is the retrospective study which shows the number of patients with PPTE treated in Intensive care unit of Clinic for pulmonary diseases an TB “Podhrastovi” in three-year period : from 01.06.2011.-01.06.2014. It represents the number of these patients, per cent of patients with PPTE of total patients with PTE, age and sex of patients, type of surgery, period expressed in days from surgery to diagnosis of PTE, presence of deep venous thrombosis (DVT) of lower extremities, massiveness of PPTE e.g. level of pulmonary artery with embolus. Results: In three-year period 232 patients with PTE were treated in Intensive care unit of Clinic “Podhrastovi”. 60 of them or 25.86% were patients with 24 males or 40% middle-aged 58.5 years, and 36 females or 60% middle-aged 56.3 years. PPTE developed in 15 patients with abdominal, 11 with urologic, 8 with gynecologic, 15 with orthopedic, 4 with cardiologic, 2 with vascular, 3 with neurosurgical, 1 with glandular and 1 with orl operations. The average period from operation to diagnosis of PPTE was 10.5 days for women, and 13.8 days for men. Only two patients had acute DVT after operation (one man and one woman), and five had amnesias of previous DVT or PTE. The level or the site of pulmonary embolus was different from segmental to main branches of pulmonary artery. Conclusion: Different surgical operations are the big risk factor for the development of PTE. There is great significance of anticoagulant prophylaxis before surgery even in patients with no anamnesis of previous DVT or PTE. PMID:25568626

Independent risk factors of 30-day outcomes in 1264 patients with peptic ulcer bleeding in the USA - large ulcers do worse

PubMed Central

Camus, Marine; Jensen, Dennis M.; Kovacs, Thomas O.; Jensen, Mary Ellen; Markovic, Daniela; Gornbein, Jeffrey

2016-01-01

Background Predictors of worse outcomes (rebleeding, surgery and death) of peptic ulcer bleeding (PUB’s) are essential indicators because of significant morbidity and mortality. rates of PUB’s. However those have been rarely infrequently reported since changes in medical therapy (proton poump inhibitors-PPI) and application of newer endoscopic hemostasis. Aim Our purposes were to determine: 1) independent risk factors of 30-day rebleeding, surgery, and death and 2) whether ulcer size is an independent predictor of major outcomes in patients with severe PUB’s after successful endoscopic hemostasis and treatment with optimal medical (high dose IV PPI) vs. prior treatment (high dose IV histamine 2 antagonists – H2RA’s). Methods A large prospectively followed population of patients hospitalized with severe PUB’s between 1993 and 2011 at two US tertiary care academic medical centers, stratified by stigmata of recent hemorrhage (SRH) was studied. Using multivariable logistic regression analyses, independent risk factors of each outcome (rebleeding, surgery, and death) up to 30 days were analyzed. Effects of medical treatment (H2RA patients 1993–2005 vs. PPI’s 2006–2011) were also analysed. Results 1264 patients were included. For ulcers ≥10mm, the odds of 30-day rebleeding increased 6% per each 10% increase in ulcer size (OR 1.06, 95%CI 1.02–1.10, p=0.0053). Other risk factors of 30-day rebleeding were major SRH, inpatient start of bleeding, and prior GI bleeding. Major SRH and ulcer size ≥10 mm were predictors of 30-day surgery. Risk factors of 30-day death were major SRH, inpatient bleeding, any initial platelet transfusion or fresh frozen plasma transfusion ≥2 units. Among patients with major SRH and outpatient start of bleeding, larger ulcer size was also a risk factor for death (OR 1.08 per 10% increase in ulcer size, 95%CI 1.02–1.14, p=0.0095). Ulcer size was a significant independent variable for both time periods. Conclusions Ulcer size is a risk factor and should be carefully recorded at initial endoscopy to improve patient triage and management. PMID:27000531

[Mortality following cardiac surgery in the National Health Service Hospitals of the Community of Valencia in 2007: a descriptive analysis].

PubMed

Vicente, R; Pajares, A; Vicente, J L; Aparicio, R; Loro, J M; Moreno, I; Soria, A; López, A; Porta, J; de la Fuente, C; Herrera, P; Tur, A; Osseyran, F; Guillén, A; Martí, F; Llagunes, J; Mateo, E; Aguar, F; Peña, J J; Marqués, J I; Ripoll, A; Reina, C; Ferrandis, P; Muedra, V; Llopis, E; Cantó, M; García, C

2010-02-01

To analyze clinical records of cardiac surgery patients in an attempt to identify factors associated with mortality in the postoperative critical care units of the public health service hospitals in the Community of Valencia, Spain, in 2007. Retrospective study of cases from January 1, 2007 to December 31, 2007. The charts of all patients who underwent cardiac surgery with or without extracorporeal circulation were reviewed. A data collection protocol was followed to obtain information on age, sex, body mass index (BMI), presurgical risk factors, type of surgery, duration of extracorporeal circulation, duration of ischemia, cause of death, and length of stay in the postoperative critical care unit. The study population consisted of 2113 patients at 5 public hospitals; 124 patients (70 men, 54 women) died. The mean (SD) age was 70 (9.43) years (range, 36-91 years). The mean BMI was 28.19 kg/m2 (maximum, 42 kg/m2). The mean Euroscore was 21.92 (maximum, 94.29). Hypertension was present as a preoperative risk factor in most patients (74.2%); dyslipidemia was present in 51.6%, diabetes mellitus in 38.7%, stroke in 73%, and renal failure in 2.4%. It was noteworthy was that the group who underwent coronary revascularization had the highest mortality rate (nearly 35% of the 124 patients). The next highest mortality rate (19.4%) was in patients who had combined procedures (valve repair or substitution plus coronary revascularization). Mortality was 18.5% in the group undergoing aortic valve surgery and 11.3% in those undergoing mitral valve surgery. The mean duration of extracorporeal circulation was 148.63 minutes. The mean duration of myocardial ischemia was 94.91 minutes. The most frequent cause of death was cardiogenic shock (54.8%). This was followed by distributive shock (29.8%) and hemorrhagic shock (8.9%). The mean length of stay in the postoperative critical care unit was 13.6 days. Overall mortality was 5.87%. The highest mortality rate among cardiac surgery patients in postoperative critical care units in hospitals in the Community of Valencia in 2007 was in patients who underwent coronary revascularization. The most prevalent preoperative risk factor was hypertension. Cardiogenic shock and distributive shock were the most frequent causes of death in these patients. A system for classifying risk is needed in order to predict mortality in critical care units and improve perioperative care.

Surgical injury: comparing open surgery and laparoscopy by markers of tissue damage

PubMed Central

Máca, Jan; Peteja, Matúš; Reimer, Petr; Jor, Ondřej; Šeděnková, Věra; Panáčková, Lucie; Ihnát, Peter; Burda, Michal; Ševčík, Pavel

2018-01-01

Background Major abdominal surgery (MAS) is high-risk intervention usually accompanied by tissue injury leading to a release of signaling danger molecules called alarmins. This study evaluates the surgical injury caused by two fundamental types of gastrointestinal surgical procedures (open surgery and laparoscopy) in relation to the inflammation elicited by alarmins. Patients and methods Patients undergoing MAS were divided into a mixed laparoscopy group (LPS) and an open surgery group (LPT). Serum levels of alarmins (S100A8, S100A12, HMGB1, and HSP70) and biomarkers (leukocytes, C-reactive protein [CRP], and interleukin-6 [IL-6]) were analyzed between the groups. The secondary objectives were to compare LPT and LPS cancer subgroups and to find the relationship between procedure and outcome (intensive care unit length of stay [ICU-LOS] and hospital length of stay [H-LOS]). Results A total of 82 patients were analyzed. No significant difference was found in alarmin levels between the mixed LPS and LPT groups. IL-6 was higher in the LPS group on day 2 (p=0.03) and day 3 (p=0.04). Significantly higher S100A8 protein levels on day 1 (p=0.02) and day 2 (p=0.01) and higher S100A12 protein levels on day 2 (p=0.03) were obtained in the LPS cancer subgroup. ICU-LOS and H-LOS were longer in the LPS cancer subgroup. Conclusion The degree of surgical injury elicited by open MAS as reflected by alarmins is similar to that of laparoscopic procedures. Nevertheless, an early biomarker of inflammation (IL-6) was higher in the laparoscopy group, suggesting a greater inflammatory response. Moreover, the levels of S100A8 and S100A12 were higher with a longer ICU-LOS and H-LOS in the LPS cancer subgroup. PMID:29881282

Measuring quality indicators in the operating room: cleaning and turnover time.

PubMed

Jericó, Marli de Carvalho; Perroca, Márcia Galan; da Penha, Vivian Colombo

2011-01-01

This exploratory-descriptive study was carried out in the Surgical Center Unit of a university hospital aiming to measure time spent with concurrent cleaning performed by the cleaning service and turnover time and also investigated potential associations between cleaning time and the surgery's magnitude and specialty, period of the day and the room's size. The sample consisted of 101 surgeries, computing cleaning time and 60 surgeries, computing turnover time. The Kaplan-Meier method was used to analyze time and Pearson's correlation to study potential correlations. The time spent in concurrent cleaning was 7.1 minutes and turnover time was 35.6 minutes. No association between cleaning time and the other variables was found. These findings can support nurses in the efficient use of resources thereby speeding up the work process in the operating room.

Minimized extracorporeal circulation in coronary artery bypass surgery is equivalent to standard extracorporeal circulation in patients with reduced left ventricular function.

PubMed

Puehler, T; Haneya, A; Philipp, A; Camboni, D; Hirt, S; Zink, W; Lehle, K; Rupprecht, L; Kobuch, R; Diez, C; Schmid, C

2010-06-01

Minimized extracorporeal circulation (MECC) is a promising alternative to standard extracorporeal circulation (ECC) and its use is increasing in routine coronary bypass surgery. We analyzed the clinical outcome of patients with reduced left ventricular function who underwent coronary artery bypass surgery with MECC or with standard ECC. From January 2003 to September 2008, 238 patients with a left ventricular function < 30 % underwent bypass surgery with ECC or MECC. The primary end point of our retrospective observational study was 30-day mortality. Secondary endpoints were the transfusion requirements, as well as intensive care and the in-hospital course. Demographic data, comorbidities and left ventricular function were similar in the study groups. MECC patients had a tendency towards a lower 30-day mortality rate, a better postoperative renal function and reduced ventilation times. Extracorporeal circulation time and postoperative high-dose inotropic support were significantly lower in the MECC group, while the stays in the intensive care unit and in hospital were comparable between the two groups. In our study, age in the ECC group, and previous infarction and New York Heart Association grade IV in the MECC group were preoperative risk factors associated with a higher mortality. Coronary bypass surgery using MECC is feasible and safe for patients with severely impaired left ventricular function. It is a promising alternative to ECC with a low mortality rate and a more favorable postoperative course.

Factors associated with prolonged length of stay following cardiac surgery in a major referral hospital in Oman: a retrospective observational study.

PubMed

Almashrafi, Ahmed; Alsabti, Hilal; Mukaddirov, Mirdavron; Balan, Baskaran; Aylin, Paul

2016-06-08

Two objectives were set for this study. The first was to identify factors influencing prolonged postoperative length of stay (LOS) following cardiac surgery. The second was to devise a predictive model for prolonged LOS in the cardiac intensive care unit (CICU) based on preoperative factors available at admission and to compare it against two existing cardiac stratification systems. Observational retrospective study. A tertiary hospital in Oman. All adult patients who underwent cardiac surgery at a major referral hospital in Oman between 2009 and 2013. 30.5% of the patients had prolonged LOS (≥11 days) after surgery, while 17% experienced prolonged ICU LOS (≥5 days). Factors that were identified to prolong CICU LOS were non-elective surgery, current congestive heart failure (CHF), renal failure, combined coronary artery bypass graft (CABG) and valve surgery, and other non-isolated valve or CABG surgery. Patients were divided into three groups based on their scores. The probabilities of prolonged CICU LOS were 11%, 26% and 28% for group 1, 2 and 3, respectively. The predictive model had an area under the curve of 0.75. Factors associated with prolonged overall postoperative LOS included the body mass index, the type of surgery, cardiopulmonary bypass machine use, packed red blood cells use, non-elective surgery and number of complications. The latter was the most important determinant of postoperative LOS. Patient management can be tailored for individual patient based on their treatments and personal attributes to optimise resource allocation. Moreover, a simple predictive score system to enable identification of patients at risk of prolonged CICU stay can be developed using data that are routinely collected by most hospitals. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Oral health related quality of life (OHRQoL) following third molar surgery in Sub-Saharan Africans: an observational study.

PubMed

Braimah, Ramat Oyebunmi; Ndukwe, Kizito Chioma; Owotade, Foluso John; Aregbesola, Stephen Babatunde

2016-01-01

Surgical extraction of the impacted third molar is one of the commonest minor oral surgical procedures carried out in oral surgery. Problems created by the disturbances in post-extraction wound healing and physiologic sequelae of third molar surgery can significantly affect the patient's quality of life. The study population consisted of 135 subjects that required surgical extraction of mandibular third molar under local anesthesia and met the inclusion criteria. Patients were assessed pre-operatively and post-operatively on days 1,3,5,7, and 14 using the United Kingdom Oral Health related Quality of Life questionnaire (UK-OHRQoL). This study also showed that surgical removal of impacted teeth exerted a negative influence on patient's Quality of life (QoL) across various physical, social, psychological aspects of life. UK-OHRQoL-16 mean scores showed that severe difficulty in eating was experienced by 106 (78%) patients on postoperative day (POD) 1. The symptom however improved within the first week with only 16 (11.9%) experiencing this symptom by POD 7 and none by POD 14. There was a deterioration in oral health related quality of life in the immediate postoperative period particularly POD 1 and 3 following third molar surgery, which slowly returned to preoperative level by 7th day. Routines such as eating, laughing and smiling, work and speech were also affected. Patients need to be informed of these symptoms after third molar removal so as to enable them prepare very well for the procedure and its sequelae.

[Nutritional status and risk in hospitalized children].

PubMed

Hankard, R; Bloch, J; Martin, P; Randrianasolo, H; Bannier, M F; Machinot, S; Cézard, J P

2001-11-01

A few studies report malnutrition in hospitalized patients. This one-day cross-sectional survey performed in January 1999 assessed nutritional status and protein-energy intake in a pediatric population hospitalized in medicine or surgery units. Every child older than six months, hospitalized for more than 48 h and free of nutritional support (parenteral, enteral, or special regimens for metabolic diseases) was included. Fifty-eight children among the 183 present the day of the study met the inclusion criteria and were included in the statistical analysis. They were hospitalized in medicine (48%), psychiatry (31%) and surgery (21%). The body mass index (BMI) was below -2 standard deviations (DS) in 21% of them. Excluding patients with anorexia nervosa, BMI was < -2 SD, > +2 SD, or in between these limits in respectively 12, 14 and 74%. Energy intake measured at the hospital was below 75% of the recommended dietary allowances in two-thirds of the children whether malnourished or not. Fifty percent of the malnourished children had been referred to a dietician the day of the study. Malnutrition is frequent in a population of hospitalized children. Energy intake and referral to a dietician are insufficient.

[Decree of anaesthesia of 1994, day surgery and medical responsibility: necessary reflections on the inevitable conciliation between regulations and recommendations].

PubMed

Bontemps, G; Daver, C; Ecoffey, C

2014-12-01

Day surgery is often considered as a marker of the necessity of reorganizing the hospital to take care globally and so better meet the expectations of improvement of the management of patients. But the actual deployment of day surgery can also act as a real revelation of the stakes of conciliation between the regulations, which supervise professional practices and organization, and the functioning of hospitals. Between the regulations supervising hospitals and professional practices and the place of the recommendations, between the general legal framework of the medical activity and specific legal framework (decree of anesthesia of 1994) and the Evidence-Based Medicine, the pretext of the improvement of the patient flow in day surgery, recommended by several institutions (Sfar, ANAP, HAS), questions about the legal obligation of the passage of all the patients in the postanesthesia care unit (PACU). Seen under the angle of a legal action against a medical doctor, the study of the French jurisprudence reveals that every practitioner has to respect the recommendations and the Evidence-Based Medicine, and this in the standardized frame of the MD's activity and the respect for a very strict legal environment. The question of an obvious conciliation between all these measures arises today clearly. In the case of a potential conflict, the key of resolution, based only on legal standards (constitution, laws, decrees), is not enough for arbitrating. Applying that the only respect for the decree of anesthesia would be enough for exempting itself from any contentious risk does not satisfy more. There is a real difficulty defining the legal precise nature of the recommendations, so best practices as better organization, which are more and more frequently. Even if these recommendations originally had not their place in the hierarchy of the legal standards, they are brought in there today. There is a real brake in the deployment of the day surgery because the strict respect for the decree of 94 on the systematic passage in PACU can be paradoxical with a better quality of the care. Twenty years after the publication of the decree of anesthesia, it seems essential to ask at first if it's possible to fast-track discharge without any stay in the PACU and thus of the inevitable conciliation between all these measures. Secondly it's necessary of modifying this decree to impulse the deployment of the day surgery. Copyright © 2014 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.

Early cavopulmonary anastomosis in very young infants after the Norwood procedure: impact on oxygenation, resource utilization, and mortality.

PubMed

Jaquiss, Robert D B; Ghanayem, Nancy S; Hoffman, George M; Fedderly, Raymond T; Cava, Joseph R; Mussatto, Kathleen A; Tweddell, James S

2004-04-01

The optimal timing of second-stage palliation after Norwood operations remains undefined. Advantages of early cavopulmonary anastomosis are early elimination of volume load and shortening the high-risk interstage period. Potential disadvantages include severe cyanosis, prolonged pleural drainage and hospitalization, and excess mortality. We reviewed our recent experience to evaluate the safety of early cavopulmonary anastomosis. Eighty-five consecutive patients undergoing post-Norwood operation cavopulmonary anastomosis were divided into group I (cavopulmonary anastomosis at <4 months; n = 33) and group II (cavopulmonary anastomosis at >4 months; n = 52). Groups were compared for age; size; early and late mortality; preoperative, initial postoperative, and discharge oxygen saturation; and duration of mechanical ventilation, intensive care unit stay, pleural drainage, and hospitalization. Group I patients were younger than group II patients (94 +/- 21 days vs 165 +/- 44 days, respectively; P <.001) and smaller (4.8 +/- 0.8 kg vs 5.8 +/- 0.9 kg; P <.001). The preoperative oxygen saturation was not different (group I, 75% +/- 10%; group II, 78% +/- 8%; P =.142). The oxygen saturation was lower immediately after surgery in group I compared with group II (75% +/- 7% vs 81% +/- 7%, respectively; P <.001) but not by discharge (group I, 79% +/- 4%; group II, 80% +/- 4%). Younger patients were ventilated longer (62 +/- 86 hours vs 19 +/- 42 hours; P =.001), in the intensive care unit longer (130 +/- 111 hours vs 104 +/- 94 hours; P =.049), hospitalized longer (12.5 +/- 11.5 days vs 10.3 +/- 14.8 days; P =.012), and required longer pleural drainage (106 +/- 45 hours vs 104 +/- 93 hours; P =.046). Hospital survival was 100% in both groups. Actuarial survival to 12 months was 96% +/- 4% for group I and 96% +/- 3% for group II. Early cavopulmonary anastomosis after the Norwood operation is safe. Younger patients are more cyanotic initially after surgery and have a longer duration of mechanical ventilation, pleural drainage, intensive care unit stay, and hospitalization.

Applying a managerial approach to day surgery.

PubMed

Onetti, Alberto

2008-01-01

The present article explores the day surgery topic assuming a managerial perspective. If we assume such a perspective, day surgery can be considered as a business model decision care and not just a surgical procedure alternative to the traditional ones requiring patient hospitalization. In this article we highlight the main steps required to develop a strategic approach [Cotta Ramusino E, Onetti A. Strategia d'Impresa. Milano; Il Sole 24 Ore; Second Edition, 2007] at hospital level (Onetti A, Greulich A. Strategic management in hospitals: the balanced scorecard approach. Milano: Giuffé; 2003) and to make day surgery part of it. It means understanding: - how and when day surgery can improve the health care providers' overall performance both in terms of clinical effectiveness and financial results, and, - how to organize and integrate it with the other hospital activities in order to make it work. Approaching day surgery as a business model decision requires to address in advance a list of potential issues and necessitates of continued audit to verify the results. If it does happen, day surgery can be both safe and cost effective and impact positively on surgical patient satisfaction. We propose a sort of "check-up list" useful to hospital managers and doctors that are evaluating the option of introducing day surgery or are trying to optimize it.

Experiences of mothers of infants with congenital heart disease before, during, and after complex cardiac surgery.

PubMed

Harvey, Kayla A; Kovalesky, Andrea; Woods, Ronald K; Loan, Lori A

2013-01-01

Experiences of mothers of infants undergoing complex heart surgery were explored to build evidence-based family-centered interventions. Congenital heart disease is the most frequent birth defect in the United States and is common worldwide. Eight mothers recalled through journal entries their experiences of the days before, during, and after their infant's surgery and shared advice for other mothers. Colaizzi's phenomenological method was utilized for data analysis. A validation survey of seven additional mothers from a support group occurred via email. Six themes were identified and validated: Feeling Intense Fluctuating Emotion; Navigating the Medical World; Dealing with the Unknown; Facing the Possibility of My Baby Dying, Finding Meaning and Spiritual Connection, and the umbrella theme of Mothering Through It All. Through a clearer understanding of experiences as described by mothers, health-care providers may gain insight as to how to better support mothers of infants undergoing heart surgery. Copyright © 2013 Elsevier Inc. All rights reserved.

Clostridium difficile infection after colorectal surgery: a rare but costly complication.

PubMed

Damle, Rachelle N; Cherng, Nicole B; Flahive, Julie M; Davids, Jennifer S; Maykel, Justin A; Sturrock, Paul R; Sweeney, W Brian; Alavi, Karim

2014-10-01

The incidence and virulence of Clostridium difficile infection (CDI) are on the rise. The characteristics of patients who develop CDI following colorectal resection have been infrequently studied. We utilized the University HealthSystem Consortium database to identify adult patients undergoing colorectal surgery between 2008 and 2012. We examined the patient-related risk factors for CDI and 30-day outcomes related to its occurrence. A total of 84,648 patients met our inclusion criteria, of which the average age was 60 years and 50% were female. CDI occurred in 1,266 (1.5%) patients during the years under study. The strongest predictors of CDI were emergent procedure, inflammatory bowel disease (IBD), and major/extreme APR-DRG severity of illness score. CDI was associated with a higher rate of complications, intensive care unit (ICU) admission, longer preoperative inpatient stay, 30-day readmission rate, and death within 30 days compared to non-CDI patients. Cost of the index stay was, on average, $14,130 higher for CDI patients compared with non-CDI patients. Emergent procedures, higher severity of illness, and inflammatory bowel disease are significant risk factors for postoperative CDI in patients undergoing colorectal surgery. Once established, CDI is associated with worse outcomes and higher costs. The poor outcomes of these patients and increased costs highlight the importance of prevention strategies targeting high-risk patients.

Enteral Docosahexaenoic Acid Reduces Analgesic Administration in Neonates Undergoing Cardiovascular Surgery.

PubMed

Bernabe-Garcia, Mariela; López-Alarcon, Mardia; Salgado-Sosa, Alfredo; Villegas-Silva, Raul; Maldonado-Hernandez, Jorge; Rodríguez-Cruz, Maricela; Rivas-Ruiz, Rodolfo; Chavez-Sanchez, Luis; Blanco-Favela, Francisco A; Mancilla-Ramirez, Javier; Gordillo-Alvarez, Virginia; Madrigal-Muñiz, Olivia

2016-01-01

Neonates undergoing surgery require analgesic medication to ameliorate acute pain. These medications produce negative side effects. Docosahexaenoic acid (DHA) has an antinociceptive effect in animals, but this has not been evaluated in human neonates. We evaluated the DHA effect on cumulative dose and duration of analgesics administered to neonates undergoing cardiovascular surgery. A secondary analysis was performed with data from a clinical trial, in which enteral DHA was administered perioperatively compared with sunflower oil (SO). Present study assessed the antinociceptive effect of DHA by measuring the cumulative dose and duration of analgesics administered during postoperative stay in a neonatal intensive care unit. Multivariate linear regression models were performed. Seventeen neonates received DHA and 18 received SO in the control group. Compared with the control group, the DHA group received lower cumulative dose (14.6 ± 2.2 vs. 25.2 ± 4.8 μg/kg, p = 0.029) and shorter duration of buprenorphine (2 days (1-8) vs. 4.5 days (1-12); p = 0.053). After adjusting for confounders, the DHA group received significantly lesser buprenorphine (β = -27 μg/kg, p = 0.028; R2 model = 0.90) for shorter duration (β = -9 days, p = 0.003; R2 model = 0.94). No differences in fentanyl or ketorolac were detected. Buprenorphine administration was reduced in neonates who received DHA, suggesting that DHA likely has analgesic effects. © 2016 S. Karger AG, Basel.

Efficacy of a high-observation protocol in major head and neck cancer surgery: A prospective study.

PubMed

Barber, Brittany; Harris, Jeffrey; Shillington, Cameron; Rychlik, Shannon; Dort, Joseph; Meier, Michael; Estey, Angela; Elwi, Adam; Wickson, Patty; Buss, Michael; Zygun, David; Ansari, Kal; Biron, Vincent; O'Connell, Daniel; Seikaly, Hadi

2017-08-01

The purpose of this study was to optimize an existing clinical care pathway (CCP) for head and neck cancer with a high-observation protocol (HOP) and to determine the effect on length of intensive care unit (ICU) admission and length of stay in hospital (LOS). The HOP mandated initiation of spontaneous breathing trials before the conclusion of the surgery, weaning of sedation, and limiting mechanical ventilation. All patients with head and neck cancer undergoing primary surgery on the HOP were compared to a historical cohort regarding length of ICU admission, ICU readmissions, and LOS. Ninety-six and 52 patients were observed in "historical" and "HOP" cohorts. The length of ICU admission (1.9 vs 1.2 days; p = .021), LOS (20.3 vs 14.1 days; p = .020), and ICU readmissions (10.4% vs 1.9%; p = .013) were significantly decreased in the "HOP" cohort. Rapid weaning of sedation and limiting mechanical ventilation may contribute to a shorter length of ICU admission and LOS, as well as decreased ICU readmissions. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1689-1695, 2016. © 2017 Wiley Periodicals, Inc.

Effect of dexmedetomidine on preventing agitation and delirium after microvascular free flap surgery: a randomized, double-blind, control study.

PubMed

Yang, Xudong; Li, Zhenzhen; Gao, Chunyan; Liu, Ruichang

2015-06-01

To determine whether dexmedetomidine sedation in the postanesthesia care unit (PACU) could decrease agitation and delirium after free flap surgery. Eighty patients were randomly divided into 2 groups. In the experimental group, dexmedetomidine was given at an hourly infusion rate of 0.5 μg/kg for 1 hour before the operation was completed and continued in the PACU at 0.2 to 0.7 μg/kg continuously until the next morning. In the control group, normal saline was given during the same periods. Patients in the 2 groups received sufentanil and midazolam for sedation and pain relief when necessary. Agitation was monitored with the Riker Sedation-Agitation Scale in the PACU and delirium was monitored with the Confusion Assessment Method for the Intensive Care Unit for 5 days postoperatively. The overall incidence of agitation was similar between the 2 groups. However, when the influence of patient shifting was excluded, the incidence of agitation in the dexmedetomidine group was apparently lower than that in the control group (10.3 vs 30%; P = .029). No difference was found in the occurrence of delirium between the experimental and control groups (5.1 vs 12.5%; P = .432). Dexmedetomidine does not change the overall incidence of agitation after free flap surgery; however, it does decrease agitation after PACU admission. It does not prevent delirium within 5 days postoperatively. Copyright © 2015 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Does chronic warfarin cause increased blood loss and transfusion during lumbar spinal surgery?

PubMed

Young, Ernest Y; Ahmadinia, Kasra; Bajwa, Navkirat; Ahn, Nicholas U

2013-10-01

The use of oral anticoagulation therapy such as warfarin is projected to increase significantly as the population ages and the prevalence of cardiovascular disease increases. Current recommendations state that warfarin be discontinued before surgery and the international normalized ratio (INR) normalized. To determine if stopping warfarin 7 days before surgery and correcting INR had any effect on intraoperative blood loss or the requirements for blood product transfusion. This was a retrospective cohort study in a high-volume tertiary care center. Sample comprised 263 consecutive patients who underwent elective lumbar spinal surgery. The outcome measures were intraoperative blood loss, intraoperative blood transfusion, postoperative blood transfusion, and the number of blood products transfused. The records of patients undergoing elective spinal surgery were analyzed for patient demographic data, comorbidities, coagulation panel laboratory findings, operative characteristics, blood loss, and blood transfusion requirements. These included patients undergoing full laminectomies with or without posterolateral fusion and instrumentation. Patients on warfarin were analyzed for the mean dosage of warfarin and underlying pathology that required anticoagulation. All patients on warfarin had their anticoagulation therapy stopped 7 days before surgery and their INR checked preoperatively to confirm normalization. Both univariate and multiple linear regression analyses were performed. The patients on warfarin had a mean intraoperative blood loss of 839 mL compared with 441 mL for patients not on warfarin (p<.01). Multiple regression analysis determined that warfarin and number of spinal levels decompressed/fused/instrumented were predictors for increased blood loss (R(2)=0.37). Patients on warfarin also had increased postoperative blood transfusions (23.1% compared with 7.4%, p=.04). There was no significant difference between groups in terms of intraoperative blood transfusion or number of units transfused. Patients on chronic anticoagulation therapy with warfarin who have their therapy stopped 7 days before surgery and have their INR normalized still demonstrated increased intraoperative blood loss and requirement for postoperative transfusion. Surgeons should be aware of the increased propensity of these patients to bleed despite adherence to protocols and should attempt to mitigate this risk. Copyright © 2013 Elsevier Inc. All rights reserved.

The use of standard operating procedures in day case anterior cruciate ligament reconstruction.

PubMed

Khan, T; Jackson, W F; Beard, D J; Marfin, A; Ahmad, M; Spacie, R; Jones, R; Howes, S; Barker, K; Price, A J

2012-08-01

The current rate of day-case anterior cruciate ligament reconstruction (ACLR) in the UK remains low. Although specialised care pathways with standard operating procedures (SOPs) have been effective in reducing length of stay following some surgical procedures, this has not been previously reported for ACLR. We evaluate the effectiveness of SOPs for establishing day-case ACLR in a specialist unit. Fifty patients undergoing ACLR between May and September 2010 were studied prospectively ("study group"). SOPs were designed for pre-operative assessment, anaesthesia, surgical procedure, mobilisation and discharge. We evaluated length of stay, readmission rates, patient satisfaction and compliance to SOPs. A retrospective analysis of 50 patients who underwent ACLR prior to implementation of the day-case pathway was performed ("standard practice group"). Eighty percent of patients in the study group were discharged on the day of surgery (mean length of stay=5.3h) compared to 16% in the standard practice group (mean length of stay=21.6h). This difference was statistically significant (p<0.05, Mann-Whitney U test). All patients were satisfied with the day case pathway. Ninety-two percent of the study group were discharged on the day of surgery when all SOPs were followed and 46% where they were not. High rates of day-case ACLR with excellent patient satisfaction can be achieved with the use of a specialised patient pathway with SOPs. Copyright © 2011 Elsevier B.V. All rights reserved.

[Partial gangrene of the scrotum and penis. A complication of sclerotherapy of testicular hydrocele].

PubMed

Dahl, B H

1993-04-20

Localized gangrene of the scrotum and penis as a complication to tetracycline sclerotherapy for hydrocele has not been reported before. I describe the complication in a 56 year-old man who was admitted to our plastic surgery unit for excision and reconstruction four days after sclerotherapy. The procedure of tapping and injection, and how to avoid this type of complication, are discussed.

Medical Department, United States Army. Surgery in World War II. Neurosurgery. Volume 1

DTIC Science & Technology

1958-01-01

116 Photomicrograph showing petechial hemorrhages in cortex ------------------- 378 117 Photomicrograph showing nerve cell changes in caudate nucleus...headache unrelieved by ordinary medication or when there were signs of increasing intracranial hypertension; and (4) diagnosis of persistent fever ...hemorrhage at various points along the track of the bullet, was almost. invariably present for some days, or even for weeks, after injury. Fever was also

Waiting time of inpatients before elective surgical procedures at a State Government Teaching Hospital in India.

PubMed

Ray, Shreyasi; Kirtania, Jyotirmay

2017-01-01

Abundant published literature exists addressing the issues of outpatient waiting lists before surgery. However, there is no published literature on inpatient waiting time before elective surgical procedures. This study aims to measure the inpatient waiting time, identify the factors that affect the inpatient waiting time, and recommend the ways of reducing the waiting time of inpatients before elective surgical procedures, at a state government teaching hospital in India. Descriptive research methods and quality control tools were used for this prospective observational study. Descriptive statistics, Shapiro-Wilk test of normality, Wilcoxon-Mann-Whitney Test, and Kruskal-Wallis test were used. Pareto charts were used to highlight the most important modifiable factors among the set of factors causing increased waiting time. We also applied the M/M/c model (Erlang - A model) of queue theory to analyze the traffic intensity and system congestion. The median waiting time of inpatients before elective surgery was 12 days (interquartile range = 11.5 days). The waiting time was influenced significantly (P < 0.05) by the patient's age, physical status, and the financial status. The surgical specialty, blood product booking and procurement, cross-specialty consultation before surgery, and Intensive Care Unit booking were the other important factors. Modifiable and nonmodifiable factors affecting the inpatient waiting time of surgical patients were identified. Control measures that can reduce the waiting time of inpatients before elective surgery were identified.

Intraoperative Methadone in Same-Day Ambulatory Surgery: A Randomized, Double-Blinded, Dose-Finding Pilot Study.

PubMed

Komen, Helga; Brunt, L Michael; Deych, Elena; Blood, Jane; Kharasch, Evan D

2018-05-25

Approximately 50 million US patients undergo ambulatory surgery annually. Postoperative opioid overprescribing is problematic, yet many patients report inadequate pain relief. In major inpatient surgery, intraoperative single-dose methadone produces better analgesia and reduces opioid use compared with conventional repeated dosing of short-duration opioids. This investigation tested the hypothesis that in same-day ambulatory surgery, intraoperative methadone, compared with short-duration opioids, reduces opioid consumption and pain, and determined an effective intraoperative induction dose of methadone for same-day ambulatory surgery. A double-blind, dose-escalation protocol randomized 60 patients (2:1) to intraoperative single-dose intravenous methadone (initially 0.1 then 0.15 mg/kg ideal body weight) or conventional as-needed dosing of short-duration opioids (eg, fentanyl, hydromorphone; controls). Intraoperative and postoperative opioid consumption, pain, and opioid side effects were assessed before discharge. Patient home diaries recorded pain, opioid use, and opioid side effects daily for 30 days postoperatively. Primary outcome was in-hospital (intraoperative and postoperative) opioid use. Secondary outcomes were 30 days opioid consumption, pain intensity, and opioid side effects. Median (interquartile range) methadone doses were 6 (5-6) and 9 (8-9) mg in the 0.1 and 0.15 mg/kg methadone groups, respectively. Total opioid consumption (morphine equivalents) in the postanesthesia care unit was significantly less compared with controls (9.3 mg, 1.3-11.0) in subjects receiving 0.15 mg/kg methadone (0.1 mg, 0.1-3.3; P < .001) but not 0.1 mg/kg methadone (5.0 mg, 3.3-8.1; P = .60). Dose-escalation ended at 0.15 mg/kg methadone. Total in-hospital nonmethadone opioid use after short-duration opioid, 0.1 mg/kg methadone, and 0.15 mg/kg methadone was 35.3 (25.0-44.0), 7.1 (3.7-10.0), and 3.3 (0.1-5.8) mg morphine equivalents, respectively (P < .001 for both versus control). In-hospital pain scores and side effects were not different between groups. In the 30 days after discharge, patients who received methadone 0.15 mg/kg had less pain at rest (P = .02) and used fewer opioid pills than controls (P < .0001), whereas patients who received 0.1 mg/kg had no difference in pain at rest (P = .69) and opioid use compared to controls (P = .08). In same-day discharge surgery, this pilot study identified a single intraoperative dose of methadone (0.15 mg/kg ideal body weight), which decreased intraoperative and postoperative opioid requirements and postoperative pain, compared with conventional intermittent short-duration opioids, with similar side effects.

Constipation in intensive care unit: incidence and risk factors.

PubMed

Nassar, Antonio Paulo; da Silva, Fernanda Maria Queiroz; de Cleva, Roberto

2009-12-01

Although gastrointestinal motility disorders are common in critically ill patients, constipation and its implications have received very little attention. We aimed to determine the incidence of constipation to find risk factors and its implications in critically ill patients During a 6-month period, we enrolled all patients admitted to an intensive care unit from an universitary hospital who stayed 3 or more days. Patients submitted to bowel surgery were excluded. Constipation occurred in 69.9% of the patients. There was no difference between constipated and not constipated in terms of sex, age, Acute Physiology and Chronic Health Evaluation II, type of admission (surgical, clinical, or trauma), opiate use, antibiotic therapy, and mechanical ventilation. Early (<24 hours) enteral nutrition was associated with less constipation, a finding that persisted at multivariable analysis (P < .01). Constipation was not associated with greater intensive care unit or mortality, length of stay, or days free from mechanical ventilation. Constipation is very common among critically ill patients. Early enteral nutrition is associated with earlier return of bowel function.

Association of Model for End-Stage Liver Disease Score With Mortality in Emergency General Surgery Patients.

PubMed

Havens, Joaquim M; Columbus, Alexandra B; Olufajo, Olubode A; Askari, Reza; Salim, Ali; Christopher, Kenneth B

2016-07-20

Emergency general surgery (EGS) patients have a disproportionate burden of death and complications. Chronic liver disease (CLD) increases the risk of complications following elective surgery. For EGS patients with CLD, long-term outcomes are unknown and risk stratification models do not reflect severity of CLD. To determine whether the Model for End-Stage Liver Disease (MELD) score is associated with increased risk of 90-day mortality following intensive care unit (ICU) admission in EGS patients. We performed a retrospective cohort study of patients with CLD who underwent an EGS procedure based on International Classification of Diseases, Ninth Revision (ICD-9) procedure codes and were admitted to a medical or surgical ICU within 48 hours of surgery between January 1, 1998, and September 20, 2012, at 2 academic medical centers. Chronic liver disease was identified using ICD-9 codes. Multivariable logistic regression was performed. The analysis was conducted from July 1, 2015, to January 1, 2016. The primary outcome was all-cause 90-day mortality. A total of 13 552 EGS patients received critical care; of these, 707 (5%) (mean [SD] age at hospital admission, 56.6 [14.2] years; 64% male; 79% white) had CLD and data to determine MELD score at ICU admission. The median MELD score was 14 (interquartile range, 10-20). Overall 90-day mortality was 30.1%. The adjusted odds ratio of 90-day mortality for each 10-point increase in MELD score was 1.63 (95% CI, 1.34-1.98). A decrease in MELD score of more than 3 in the 48 hours following ICU admission was associated with a 2.2-fold decrease in 90-day mortality (odds ratio = 0.46; 95% CI, 0.22-0.98). In this study, MELD score was associated with 90-day mortality following EGS in patients with CLD. The MELD score can be used as a prognostic factor in this patient population and should be used in preoperative risk prediction models and when counseling EGS patients on the risks and benefits of operative intervention.

Postoperative Pain, an Unmet Problem in Day or Overnight Italian Surgery Patients: A Prospective Study

PubMed Central

Antonielli D'Oulx, Maria Delfina; Paradiso, Rosetta; Perretta, Laura; Dimonte, Valerio

2016-01-01

Background. Because of economic reasons, day surgery rates have steadily increased in many countries and the trend is to perform around 70% of all surgical procedures as day surgery. Literature shows that postoperative pain treatment remains unfulfilled in several fields such as orthopedic and general surgery patients. In Italy, the day surgery program is not yet under governmental authority and is managed regionally by local practices. Aim. To investigate the trends in pain intensity and its relation to type of surgeries and pain therapy protocols, in postoperative patients, discharged from three different Ambulatory Surgeries located in North West Italy (Piedmont region). Method. The present study enrolled 276 patients who undergone different surgical procedures in ambulatory regimen. Patients recorded postoperative pain score twice a day, compliance with prescribed drugs, and pain related reasons for contacting the hospital. Monitoring lasted for 7 days. Results. At discharge, 72% of patients were under weak opioids, 12% interrupted the treatment due to side effects, 17% of patients required extra drugs, and 15% contacted the hospital reporting pain problems. About 50% of patients experienced moderate pain during the first day after surgery. Results from our study show that most of the patients experienced avoidable pain after discharge. PMID:28115878

Predictors of Outcome in Modern Surgery for Lung Abscess.

PubMed

Schweigert, Michael; Solymosi, Norbert; Dubecz, Attila; John, Joseph; West, Doug; Boenisch, Paul Leonhard; Karmy-Jones, Riyad; Ospina, Carlos F Giraldo; Almeida, Ana Beatriz; Witzigmann, Helmut; Stein, Hubert J

2017-10-01

Background  Surgery for lung abscess is a challenging task. Timing and indications for surgery are not well established. Identification of predictors of outcome could help to clarify the role of surgery. Methods  Patients who underwent major thoracic surgery for infectious lung abscess were identified at six centers for general thoracic surgery in Germany, Spain, the United Kingdom, and the United States. Study period was 2000 to 2016. Results  There were 91 patients. Pulmonary sepsis (48), pleural empyema (43), persistent air leakage (25), acute renal failure (12), and respiratory failure with mechanical ventilation (25) were already preoperatively present. The mean Charlson index of comorbidity was 3.0 (median: 2.0; interquartile range: 3). Procedures were segmentectomy (18), lobectomy (58), and pneumonectomy (15). The 30-day mortality following surgery was 13/91.Preoperative sepsis (odds ratio [OR]: 13.69; 95% confidence interval [CI]: 1.86-610.53; p  < 0.01), preoperative persistent air leak (OR: 13.46, 95% CI: 3.00-85.37, p  < 0.01), respiratory failure (OR: 5.60; 95% CI: 1.41-24.84; p  < 0.01), acute renal failure (OR: 6.15 ; 95% CI: 1.24-29.56 ; p  = 0.01), and Charlson index of comorbidity ≥ 3 (OR: 7.19 ; 95% CI: 1.43-71.21 ; p  < 0.01) are associated with higher mortality, whereas age > 70 years ( p  = 0.46) and the extent of pulmonary resection (segmentectomy, lobectomy, pneumonectomy) have no significant influence on mortality. Patients with fatal outcome have significantly higher Charlson index of comorbidity ( p  < 0.01). Conclusions  Delayed referral for surgery is common. Significant predictors for fatal outcome are pulmonary sepsis, septic complications (air leak, pleural empyema), septic organ failure (respiratory, acute renal failure), and preexisting comorbidity (Charlson index of comorbidity ≥ 3). The extent of surgical resection shows no significant influence. Georg Thieme Verlag KG Stuttgart · New York.

Which postoperative complications matter most after bariatric surgery? Prioritizing quality improvement efforts to improve national outcomes.

PubMed

Daigle, Christopher R; Brethauer, Stacy A; Tu, Chao; Petrick, Anthony T; Morton, John M; Schauer, Philip R; Aminian, Ali

2018-05-01

National quality programs have been implemented to decrease the burden of adverse events on key outcomes in bariatric surgery. However, it is not well understood which complications have the most impact on patient health. To quantify the impact of specific bariatric surgery complications on key clinical outcomes. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. Data from patients who underwent primary bariatric procedures were retrieved from the MBSAQIP 2015 participant use file. The impact of 8 specific complications (bleeding, venous thromboembolism [VTE], leak, wound infection, pneumonia, urinary tract infection, myocardial infarction, and stroke) on 5 main 30-day outcomes (end-organ dysfunction, reoperation, intensive care unit admission, readmission, and mortality) was estimated using risk-adjusted population attributable fractions. The population attributable fraction is a calculated measure taking into account the prevalence and severity of each complication. The population attributable fractions represents the percentage reduction in a given outcome that would occur if that complication were eliminated. In total, 135,413 patients undergoing sleeve gastrectomy (67%), Roux-en-Y gastric bypass (29%), adjustable gastric banding (3%), and duodenal switch (1%) were included. The most common complications were bleeding (.7%), wound infection (.5%), urinary tract infection (.3%), VTE (.3%), and leak (.2%). Bleeding and leak were the largest contributors to 3 of 5 examined outcomes. VTE had the greatest effect on readmission and mortality. This study quantifies the impact of specific complications on key surgical outcomes after bariatric surgery. Bleeding and leak were the complications with the largest overall effect on end-organ dysfunction, reoperation, and intensive care unit admission after bariatric surgery. Furthermore, our findings suggest that an initiative targeting reduction of post-bariatric surgery VTE has the greatest potential to reduce mortality and readmission rates. Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.

Cerebral oxygenation in the beach chair position for shoulder surgery in regional anesthesia: impact on cerebral blood flow and neurobehavioral outcome.

PubMed

Aguirre, José A; Märzendorfer, Olivia; Brada, Muriel; Saporito, Andrea; Borgeat, Alain; Bühler, Philipp

2016-12-01

Beach chair position is considered a potential risk factor for central neurological events particularly if combined with low blood pressure. The aim of this study was to assess the impact of regional anesthesia on cerebral blood flow and neurobehavioral outcome. This is a prospective, assessor-blinded observational study evaluating patients in the beach chair position undergoing shoulder surgery under regional anesthesia. University hospital operating room. Forty patients with American Society of Anesthesiologists classes I-II physical status scheduled for elective shoulder surgery. Cerebral saturation and blood flow of the middle cerebral artery were measured prior to anesthesia and continued after beach chair positioning until discharge to the postanesthesia care unit. The anesthesiologist was blinded for these values. Controlled hypotension with systolic blood pressure≤100mm Hg was maintained during surgery. Neurobehavioral tests and values of regional cerebral saturation, bispectral index, the mean maximal blood flow of the middle cerebral artery, and invasive blood pressure were measured prior to regional anesthesia, and measurements were repeated after placement of the patient on the beach chair position and every 20 minutes thereafter until discharge to postanesthesia care unit. The neurobehavioral tests were repeated the day after surgery. The incidence of cerebral desaturation events was 5%. All patients had a significant blood pressure drop 5 minutes after beach chair positioning, measured at the heart as well as the acoustic meatus levels, when compared with baseline values (P<.05). There was no decrease in either the regional cerebral saturation (P=.136) or the maximal blood flow of the middle cerebral artery (P=.212) at the same time points. Some neurocognitive tests showed an impairment 24 hours after surgery (P<.001 for 2 of 3 tests). Beach chair position in patients undergoing regional anesthesia for shoulder surgery had no major impact on cerebral blood flow and cerebral oxygenation. However, some impact on neurobehavioral outcome 24 hours after surgery was observed. Copyright © 2016 Elsevier Inc. All rights reserved.

Day case hernia repair: weak evidence or practice gap?

PubMed

Scarfe, Anje; Duncan, Joanna; Ma, Ning; Cameron, Alun; Rankin, David; Karatassas, Alex; Fletcher, David; Watters, David; Maddern, Guy

2018-06-01

Analysis of a private insurer's administrative data set revealed significant variation in the length of hospital stay following hernia surgery. This review examined factors influencing the performance of day surgery for inguinal, femoral and umbilical hernia repair in adults. A systematic literature search was conducted in the PubMed, Embase and Cochrane Library databases to identify studies and clinical practice guidelines (CPGs) comparing same day hernia surgery to surgery followed by an overnight stay. Screening of studies by abstract and full text was completed by a single researcher and checked by a second. Studies were selected for inclusion based on a step-wise approach across three phases. Limited evidence from one systematic review, and three case series studies including 3213 patients found that same day hernia surgery was as safe and effective as an overnight stay. All identified CPGs recommended a same day procedure for most patients. Two case series studies reported that 3-8% of patients were ineligible for day procedures due to medical reasons; however, the characteristics of patients, in general, which are not suitable, have not been adequately investigated. Day surgery for groin hernia repair is safe and effective for most patients. However, evidence-based support is only one of many factors that may contribute to the uptake of day surgery in Australia. There is an opportunity for key stakeholders across the private healthcare system to deliver an equally effective but more sustainable and affordable hernia care by increasing the day surgery rates. © 2018 Royal Australasian College of Surgeons.

A multicenter randomized controlled fellow eye trial of pulse-dosed difluprednate 0.05% versus prednisolone acetate 1% in cataract surgery.

PubMed

Donnenfeld, Eric D; Holland, Edward J; Solomon, Kerry D; Fiore, Jay; Gobbo, Anthony; Prince, Jessica; Sandoval, Helga P; Shull, Emily R; Perry, Henry D

2011-10-01

To compare the effects of 2 corticosteroids on corneal thickness and visual acuity after cataract surgery. Multicenter, randomized, contralateral-eye, double-masked trial. Fifty-two patients (104 eyes) underwent bilateral phacoemulsification. The first eye randomly received difluprednate 0.05% or prednisolone acetate 1%; the fellow eye received the alternative. Before surgery, 7 doses were administered over 2 hours; 3 additional doses were given after surgery, before discharge. For the remainder of the day, corticosteroids were administered every 2 hours, then 4 times daily during week 1 and twice daily during week 2. Corneal pachymetry, visual acuity, and corneal edema were evaluated before surgery and at days 1, 15, and 30 after surgery. Endothelial cell counts were evaluated before surgery and at 30 days after surgery. Retinal thickness was evaluated before surgery and at 15 and 30 days after surgery. Corneal thickness at day 1 was 33 μm less in difluprednate-treated eyes (P = .026). More eyes were without corneal edema in the difluprednate group than in the prednisolone group at day 1 (62% vs 38%, respectively; P = .019). Uncorrected and best-corrected visual acuity at day 1 were significantly better with difluprednate than prednisolone by 0.093 logMAR lines (P = .041) and 0.134 logMAR lines (P < .001), respectively. Endothelial cell density was 195.52 cells/mm(2) higher in difluprednate-treated eyes at day 30 (P < .001). Retinal thickness at day 15 was 7.74 μm less in difluprednate-treated eyes (P = .011). In this high-dose pulsed-therapy regimen, difluprednate reduced inflammation more effectively than prednisolone acetate, resulting in more rapid return of vision. Difluprednate was superior at protecting the cornea and reducing macular thickening after cataract surgery. Copyright © 2011 Elsevier Inc. All rights reserved.

Association between severity of untreated sleep apnoea and postoperative complications following major cardiac surgery: a prospective observational cohort study.

PubMed

Mason, Martina; Hernández Sánchez, Jules; Vuylsteke, Alain; Smith, Ian

2017-09-01

To examine whether untreated sleep apnoea is associated with prolonged Intensive Care Unit (ICU) stay and increased frequency of postoperative ICU complications, in patients undergoing major cardiac surgery. Adult patients, undergoing elective coronary artery bypass grafting with or without cardiac valve surgery, between March 2013 and July 2014, were considered. We excluded patients participating in other interventional studies, those who had a tracheostomy before surgery, required emergency surgery or were due to be admitted on the day of surgery. Patients underwent inpatient overnight oximetry on the night prior to their surgery to assess for the presence of sleep apnoea. Since oximetry alone cannot differentiate obstructive from central apnoea, the results are reported as sleep apnoea which was diagnosed in patients with an arterial oxygen desaturation index (ODI) ≥ 5/h. The primary outcome measure was length of stay (LoS) in ICU in days. The secondary outcome was a composite measure of postoperative complications in ICU. Multivariate models were developed to assess associations between ODI and the primary and secondary outcome measures, adjusting for preselected predictor variables, relative to primary and secondary outcomes. There was no significant association between ODI and ICU LoS, HR 1.0, 95% CI 0.99-1.02; p = 0.12. However we did find a significant association between ODI and postoperative complications in the ICU, OR = 1.1; 95% CI 1.02-1.17; p = 0.014. The probability of developing complications rose with higher ODI, reflecting sleep apnoea severity. Acknowledging the limitations of this prospective study, untreated sleep apnoea did not predict an increased length of stay in ICU but we do report an association with postoperative complications in patients undergoing major cardiac surgery. Copyright © 2017 Elsevier B.V. All rights reserved.

A cost-effectiveness comparisons of adult spinal deformity surgery in the United States and Japan.

PubMed

Yagi, Mitsuru; Ames, Christopher P; Keefe, Malla; Hosogane, Naobumi; Smith, Justin S; Shaffrey, Christopher I; Schwab, Frank; Lafage, Virginie; Shay Bess, R; Matsumoto, Morio; Watanabe, Kota

2018-03-01

Information about the cost-effectiveness of surgical procedures for adult spinal deformity (ASD) is critical for providing appropriate treatments for these patients. The purposes of this study were to compare the direct cost and cost-effectiveness of surgery for ASD in the United States (US) and Japan (JP). Retrospective analysis of 76 US and 76 JP patients receiving surgery for ASD with ≥2-year follow-up was identified. Data analysis included preoperative and postoperative demographic, radiographic, health-related quality of life (HRQOL), and direct cost for surgery. An incremental cost-effectiveness ratio (ICER) was determined using cost/quality-adjusted life years (QALY). The cost/QALY was calculated from the 2-year cost and HRQOL data. JP exhibited worse baseline spinopelvic alignment than the US (pelvic incidence and lumbar lordosis: 35.4° vs 22.7°, p < 0.01). The US had more three-column osteotomies (50 vs 16%), and shorter hospital stay (7.9 vs 22.7 days) (p < 0.05). The US demonstrated worse postoperative ODI (41.3 vs. 33.9%) and greater revision surgery rate (40 vs 10%) (p < 0.05). Due to the high initial cost and revision frequency, the US had greater total cost ($92,133 vs. $49,647) and cost/QALY ($511,840 vs. $225,668) at 2-year follow-up (p < 0.05). Retrospective analysis comparing the direct costs and cost-effectiveness of ASD surgery in the US vs JP demonstrated that the total direct costs and cost/QALY were substantially higher in the US than JP. Variations in patient cohort, healthcare costs, revision frequencies, and HRQOL improvement influenced the cost/QALY differential between these countries.

Post-operative course of coronary artery bypass surgery patients who pre-donate autologous blood.

PubMed

Jovin, Ion S; Stelzig, Georg; Strelitz, Joachim C; Taborski, Uwe; Jovin, Angelika; Heidinger, Kathrin; Klövekorn, Wolf-Peter; Müller-Berghaus, Gert

2003-12-01

Pre-operative autologous blood donation is used to reduce the need of allogeneic blood in patients undergoing coronary bypass surgery operations, but it is not clear what impact the blood donation has on the post-operative course of these patients. We studied the post-operative course of 210 patients who pre-donated autologous blood before their coronary bypass operation (donors) and of 67 patients who were eligible to pre-donate but did not (controls). The clinical variables and the technical operative parameters of the patients in the two groups were similar. There was no significant difference between the duration of assisted ventilation post-operatively (756 +/- 197 vs. 802 +/- 395 min; P=0.54) or length of stay in the intensive care unit (1.8 +/- 1.1 vs. 1.7 +/- 0.9 days; P=0.52) of the two groups. The number of autologous units of packed red cells and of fresh frozen plasma (FFP) received by the donors was significantly higher than the number of units of allogeneic packed red cells (1.5 +/- 0.9 vs. 0.3 +/- 0.9; P=0.001) and the units of homologous FFP received by the controls (2.3 +/- 0.8 vs. 0.6 +/- 1; P=0.001). We found no evidence that autologous blood donation exerted a negative influence on the post-operative course of patients undergoing coronary bypass surgery. Patients who pre-donated blood received no allogeneic blood products, but the number of autologous blood products received by donors was higher than the number of blood products received by patients who did not pre-donate.

[Pathogenesis of adhesions formation after intraabdominal operations].

PubMed

Voskanian, S É; Kyzlasov, P S

2011-01-01

The article describes the pathogenesis of adhesions formation after intraabdominal operations. Described predisposing factors leading of which is mechanical trauma, resulting from the use of surgical instruments, rough manipulations during surgery, damage to the mesothelium by dry gauze etc, which cause the adhesions. The pathogenesis of adhesions formation after intraabdominal surgery is presented in outline form, which described the changes occurring in the body starting with combination of predisposing factors and ending with the development of adhesions with blood vessels by 7-12 days after surgery. At the genetic level predisposition to adhesions formation and development of adhesive disease is treated as a manifestation of rapid acetylation phenotype, in which the intensity of fibrin formation exceeds normal rate of its catabolism. Thus, according to modem concepts, adhesive disease is a separate nosologic unit that dictates the necessity of its detailed study, development and introduction new universal methods of preventing the adhesions formation after intraabdominal operations.

Unit cost of healthcare services at 200-bed public hospitals in Myanmar: what plays an important role of hospital budgeting?

PubMed

Than, Thet Mon; Saw, Yu Mon; Khaing, Moe; Win, Ei Mon; Cho, Su Myat; Kariya, Tetsuyoshi; Yamamoto, Eiko; Hamajima, Nobuyuki

2017-09-19

Cost information is important for efficient allocation of healthcare expenditure, estimating future budget allocation, and setting user fees to start new financing systems. Myanmar is in political transition, and trying to achieve universal health coverage by 2030. This study assessed the unit cost of healthcare services at two public hospitals in the country from the provider perspective. The study also analyzed the cost structure of the hospitals to allocate and manage the budgets appropriately. A hospital-based cross-sectional study was conducted at 200-bed Magway Teaching Hospital (MTH) and Pyinmanar General Hospital (PMN GH), in Myanmar, for the financial year 2015-2016. The step-down costing method was applied to calculate unit cost per inpatient day and per outpatient visit. The costs were calculated by using Microsoft Excel 2010. The unit costs per inpatient day varied largely from unit to unit in both hospitals. At PMN GH, unit cost per inpatient day was 28,374 Kyats (27.60 USD) for pediatric unit and 1,961,806 Kyats (1908.37 USD) for ear, nose, and throat unit. At MTH, the unit costs per inpatient day were 19,704 Kyats (19.17 USD) for medicine unit and 168,835 Kyats (164.24 USD) for eye unit. The unit cost of outpatient visit was 14,882 Kyats (14.48 USD) at PMN GH, while 23,059 Kyats (22.43 USD) at MTH. Regarding cost structure, medicines and medical supplies was the largest component at MTH, and the equipment was the largest component at PMN GH. The surgery unit of MTH and the eye unit of PMN GH consumed most of the total cost of the hospitals. The unit costs were influenced by the utilization of hospital services by the patients, the efficiency of available resources, type of medical services provided, and medical practice of the physicians. The cost structures variation was also found between MTH and PMN GH. The findings provided the basic information regarding the healthcare cost of public hospitals which can apply the efficient utilization of the available resources.

Prospective comparison of perioperative antibiotic management protocols in oncological head and neck surgery.

PubMed

Bartella, Alexander K; Kamal, Mohammad; Teichmann, Jan; Kloss-Brandstätter, Anita; Steiner, Timm; Hölzle, Frank; Lethaus, Bernd

2017-07-01

The adequate perioperative antibiotic prophylaxis in head and neck cancer surgery is an important and easy applicable tool to decrease nosocomial morbidity and mortality by reducing the rate of infections. In the study a strictly perioperative antibiosis is compared with an extended postoperative prophylactic antibiosis. We aim to clarify the value of postoperative prophylactic antibiosis for the recovery and clinical course of patients. In this prospective study 75 consecutive patients, who underwent major oncological head and neck surgery were included and divided in three groups, each containing 25 patients. The first group received peri- and postoperative antibiotic prophylaxis (POAP) from the day of operation until the fifth day postoperatively. The second group was treated with perioperative antibiotic prophylaxis (PEAP) only. The third group received perioperative antibiotic prophylaxis and increased local antiseptic care (PAPAC). General anamnestic data was collected, as well as duration of hospitalisation, stay on intensive care unit, rate and type of infections, surgical closure of the tracheostomy, and postoperative blood parameters. There were no statistically significant differences in general diseases or extent of surgery between the groups. There were statistically significant fewer patients suffering from surgical site infections in subjects with POAP (n = 1) in comparison to PEAP (n = 9; p = 0.011) and PAPAC (n = 9; p = 0.011). In contrast, other nosocomial infections (pneumonia, urinary tract infection, sepsis) did not decrease under a prolonged antibiotic prophylaxis. Based on findings of the study, we recommend an extended postoperative antibiotic prophylaxis for patients undergoing major oncological head and neck surgery. Copyright © 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

A review of 111 anaesthetic patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

PubMed Central

Thong, Sze Ying; Chia, Claramae Shulyn; Ng, Oriana; Tan, Grace; Ong, Ee Teng; Soo, Khee Chee; Teo, Melissa

2017-01-01

INTRODUCTION Cytoreductive surgery (CRS) along with hyperthermic intraperitoneal chemotherapy (HIPEC) is the treatment of choice for selected patients with peritoneal carcinomatosis, a previously lethal condition with dismal survival rates. METHODS We reviewed CRS and HIPEC procedures performed at our centre from January 1997 to December 2012, focusing on perioperative events and anaesthetic implications. RESULTS In total, 111 patients underwent 113 procedures. Mean age of the patients was 51.7 (range 14–74) years and 84.1% were women. Mean duration of surgery was 9 hours 10 minutes ± 2 hours 56 minutes. Most tumours were ovarian or colorectal in origin, and the mean peritoneal cancer index (PCI) score was 14.3 ± 8.9. Mean estimated blood loss was 1,481 ± 1,064 mL. Mean total intravenous fluids and blood products administered was 8,498 ± 3,941 mL. Postoperatively, 79.5% of the patients needed intensive care, as 75.2% of the 113 procedures required interval extubation. Patients with lower PCI scores were more likely to be extubated immediately after surgery (p < 0.05). 80.0% of patients had coagulopathy postoperatively, and this was associated with longer HIPEC duration (p < 0.05). Median lengths of intensive care unit and hospital stays were two days and 14 days, respectively. Longer duration of surgery significantly correlated with longer hospitalisation. Prolonged hospitalisation was due to nosocomial pneumonia, pleural effusions, respiratory failure, sepsis, surgical complications (such as anastomotic or wound dehiscence), and intra-abdominal infections. CONCLUSION The CRS and HIPEC technique is a major surgery with significant morbidity, as highlighted by the perioperative concerns observed in our study. PMID:27121920

Impact of minimally invasive surgery on medical spending and employee absenteeism.

PubMed

Epstein, Andrew J; Groeneveld, Peter W; Harhay, Michael O; Yang, Feifei; Polsky, Daniel

2013-07-01

As many surgical procedures have undergone a transition from a standard, open surgical approach to a minimally invasive one in the past 2 decades, the diffusion of minimally invasive surgery may have had sizeable but overlooked effects on medical expenditures and worker productivity. To examine the impact of standard vs minimally invasive surgery on health plan spending and workplace absenteeism for 6 types of surgery. Cross-sectional regression analysis. National health insurance claims data and matched workplace absenteeism data from January 1, 2000, to December 31, 2009. A convenience sample of adults with employer-sponsored health insurance who underwent either standard or minimally invasive surgery for coronary revascularization, uterine fibroid resection, prostatectomy, peripheral revascularization, carotid revascularization, or aortic aneurysm repair. Health plan spending and workplace absenteeism from 14 days before through 352 days after the index surgery. There were 321,956 patients who underwent surgery; 23,814 were employees with workplace absenteeism data. After multivariable adjustment, mean health plan spending was lower for minimally invasive surgery for coronary revascularization (-$30,850; 95% CI, -$31,629 to -$30,091), uterine fibroid resection (-$1509; 95% CI, -$1754 to -$1280), and peripheral revascularization (-$12,031; 95% CI, -$15,552 to -$8717) and higher for prostatectomy ($1350; 95% CI, $611 to $2212) and carotid revascularization ($4900; 95% CI, $1772 to $8370). Undergoing minimally invasive surgery was associated with missing significantly fewer days of work for coronary revascularization (mean difference, -37.7 days; 95% CI, -41.1 to -34.3), uterine fibroid resection (mean difference, -11.7 days; 95% CI, -14.0 to -9.4), prostatectomy (mean difference, -9.0 days; 95% CI, -14.2 to -3.7), and peripheral revascularization (mean difference, -16.6 days; 95% CI, -28.0 to -5.2). For 3 of 6 types of surgery studied, minimally invasive procedures were associated with significantly lower health plan spending than standard surgery. For 4 types of surgery, minimally invasive procedures were consistently associated with significantly fewer days of absence from work.

Atenolol Is Associated with Lower Day of Surgery Heart Rate as compared to Long and Short-acting Metoprolol

PubMed Central

Schonberger, Robert B.; Brandt, Cynthia; Feinleib, Jessica; Dai, Feng; Burg, Matthew M.

2012-01-01

Objectives We analyzed the association between outpatient beta-blocker type and day-of-surgery heart rate in ambulatory surgical patients. We further investigated whether differences in day of surgery heart rate between atenolol and metoprolol could be explained by once-daily versus twice-daily dosing regimens. Design Retrospective observational study. Setting VA Hospital Participants Ambulatory surgical patients on chronic atenolol or metoprolol. Interventions None. Measurements and Main Results Using a propensity-score matched cohort, we compared day of surgery heart rates of patients prescribed atenolol versus metoprolol. We then differentiated between once-daily and twice-daily metoprolol formulations and compared day of surgery heart rates within a general linear model. Day of surgery heart rates in patients prescribed atenolol vs. any metoprolol formulation were slower by a mean of 5.1 beats/min (66.6 vs. 71.7; 95% CI of difference 1.9 to 8.3, p=0.002), a difference that was not observed in preoperative primary care visits. The general linear model demonstrated that patients prescribed atenolol (typically QD dosing) had a mean day of surgery heart rate 5.6 beats/min lower compared to patients prescribed once-daily metoprolol succinate (68.9 vs. 74.5; 95% CI of difference: −8.6 to −2.6, p<0.001) and 3.8 beats/minute lower compared to patients prescribed twice-daily metoprolol tartrate (68.9 vs. 72.7; 95% CI of difference: −6.1 to −1.6, p<0.001). Day of surgery heart rates were similar between different formulations of metoprolol (95% CI of difference: −1.0 to +4.6, p=0.22). Conclusions Atenolol is associated with lower day of surgery heart rate vs. metoprolol. The heart rate difference is specific to the day of surgery and is not explained by once-daily versus twice-daily dosing regimens. PMID:22889605

Increased blood product use among coronary artery bypass patients prescribed preoperative aspirin and clopidogrel

PubMed Central

Ray, Joel G; Deniz, Stacy; Olivieri, Anthony; Pollex, Erika; Vermeulen, Marian J; Alexander, Kurian S; Cain, David J; Cybulsky, Irene; Hamielec, Cindy M

2003-01-01

Background The administration of antiplatelet drugs before coronary artery bypass graft surgery (CABG) is associated with an increased risk of major hemorrhage and related surgical reexploration. Little is known about the relative effect of combined clopidogrel and aspirin on blood product use around the time of CABG. We evaluated the associated risk between the combined use of aspirin and clopidogrel and the transfusion of blood products perioperatively. Methods We retrospectively studied a cohort of 659 individuals who underwent a first CABG, without concomitant valvular or aortic surgery, at a single large Canadian cardiac surgical centre between January 2000 and April 2002. The four study exposure groups were those prescribed aspirin (n = 105), clopidogrel (n = 11), the combination of both (n = 46), or neither drug (n = 497), within 7 days prior to CABG. The primary study outcome was the excessive transfusion of blood products during CABG and up to the second post-operative day, defined as ≥ 2 units of packed red blood cells (PRBC), ≥ 2 units of fresh frozen plasma, ≥ 5 units of cryoprecipitate or ≥ 5 units of platelets. Secondary outcomes included the mean number of transfused units of each type of blood product. Results A greater mean number of units of PRBC were transfused among those who received clopidogrel alone (2.9) or in combination with aspirin (2.4), compared to those on aspirin alone (1.9) or neither antiplatelet drug (1.4) (P = 0.001). A similar trend was seen for the respective mean number of transfused units of platelets (3.6, 3.7, 1.3 and 1.0; P < 0.001) and fresh frozen plasma (2.5, 3.1, 2.3, 1.6; P = 0.01). Compared to non-users, the associated risk of excessive blood product transfusion was highest among recipients of aspirin and clopidogrel together (adjusted OR 2.2, 95% CI 1.1–4.3). No significant association was seen among lone users of aspirin (adjusted OR 1.0, 95% CI 0.6–1.6) or clopidogrel (adjusted OR 0.7, 95% CI 0.2–2.5), compared to non-users. Conclusions While combined use of aspirin and clopidogrel shortly before CABG surgery may increase the associated risk of excess transfusion of blood products perioperatively, several study limitations prevent any confident conclusions from being drawn. Beyond challenging these findings, future research might focus on the value of both intraoperative monitoring of platelet function, and the effectiveness of antifibrinolytic agents, at reducing the risk of postoperative bleeding. PMID:12769833

Resource variation in colorectal surgery: a national centre level analysis.

PubMed

Drake, T M; Lee, M J; Senapati, A; Brown, S R

2017-07-01

Delivery of quality colorectal surgery requires adequate resources. We set out to assess the relationship between resources and outcomes in English colorectal units. Data were extracted from the Association of Coloproctology of Great Britain and Ireland resource questionnaire to profile resources. This was correlated with Hospital Episode Statistics outcome data including 90-day mortality and readmissions. Patient satisfaction measures were extracted from the Cancer Experience Patient Survey and compared at unit level. Centres were divided by workload into low, middle and top tertile. Completed questionnaires were received from 75 centres in England. Service resources were similar between low and top tertiles in access to Confidential Enquiry into Patient Outcome and Death (CEPOD) theatre, level two or three beds per 250 000 population or the likelihood of having a dedicated colorectal ward. There was no difference in staffing levels per 250 000 unit of population. Each 10% increase in the proportion of cases attempted laparoscopically was associated with reduced 90-day unplanned readmission (relative risk 0.94, 95% CI 0.91-0.97, P < 0.001). The presence of a dedicated colorectal ward (relative risk 0.85, 95% CI 0.73-0.99, P = 0.040) was also associated with a significant reduction in unplanned readmissions. There was no association between staffing or service factors and patient satisfaction. Resource levels do not vary based on unit of population. There is benefit associated with increased use of laparoscopy and a dedicated surgical ward. Alternative measures to assess the relationship between resources and outcome, such as failure to rescue, should be explored in UK practice. Colorectal Disease © 2017 The Association of Coloproctology of Great Britain and Ireland.

Utilization profile of the trauma intensive care unit at the Role 3 Multinational Medical Unit at Kandahar Airfield between May 1 and Oct. 15, 2009

PubMed Central

Shah, Kalpa; Pirie, Steven; Compton, Lisa; McAlister, Vivian; Church, Brian; Kao, Raymond

2011-01-01

Background In the war against the Taliban, Canada was the lead North Atlantic Treaty Organization (NATO) nation to provide medical and surgical care to NATO soldiers, Afghanistan National Army soldiers, Afghanistan Nation Police, civilians working in and outside Kandahar Airfield and Afghanistan civilians at the Role 3 Multinational Medical Unit (R3MMU) from February 2006 to October 2009. Methods We obtained data from the Joint Theatre Trauma Registry between May 1 and Oct. 15, 2009; 188 patients were admitted to the R3MMU intensive care unit (ICU). We analyzed the ICU data according to types and causes of trauma, mechanical ventilation prevalence, ICU medical and surgical complications, blood products utilization, length of stay in the ICU and mortality. Results The admitting services were general surgery (35%), neurosurgery (29%), orthopedic surgery (18%) and internal medicine (3%). Improvised explosive devices (46%) and gunshot wounds (26%) were the main causes of ICU admissions. The mean injury severity score for all patients admitted to the ICU was 37, and 81% of ICU patients required mechanical ventilation for a mean duration of 3 days. The main ICU complications were coagulopathy (6.4%), aspiration pneumonia (4.3%), pneumothorax (3.7%) and wound infection (2.7%). The following blood products were most used: packed red blood cells (55%), fresh frozen plasma (54%), platelets (29%) and cryoprecipitate (23%). The average length of stay in the ICU was 4.3 days, and the survival rate was 93%. Conclusion The high survival rate suggests that ICU care is a necessary and vital resource for a trauma hospital in a war zone. PMID:22099326

A novel interdisciplinary analgesic program reduces pain and improves function in older adults after orthopedic surgery.

PubMed

Morrison, R Sean; Flanagan, Steven; Fischberg, Daniel; Cintron, Alexie; Siu, Albert L

2009-01-01

To examine the effect of a multicomponent intervention on pain and function after orthopedic surgery. Controlled prospective propensity score-matched clinical trial. New York City acute rehabilitation hospital. Two hundred forty-nine patients admitted to rehabilitation after hip fracture repair (n=51) or hip (n=64) or knee (n=134) arthroplasty. Pain assessment at rest and with physical therapy (PT) by staff using numeric rating scales (1 to 5). Physician protocols for standing analgesia and preemptive analgesia before PT were implemented on the intervention unit. Control unit patients received usual care. Pain, analgesic prescribing, gait speed, transfer time, and percentage of PT sessions completed during admission. Pain and difficulty walking at 6, 12, 18, and 24 weeks after discharge. In multivariable analyses intervention patients were significantly more likely than controls to report no or mild pain at rest (66% vs 49%, P=.004) and with PT (52% vs 38%, P=.02) on average for the first 7 days of rehabilitation, had faster 8-foot-walk times on Days 4 (9.3 seconds vs 13.2 seconds, P=.02) and 7 (6.9 vs 9.2 seconds, P=.02), received more analgesia (23.6 vs 15.6 mg of morphine sulfate equivalents per day, P<.001), were more likely to receive standing orders for analgesia (98% vs 48%, P<.001), and had significantly shorter lengths of stay (10.1 vs 11.3 days, P=.005). At 6 months, intervention patients were less likely than controls to report moderate to severe pain with walking (4% vs 15%, P=.02) and that pain did not interfere with walking (7% vs 18%, P=.004) and were less likely to be taking analgesics (35% vs 51%, P=.03). The intervention improved postoperative pain, reduced chronic pain, and improved function.

The refinement of a cultural standardized patient examination for a general surgery residency program.

PubMed

Chun, Maria B J; Deptula, Peter; Morihara, Sarah; Jackson, David S

2014-01-01

Recent articles have documented the importance of cultural competency in surgery. Surgical residency programs have used the Objective Structured Clinical Examinations or cultural standardized patient examinations as a training tool. Past studies evaluating cultural competency have noted the importance of including an observational (control) arm, which would allow for a more objective assessment of a resident's competency in this area. The purpose of our article is to present the results of a follow-up study to a pilot cultural standardized patient examination for surgery residents. All first-year surgery residents were required to participate in the videotaped cultural SP examination as part of the general surgery residency curriculum. Two measures were used to assess resident performance. On the day of the examination, the Cross-Cultural Care Survey was administered. The examination was assessed by the residents themselves, faculty observers, and standardized patients, using a written checklist that was developed to evaluate residents on all 6 Accreditation Council for Graduate Medical Education competencies. The current study includes 20 first-year surgery residents from academic years 2011 to 2012 and 2012 to 2013. The examination of pretest differences in groups found that students born outside of the United States had significantly higher scores on attitude (t = -2.68, df = 18, p = 0.02), but no statistically significant differences were found in skillfulness or knowledge or in the overall rating scale. For the overall rating scale, change from pretest to posttest was statistically significant (t = -2.25, df = 18, p = 0.04). Further analysis revealed that students who were born in the United States demonstrated a significant increase in ratings (t = -3.08, df = 10, p = 0.01) whereas students who were not born in the United States showed little change (t = -0.35, df = 7, p = 0.74). These results show that the means in attitude scales changed little for all groups, but both white and US-born students showed greater improvement on skillfulness and knowledge. Training and measurement of cross-cultural health care skills remains challenging. However, studies like these provide a good starting point from which to build. © 2013 Published by Association of Program Directors in Surgery on behalf of Association of Program Directors in Surgery.

Does Day of Surgery Affect Hospital Length of Stay and Charges Following Minimally Invasive Transforaminal Lumbar Interbody Fusion?

PubMed

Hijji, Fady Y; Narain, Ankur S; Haws, Brittany E; Khechen, Benjamin; Kudaravalli, Krishna T; Yom, Kelly H; Singh, Kern

2018-06-01

Retrospective Cohort. To determine if an association exists between surgery day and length of stay or hospital costs after minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). Length of inpatient stay after orthopedic procedures has been identified as a primary cost driver, and previous research has focused on determining risk factors for prolonged length of stay. In the arthroplasty literature, surgery performed later in the week has been identified as a predictor of increased length of stay. However, no such investigation has been performed for MIS TLIF. A surgical registry of patients undergoing MIS TLIF between 2008 and 2016 was retrospectively reviewed. Patients were grouped based on day of surgery, with groups including early surgery and late surgery. Day of surgery group was tested for an association with demographics and perioperative variables using the student t test or χ analysis. Day of surgery group was then tested for an association with direct hospital costs using multivariate linear regression. In total, 438 patients were analyzed. In total, 51.8% were in the early surgery group, and 48.2% were in the late surgery group. There were no differences in demographics between groups. There were no differences between groups with regard to operative time, intraoperative blood loss, length of stay, or discharge day. Finally, there were no differences in total hospital charges between early and late surgery groups (P=0.247). The specific day on which a MIS TLIF procedure occurs is not associated with differences in length of inpatient stay or total hospital costs. This suggests that the postoperative course after MIS TLIF procedures is not affected by the differences in hospital staffing that occurs on the weekend compared with weekdays.

Obesity and Diabetes Mellitus Adversely Affect Outcomes after Cardiac Surgery in Children's Hospitals.

PubMed

Shamszad, Pirouz; Rossano, Joseph W; Marino, Bradley S; Lowry, Adam W; Knudson, Jarrod D

2016-09-01

To assess how obesity or diabetes mellitus impacts outcomes in patients undergoing cardiac surgery in pediatric hospitals. A multi-institutional, matched case-control study of the Pediatric Health Information System database was performed. Tertiary children's hospitals in the United States. All cardiac surgical cases in patients with obesity or diabetes mellitus between 2004 and 2012 were included. Cases were matched to controls by age, sex, race, and Risk Adjustment for Congenital Heart Surgery score. Mortality, surgical complications, and hospital utilization. Differences in outcome measures were assessed by chi-square and Mann-Whitney tests. P value < .05 was significant. Six hundred twenty-nine cardiac surgical cases (median age 17 years [IQR 12-32]) with obesity or diabetes mellitus were matched to 629 controls. Cases demonstrated lower median household income than those in the control group ($38,031 [IQR $31,900-$48,844] vs. ($41,896 [IQR $32,854-$56,020], P < .001). Mortality was similar between cases and controls (22% vs. 1.9%, P =.692). Surgical complications occurred similarly between cases and controls (13.5% vs. 12.4%, P = .535). Cases had longer intensive care unit length of stay than controls (3 vs. 2 days, P = .001), resulting in longer overall hospital length of stay (5 vs. 4 days, P < .001). Cases also had a higher odds of undergoing mechanical ventilation for >96 hours (OR 2.0, 95% CI 1.1-3.7) and higher rate of total parenteral nutrition use (7.2% vs. 4.5%, P = .040). Median hospital charges were higher in cases (clinical: $6,696 vs. $5,872; laboratory: $14,168 vs. $12,251; pharmacy: $12,971 vs. $10,426; imaging: $6,259 vs. $5,660; P ≤ .030 for all). The presence of obesity or diabetes mellitus was associated with increased postoperative morbidity, hospital utilization, and cost in patients undergoing cardiac surgery in pediatric hospitals. © 2016 Wiley Periodicals, Inc.

Case scheduling preferences of one Surgeon's cataract surgery patients.

PubMed

Dexter, Franklin; Birchansky, Lee; Bernstein, James M; Wachtel, Ruth E

2009-02-01

The increase in the number of operating rooms nationwide in the United States may reflect preferences of patients for scheduling of outpatient surgery. Yet, little is known of the importance that patients place on scheduling convenience and flexibility. Fifty cataract surgery patients seen by a surgeon at his main office during a 6-mo period responded to a marketing survey. All the patients had Medicare insurance and supplemental insurance permitting surgery at any facility. A telephone questionnaire included four vignettes describing different choices in the scheduling of cataract surgery. Respondents were asked how far they would be willing to travel for one option instead of another. For example, "Your surgery will be on Thursday in three weeks at 2 pm. You can drink water until 9 am. You arrive at 10 am, because your surgery might start early. If you travel farther, you would arrive at 8 am for 9 am surgery." The median (50th percentile) additional travel time was 60 min (lower 95% confidence bound >or=52 min) for each of four options: to receive care on a day chosen by the patient instead of assigned by the physician, to receive care at a single site instead of both the surgeon's office and a surgery center at a different location, to combine the examination and the surgery into a single visit instead of two visits, and to have surgery in the morning instead of the afternoon. The patients of this ophthalmologist placed a high value on convenience and flexibility in scheduling their surgery. In general, this would be achievable only if many operating rooms were available each morning.

Reconstructive Microsurgery: The Future Is Today.

PubMed

Amin, Kavit; Mohan, Anita T

2017-01-01

This reconstructive microsurgery course will run yearly and was borne and popularized from its infant meeting the year before, primarily focused on perforator flaps. It is a 2-day course updating residents/registrars to attending physicians/consultants about the most topical advancements in microvascular reconstructive surgery. The course is held at the New York University Langone Hospital in the United States.The timetable is primarily lecture based with the advantage of live-surgical procedures by world-renowned faculty. The timetable includes, but not limited to, facial/hand vascularized composite allotransplantation, upper/lower limb, breast, head and neck, transgender, and lymphedema surgery. Lectures were highly informative and there was ample time for case discussion with the appreciation that managing complex situations often requires input from other colleagues. The faculty focused on the lessons they have learned and potential pitfalls to avoid. The faculty was comprised of leading experts in reconstructive microsurgery from Europe, Korea, and throughout the United States.The primary emphasis of the course was to appreciate the global recognition in advances in microsurgery.

Reduction in blood transfusion in a cohort of infants having cardiac surgery with cardiopulmonary bypass after instituting a goal-directed transfusion policy.

PubMed

Machovec, Kelly A; Smigla, Gregory; Ames, Warwick A; Schwimer, Courtney; Homi, H Mayumi; Dhakal, Ishwori B; Jaquiss, Robert D B; Lodge, Andrew J; Jooste, Edmund H

2016-10-01

Current trends in pediatric cardiac surgery and anesthesiology include goal-directed allogeneic blood transfusion, but few studies address the transfusion of platelets and cryoprecipitate. We report a quality improvement initiative to reduce the transfusion of platelets and cryoprecipitate in infants having cardiac surgery with cardiopulmonary bypass (CPB). Data from 50 consecutive patients weighing four to ten kilograms having cardiac surgery with CPB were prospectively collected after the institution of a policy to obtain each patient's platelet and fibrinogen levels during the rewarming phase of CPB. Data from 48 consecutive patients weighing four to ten kilograms having cardiac surgery with CPB prior to the implementation of the policy change were retrospectively collected. Demographics, laboratory values and blood product transfusion data were compared between the groups, using the Chi-square/Fisher's exact test or the T-Test/Wilcoxon Rank-Sum test, as appropriate. The results showed more total blood product exposures in the control group during the time from bypass through the first twenty-four post-operative hours (median of 2 units versus 1 unit in study group, p=0.012). During the time period from CPB separation through the first post-operative day, 67% of patients in the control group received cryoprecipitate compared to 32% in the study group (p=0.0006). There was no difference in platelet exposures between the groups. Checking laboratory results during the rewarming phase of CPB reduced cryoprecipitate transfusion by 50%. This reproducible strategy avoids empiric and potentially unnecessary transfusion in this vulnerable population. © The Author(s) 2016.

Epidemiologic analysis: Prophylaxis and multidrug-resistance in surgery.

PubMed

Solís-Téllez, H; Mondragón-Pinzón, E E; Ramírez-Marino, M; Espinoza-López, F R; Domínguez-Sosa, F; Rubio-Suarez, J F; Romero-Morelos, R D

Surgical site infection is defined as an infection related to the surgical procedure in the area of manipulation occurring within the first 30 postoperative days. The diagnostic criteria include: purulent drainage, isolation of microorganisms, and signs of infection. To describe the epidemiologic characteristics and differences among the types of prophylactic regimens associated with hospital-acquired infections at the general surgery service of a tertiary care hospital. The electronic case records of patients that underwent general surgery at a tertiary care hospital within the time frame of January 1, 2013 and December 31, 2014 were reviewed. A convenience sample of 728 patients was established and divided into the following groups: Group 1: n=728 for the epidemiologic study; Group 2: n=638 for the evaluation of antimicrobial prophylaxis; and Group 3: n=50 for the evaluation of multidrug-resistant bacterial strains in the intensive care unit. The statistical analysis was carried out with the SPSS 19 program, using the Mann-Whitney U test and the chi-square test. A total of 728 procedures were performed (65.9% were elective surgeries). Three hundred twelve of the patients were males and 416 were females. Only 3.98% of the patients complied with the recommended antimicrobial prophylaxis, and multidrug-resistant bacterial strains were found in the intensive care unit. A single prophylactic dose is effective, but adherence to this recommendation was not adequate. The prophylactic guidelines are not strictly adhered to in our environment. There was a significant association between the development of nosocomial infections from multidrug-resistant germs and admission to the intensive care unit. Copyright © 2016 Asociación Mexicana de Gastroenterología. Publicado por Masson Doyma México S.A. All rights reserved.

Injury to endoscopic personnel from tripping over exposed cords, wires, and tubing in the endoscopy suite: a preventable cause of potentially severe workplace injury.

PubMed

Cappell, Mitchell S

2010-04-01

BACKGROUND The endoscopy unit before remediation may be a high-risk area for slip and fall injuries due to a large number of exposed above-the-floor wires in the endoscopy rooms, dimmed lighting during endoscopic procedures, and staff inattention to obstacles due to preoccupation with the endoscopic patient. AIM To describe a novel, previously unappreciated workplace hazard to endoscopic personnel: Exposed wires in the endoscopy unit.METHODS This study is a retrospective review of 110,000 endoscopic procedures performed during the last 5 years at an academic, teaching hospital with a high-volume endoscopy unit. All significant orthopedic injuries to endoscopic personnel from slips, twists, and falls from tripping over exposed cords in the endoscopy unit were reviewed. The severity of injury was documented based on roentgenographic findings, number of days of missed work, number of days with a modified work schedule, and requirement for orthopedic surgery. The number of potentially exposed cords per endoscopy room was determined. RESULTS During the 5-year study period, three endoscopic personnel suffered significant orthopedic injuries from slips, twists, and falls from tripping over cords, wires, or tubing lying exposed over the floor in the endoscopy suite: The resulting injuries consisted of fourth and fifth metacarpal hand fractures due to a fall after tripping on oxygen tubing; a rib fracture due to tripping on electrical wires trailing from an endoscopy cart; and a grade II ankle sprain due to the foot becoming entangled in oxygen tubing. All injuries resulted in lost days of work [mean 9.3 +/- 11.0 (SD) days] and in additional days of restricted work (mean 41.7 +/- 31.8 days). One injury required orthopedic surgery. Hospital review revealed a mean of 35.3 +/- 7.5 cords, wires, or tubing per endoscopy procedure room, the majority of which were exposed above the floor before remediation (n = 10 rooms). Remediation of exposed wires included: bundling related wires together in a cable to reduce the number of independent wires, covering exposed wires on the floor with a nonslip heavy mat, and running wires from ceiling outlets to equipment high above ground (e.g. mounted endoscopy video monitors). CONCLUSIONS Tripping, slipping, and falling over exposed wires can cause significant injury to endoscopic personnel. This previously undescribed hazard should be preventable by simple remediation, and all endoscopic personnel, hospital architects, hospital administrators, and governmental regulators should be alerted to this potential hazard

Surgery for doubly committed ventricular septal defects.

PubMed

Shamsuddin, Ahmad Mahir; Chen, Yen Chuan; Wong, Abdul Rahim; Le, Trong-Phi; Anderson, Robert H; Corno, Antonio F

2016-08-01

Doubly committed ventricular septal defects (VSDs) account for up to almost one-third of isolated ventricular septal defects in Asian countries, compared with only 1/20th in western populations. In our surgical experience, this type of defect accounted for almost three-quarters of our practice. To date, patch closure has been considered the gold standard for surgical treatment of these lesions. Our objectives are to evaluate the indications and examine the outcomes of surgery for doubly committed VSDs. Between October 2013, when our service of paediatric cardiac surgery was opened, and December 2014, 24 patients were referred for surgical closure of VSDs. Among them, 17 patients (71%), with the median age of 6 years, ranging from 2 to 9 years, and with a median body weight of 19 kg, ranging from 11 to 56 kg, underwent surgical repair for doubly committed defects. In terms of size, the defect was considered moderate in 4 and large in 13. Aortic valvular regurgitation (AoVR) was present in 11 patients (65%) preoperatively, with associated malformations found in 14 (82%), with 5 patients (29%) having two or more associated defects. After surgery, there was trivial residual shunting in 2 patients (12%). AoVR persisted in 6 (35%), reducing to trivial in 5 (29%) and mild in 1 (6%). Mean stays in the intensive care unit and hospital were 2.6 ± 1.2 days, ranging from 2 to 7 days, and 6.8 ± 0.8 days, ranging from 6 to 9 days, respectively. The mean follow-up was 14 ± 4 months, ranging from 6 to 20 months, with no early or late deaths and without clinical deterioration. The incidence of doubly committed lesions is high in our experience, frequently associated with AoVR and other associated malformation. Early detection is crucial to prevent further progression of the disease. Patch closure remains the gold standard in management, not least since it allows simultaneous repair of associated intracardiac defects. © The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

[Effect of dexmedetomidine on emergence agitation after general anesthesia in children undergoing odontotherapy in day-surgery operating room].

PubMed

Lin, Luo; Yueming, Zhang; Meisheng, Li; Jiexue, Wang; Yang, Ji

2017-12-01

To study the effectiveness of dexmedetomidine used for general anesthesia maintenance in children undergoing odontotherapy in day-surgery operating room in reducing the incidence of emergence agitation (EA). Eighty children undergoing odontotherapy and under general anesthesia in day-surgery operating room were randomized into two groups, group A (n=40) and group B (n=40). Each patient in group A was administered with a bolus dose of dexmedetomidine (1.0 μg·kg⁻¹, saline diluted to 10 mL) pump-infused after intubation and a maintenance dose of 0.1-0.4 mL·(kg·h)⁻¹ followed-up until 45 min before the end of operation. Each patient in group B was administered with a bolus dose of normal saline 10 mL pump-infused after intubation and maintenance dose of 0.1-0.4 mL·(kg·h)⁻¹ followed-up until 45 min before the end of operation. Gender, age, weight, physical status according to the American Society of Anesthesiologists, perioperative heart rate (HR), mean arterial pressure (MAP), pulse oxygen saturation (SpO₂), sufentanil dosage, duration of surgery, time of extubation, time of regaining consciousness, and time to reach modified Aldrete's score≥12 were recorded. Behavior in postanesthesia care unit was rated on the four-point agitation scale. Compared with group B, decreases were observed in HR and MAP at the beginning of operation, in 10 and 30 min, 1 and 2 h after the beginning of operation, and after extubation of group A (P<0.05). Sufentanil dosage and incidence of EA during recovery of group A were also lower than those of group B (P<0.05). Time to regain consciousness and time to reach modified Aldrete's score≥12 of group A were longer than those of group B (P<0.05). No statistical difference was observed between other indexes of the two groups. As an anesthetic used for general anesthesia maintenance in children undergoing odontotherapy in day-surgery operating room, dexmedetomidine results in low incidence of EA during recovery and more stable vital signs.

Postoperative adverse outcomes among physicians receiving major surgeries

PubMed Central

Yeh, Chun-Chieh; Liao, Chien-Chang; Shih, Chun-Chuan; Jeng, Long-Bin; Chen, Ta-Liang

2016-01-01

Abstract Outcomes after surgeries involving physicians as patients have not been researched. This study compares postoperative adverse events between physicians as surgical patients and nonhealth professional controls. Using reimbursement claims data from Taiwan's National Health Insurance Program, we conducted a matched retrospective cohort study of 7973 physicians as surgical patients and 7973 propensity score–matched nonphysician controls receiving in-hospital major surgeries between 2004 and 2010. We compared postoperative major complications, length of hospital stay, intensive care unit (ICU), medical expenditure, and 30-day mortality. Compared with nonphysician controls, physicians as surgical patients had lower adjusted odds ratios (ORs) with 95% confidence intervals (CIs) of postoperative deep wound infection (OR 0.63, 95% CI 0.40–0.99; P < 0.05), prolonged length of stay (OR 0.68, 95% CI 0.62–0.75; P < 0.0001), ICU admission (OR 0.74, 95% CI 0.66–0.83; P < 0.0001), and increased medical expenditure (OR 0.80, 95% CI 0.73–0.88; P < 0.0001). Physicians as surgical patients were not associated with 30-day in-hospital mortality after surgery. Physicians working at medical centers (P < 0.05 for all), dentists (P < 0.05 for all), and those with fewer coexisting medical conditions (P < 0.05 for all) had lower risks for postoperative prolonged length of stay, ICU admission, and increased medical expenditure. Although our study's findings suggest that physicians as surgical patients have better outcomes after surgery, future clinical prospective studies are needed for validation. PMID:27684836

Intraoperative transfusion of 1 U to 2 U packed red blood cells is associated with increased 30-day mortality, surgical-site infection, pneumonia, and sepsis in general surgery patients.

PubMed

Bernard, Andrew C; Davenport, Daniel L; Chang, Phillip K; Vaughan, Taylor B; Zwischenberger, Joseph B

2009-05-01

Transfusion of packed red blood cells (PRBCs) increases morbidity and mortality in select surgical specialty patients. The impact of low-volume, leukoreduced RBC transfusion on general surgery patients is less well understood. The American College of Surgeons National Surgical Quality Improvement Program participant use file was queried for general surgery patients recorded in 2005 to 2006 (n = 125,223). Thirty-day morbidity (21 uniformly defined complications) and mortality, demographic, preoperative, and intraoperative risk variables were obtained. Infectious complications and composite morbidity and mortality were stratified across intraoperative PRBCs units received. Multivariable logistic regression was used to assess influence of transfusion on outcomes, while adjusting for transfusion propensity, procedure type, wound class, operative duration, and 30+ patient risk factors. After adjustment for transfusion propensity, procedure group, wound class, operative duration, and all other important risk variables, 1 U PRBCs significantly (p < 0.05) increased risk of 30-day mortality (odds ratio [OR] = 1.32), composite morbidity (OR = 1.23), pneumonia (OR = 1.24), and sepsis/shock (OR = 1.29). Transfusion of 2 U additionally increased risk for these outcomes (OR = 1.38, 1.40, 1.25, 1.53, respectively; p

Parental Satisfaction with Pediatric Day-Care Surgery and its Determinants in a Tertiary Care Hospital

PubMed Central

Sam, Cenita James; Arunachalam, Pavai A.; Manivasagan, Sivamani; Surya, T.

2017-01-01

Objective: The objective is to assess the level of parental satisfaction of pediatric day-care surgery and its different determinants. Materials and Methods: This is a descriptive study performed in a tertiary care hospital in India among parents of pediatric day-care surgery patients from June 2013 to March 2015. The core questionnaire for the assessment of patient satisfaction for general day care (COPS-D) was used. Variables related to surgery, overall satisfaction, one open-ended question, and socio-demographic data were also collected. Calculated sample size was 121. Results: The mean and standard deviation of parental satisfaction were estimated in eight domains of day care (COPS-D) using Likert scale 1–5. Preadmission visit had a mean of 4.63 (0.52), day of surgery 4.65 (0.58), operating room 4.76 (0.51), nursing care 4.46 (0.79), medical care 4.89 (0.48), information 4.51 (0.68), autonomy 4.64 (0.56), and discharge 4.50 (0.72). In elder children, there was less satisfaction on the information and discharge domains. Overall satisfaction was good in 88% of patients and was less than satisfactory when they had significant pain. Conclusion: Perception of quality of pediatric day-care surgery was assessed with a questionnaire and was found to be good. Variables related to surgery such as pain may be included in the questionnaire for assessing satisfaction in the day-care surgery. PMID:28974875

Mandibular third molar surgery in 396 patients at a Norwegian university clinic: Morbidity recorded after 1 week utilizing an e-infrastructure for clinical research.

PubMed

Øyri, Hauk; Bjørnland, Tore; Barkvoll, Pål; Jensen, Janicke Liaaen

2016-01-01

To evaluate morbidity 1 week after mandibular third molar (3M) surgery in the authors' department. A prospective 1-year clinical study of patients followed up for 1 week after 3M surgery was performed. Consecutive patients of 18 years or older having 3M surgery under local anaesthesia were included. Patients not able to attend a follow-up appointment after 1 week were excluded. Demographic data, indication for surgery and clinical findings were recorded. Outcome variables were days requiring analgesic, days absent from work/school and complications. All data recording was performed utilizing an e-infrastructure for clinical research (InReach, University Health Network, www.uhnsl.com). Three hundred and ninety-six patients were examined 1 week after surgery. Mean number of days requiring analgesics was 3.8 and mean number of days absent from work/school after surgery was 0.6. Minor complications were reported by 7% of patients. Female patients reported more days requiring analgesics compared to male patients. Smokers had a higher odds ratio for being absent ≥ 3 days. Prophylactic removal of 3Ms was associated with fewer days requiring analgesics and days absent from work/school as compared to teeth with local disease. Overall morbidity after 3M surgery was low. Compared to patients subjected to therapeutic removal of 3Ms, patients undergoing prophylactic removal seem to have less pain and a faster return to normal activities.

Changes in Sinus Membrane Thickness After Lateral Sinus Floor Elevation: A Radiographic Study.

PubMed

Makary, Christian; Rebaudi, Alberto; Menhall, Abdallah; Naaman, Nada

2016-01-01

To radiographically monitor sinus membrane swelling after lateral sinus floor elevation surgery at short and long healing periods. For 26 patients seeking posterior maxillary implant-supported reconstruction, 32 lateral sinus floor elevations were performed using Piezosurgery. Sinus membranes were grafted using synthetic calcium phosphate bone substitutes, and graft volume was measured in cubic centimeters for each case. Cone beam computed tomography (CBCT) examination was conducted preoperatively in all patients and for each grafted sinus at 1 day (n = 8), 2 days (n = 9), 3 days (n = 8), or 7 days (n = 7) after surgery. Control CBCT was then performed for all patients at 3, 6, and 12 months after surgery. Sinus membrane thickness was measured on cross-sectional CBCT images at nine standardized points per sinus, before lateral sinus floor elevation and at all postoperative examinations. Mean sinus membrane thickness was 0.73 mm before surgery, and 5 mm, 4.1 mm, 5.9 mm, and 7 mm, respectively, at 1, 2, 3, and 7 days after surgery. First week combined postoperative CBCT measurements of membrane thickness was 5.4 mm, then 1.3, 0.68, and 0.39 mm at 3, 6, and 12 months, respectively, after surgery. Membrane thickness significantly increased the first week after surgery and gradually decreased significantly at 3, 6, and 12 months in all groups (P < .001). First-week postoperative measurements showed a significant increase in membrane thickness at 3 days compared with the 1- and 2-day results (P < .001) and at 7 days compared with all other time points (P < .001). Membrane thickness at 2 days did not change significantly compared with 1-day measurements. Larger graft volume was positively correlated with an increase in membrane thickness after surgery at all time points (n = 32; r = 0.527; P < .001). After lateral sinus floor elevation surgery, transient swelling of sinus membrane is observed. It reaches a peak value 7 days after surgery and completely resolves over months. This swelling is correlated to the extent of sinus floor elevation.

Effect of inspiratory muscle training before cardiac surgery in routine care.

PubMed

Valkenet, Karin; de Heer, Frederiek; Backx, Frank J G; Trappenburg, Jaap C A; Hulzebos, Erik H J; Kwant, Simone; van Herwerden, Lex A; van de Port, Ingrid G L

2013-05-01

Inspiratory muscle training (IMT) before cardiac surgery has proved to be a promising intervention to reduce postoperative pneumonia in a randomized controlled trial setting. Effects of IMT in routine care have not been reported. The purpose of this study was to investigate the effect of IMT before cardiac surgery on postoperative pneumonia in routine care at a Dutch university medical center using propensity scoring. This was an observational cohort study. All candidates for cardiac surgery were preoperatively stratified by a physical therapist for low risk or high risk for postoperative pulmonary complications. Patients at high risk either engaged in an unsupervised IMT program (20 minutes a day) at home for at least 2 weeks before surgery (group 1) or received usual care (no IMT) (group 2). Results in terms of outcome measures were adjusted with propensity scores to reduce bias caused by nonrandom treatment assignment. The results showed that of the 94 patients at high risk in group 1, 1 patient (1.1%) developed a postoperative pneumonia. In group 2, 8 out of the 252 patients at high risk (3.2%) developed this pulmonary complication (adjusted odds ratio=0.34, 95% confidence interval=0.04-3.38). No significant differences were found regarding median (25th-75th percentile) ventilation time (7 [5-9] hours versus 7 [5-10] hours), length of stay in the intensive care unit (23 [21-24] hours versus 23 [21-25] hours), or total postoperative length of stay (7 [6-11] days versus 7 [5-9] days). The most important limitations of this study were confounding, incomplete data collection, and a low incidence of the primary outcome. Propensity scoring is believed to be a valuable tool of great potential interest to researchers in the field of observational studies. Whether IMT in routine care resulted in less postoperative pneumonia cannot be concluded.

Outcomes of laparoscopic and open surgery in children with and without congenital heart disease.

PubMed

Chu, David I; Tan, Jonathan M; Mattei, Peter; Simpao, Allan F; Costarino, Andrew T; Shukla, Aseem R; Rossano, Joseph W; Tasian, Gregory E

2017-11-17

Children with congenital heart disease (CHD) often require noncardiac surgery. We compared outcomes following open and laparoscopic intraabdominal surgery among children with and without CHD. We performed a retrospective cohort study using the 2013-2015 National Surgical Quality Improvement Project-Pediatrics. We matched 45,012 children <18years old who underwent laparoscopic surgery to 45,012 children who underwent open surgery. We determined the associations between laparoscopic (versus open) surgery and 30-day mortality, in-hospital mortality, 30-day morbidity, and postoperative length-of-stay. Among children with minor CHD, laparoscopic surgery was associated with lower 30-day mortality (Odds Ratio [OR] 0.34 [95% Confidence Interval 0.15-0.79]), inhospital mortality (OR 0.42 [0.22-0.81]) and 30-day morbidity (OR 0.61 [0.50-0.73]). As CHD severity increased, this benefit of laparoscopic surgery decreased for 30-day morbidity (ptrend=0.01) and in-hospital mortality (ptrend=0.05), but not for 30-day mortality (ptrend=0.27). Length-of-stay was shorter for laparoscopic approaches for children at cost of higher readmissions. On subgroup analysis, laparoscopy was associated with lower odds of postoperative blood transfusion in all children. Intraabdominal laparoscopic surgery compared to open surgery is associated with decreased morbidity in patients with no CHD and lower morbidity and mortality in patients with minor CHD, but not in those with more severe CHD. Level III: Treatment Study. Copyright © 2017 Elsevier Inc. All rights reserved.

Type of Valvular Heart Disease Requiring Surgery in the 21st Century: Mortality and Length-of-Stay Related to Surgery

PubMed Central

Boudoulas, Konstantinos Dean; Ravi, Yazhini; Garcia, Daniel; Saini, Uksha; Sofowora, Gbemiga G.; Gumina, Richard J.; Sai-Sudhakar, Chittoor B.

2013-01-01

Aim: While the incidence of rheumatic heart disease has declined dramatically over the last half-century, the number of valve surgeries has not changed. This study was undertaken to define the most common type of valvular heart disease requiring surgery today, and determine in-hospital surgical mortality and length-of-stay (LOS) for isolated aortic or mitral valve surgery in a United States tertiary-care hospital. Methods: Patients with valve surgery between January 2002 to June 2008 at The Ohio State University Medical Center were studied. Patients only with isolated aortic or mitral valve surgery were analyzed. Results: From 915 patients undergoing at least aortic or mitral valve surgery, the majority had concomitant cardiac proce-dures mostly coronary artery bypass grafting (CABG); only 340 patients had isolated aortic (n=204) or mitral (n=136) valve surgery. In-hospital surgical mortality for mitral regurgitation (n=119), aortic stenosis (n=151), aortic insufficiency (n=53) and mitral stenosis (n=17) was 2.5% (replacement 3.4%; repair 1.6%), 3.9%, 5.6% and 5.8%, respectively (p=NS). Median LOS for aortic insufficiency, aortic stenosis, mitral regurgitation, and mitral stenosis was 7, 8, 9 (replacement 11.5; repair 7) and 11 days, respectively (p<0.05 for group). In-hospital surgical mortality for single valve surgery plus CABG was 10.2% (p<0.005 compared to single valve surgery). Conclusions: Aortic stenosis and mitral regurgitation are the most common valvular lesions requiring surgery today. Surgery for isolated aortic or mitral valve disease has low in-hospital mortality with modest LOS. Concomitant CABG with valve surgery increases mortality substantially. Hospital analysis is needed to monitor quality and stimulate improvement among Institutions. PMID:24339838

Multicentre clinical trial experience with the HeartMate 3 left ventricular assist device: 30-day outcomes.

PubMed

Zimpfer, Daniel; Netuka, Ivan; Schmitto, Jan D; Pya, Yuriy; Garbade, Jens; Morshuis, Michiel; Beyersdorf, Friedhelm; Marasco, Silvana; Rao, Vivek; Damme, Laura; Sood, Poornima; Krabatsch, Thomas

2016-09-01

The objective of this study was to describe the operative experience and 30-day outcomes of patients implanted with the HeartMate 3 Left Ventricular Assist System (LVAS) during the Conformité Européenne (CE) Mark clinical trial. Adult patients met inclusion and exclusion criteria defining advanced-stage heart failure and included the indications of bridge to transplant and destination therapy. Operative parameters, outcomes, adverse events, physical status and quality-of-life parameters were assessed in the first 30 days after LVAS implant. Fifty patients were implanted with the HeartMate 3 at 10 centres in 6 countries. The 30-day survival rate was 98%. The median operative and cardiopulmonary bypass times were 200 (range: 95-585) min and 84 (range: 47-250) min, respectively. Patients required transfusion with packed red blood cells (3.6 ± 2.3 units), fresh frozen plasma (6.5 ± 5 units) and platelets (2 ± 1 units). Six patients (12%) required reoperation for postoperative bleeding and 10 patients (20%) did not require blood transfusion. The median intensive care time was 6 days (range: 1-112 days) and the total hospital stay was 28 days (range: 14-116 days). The most common adverse events were bleeding (15, 30%), arrhythmia (14, 28%) and infection (10, 20%). There were 2 (4%) strokes. The 30-day outcomes following implantation of the HeartMate 3 demonstrates excellent survival with low adverse event rates. The LVAD performed as intended with no haemolysis or device failure. NCT02170363. HeartMate 3™ CE Mark Clinical Investigation Plan (HM3 CE Mark). © The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Do critical care units play a role in the management of gynaecological oncology patients? The contribution of gynaecologic oncologist in running critical care units.

PubMed

Davidovic-Grigoraki, Miona; Thomakos, Nikolaos; Haidopoulos, Dimitrios; Vlahos, Giorgos; Rodolakis, Alexandros

2017-03-01

Routine post-operative care in high dependency unit (HDU), surgical intensive care unit (SICU) and intensive care unit (ICU) after high-risk gynaecological oncology surgical procedures may allow for greater recognition and correct management of post-operative complications, thereby reducing long-term morbidity and mortality. On the other hand, unnecessary admissions to these units lead to increased morbidity - nosocomial infections, increased length of hospital stay and higher hospital costs. Gynaecological oncology surgeons continue to look after their patient in the HDU/SICU and have the final role in decision-making on day-to-day basis, making it important to be well versed in critical care management and ensure the best care for their patients. Post-operative monitoring and the presence of comorbid illnesses are the most common reasons for admission to the HDU/SICU. Elderly and malnutritioned patients, as well as, bowel resection, blood loss or greater fluid resuscitation during the surgery have prolonged HDU/SICU stay. Patients with ovarian cancer have a worse survival outcome than the patients with other types of gynaecological cancer. Dependency care is a part of surgical management and it should be incorporated formally into gynaecologic oncology training programme. © 2016 John Wiley & Sons Ltd.

Preoperative oral carbohydrate treatment attenuates endogenous glucose release 3 days after surgery.

PubMed

Soop, Mattias; Nygren, Jonas; Thorell, Anders; Weidenhielm, Lars; Lundberg, Mari; Hammarqvist, Folke; Ljungqvist, Olle

2004-08-01

Postoperative metabolism is characterised by insulin resistance and a negative whole-body nitrogen balance. Preoperative carbohydrate treatment reduces insulin resistance in the first day after surgery. We hypothesised that preoperative oral carbohydrate treatment attenuates insulin resistance and improves whole-body nitrogen balance 3 days after surgery. Fourteen patients undergoing total hip replacement were double-blindly randomised to preoperative oral carbohydrate treatment (12.5%, 800 + 400 ml, n = 8) or placebo (n = 6). Glucose kinetics (6,6-D2-glucose), substrate utilisation (indirect calorimetry) and insulin sensitivity (hyperinsulinaemic-euglycaemic clamp) were measured preoperatively and on the third day after surgery. Nitrogen losses were monitored for 3 days after surgery. Values are mean (SEM). Analysis of variance (ANOVA) statistics were used. Endogenous glucose release during insulin infusion increased after surgery in the placebo group. Preoperative carbohydrate treatment, as compared to placebo, significantly attenuated postoperative endogenous glucose release (0.69 (0.07) vs. 1.21 (0.13)mg kg(-1) x min(-1), P < 0.01), while whole-body glucose disposal and nitrogen balance were similar between groups. While insulin resistance in the first day after surgery has previously been characterised by reduced glucose disposal, enhanced endogenous glucose release was the main component of postoperative insulin resistance on the third postoperative day. Preoperative carbohydrate treatment attenuated endogenous glucose release on the third postoperative day. Copyright 2004 Elsevier Ltd.

Comparative evaluation of aqueous and plasma concentration of topical moxifloxacin alone and with flurbiprofen in patients of cataract surgery

PubMed Central

Halder, Sujash; Mondal, Kanchan Kumar; Biswas, Supreeti; Mandal, Tapan Kumar; Dutta, Bakul Kumar; Haldar, Mithilesh

2013-01-01

Objectives: To determine the aqueous and plasma concentrations of moxifloxacin administered topically alone and with flurbiprofen in patients undergoing cataract surgery. Materials and Methods: A total of 50 subjects scheduled for routine cataract surgery were randomly allocated to two groups (n = 25 each). Group-1 patients were treated with topical moxifloxacin alone: One drop 6 times/day for 3 days before surgery and one drop 4 times on the day of surgery: Group-2 patients were treated with topical moxifloxacin as in Group-1 and with topical flurbiprofen: One drop 4 times/day for 3 days before and on the day of surgery. The interval between two drugs was 30 min for last 3 days and 15 min on the day of surgery. Last dose was administered 1 h before aqueous humor and blood sampling for both the groups. The antibiotic concentration in aqueous humor and plasma were determined by using high performance liquid chromatography. Results: The mean concentration of moxifloxacin in aqueous humor was 1.71 ± 0.82 mg/ml in Group-1 and 2.39 ± 1.34 mg/ml in Group-2. Concentrations of moxifloxacin in aqueous humor were significantly higher in Group-2 than that of Group-1. Conclusion: Flurbiprofen may increase the concentration of moxifloxacin in aqueous humor. PMID:23833362

Contamination of dental unit waterlines: assessment of three continuous water disinfection systems

PubMed Central

Offner, Damien; Fioretti, Florence; Musset, Anne-Marie

2016-01-01

Objectives: To assess the efficacy of three continuous water disinfection systems for dental units under real conditions of dental care. Design and settings: A prospective study carried out from 45 days to 20 months on the water microbial quality of the dental units is benefited from three different systems: two chemical treatment systems (IGN EVO/Calbenium/IGN Cartridge and Sterispray) and one physical treatment system (BacTerminator). Studied items were six dental units of the Dental Medicine and Oral Surgery Center within the University Hospital of Strasbourg (HUS), France. Results and disucussion: The IGN EVO/Calbenium/IGN Cartridge and Sterispray systems showed an immediate and long-term efficacy on contaminated dental unit waterlines. However, the first system offers ergonomic advantages (automatic system, action on the water from the water supply network). The BacTerminator system took longer to be effective and was less effective than the other two. PMID:29607068

Changes in Heart Rate and Autonomic Nervous Activity after Orthopedic Surgery in Elderly Japanese Patients

PubMed Central

TAN, CHIEKO; SAITO, NAO; MIYAWAKI, IKUKO

2016-01-01

Evidence regarding nursing support for delirium prevention is currently insufficient. An evaluation of changes in autonomic nervous activity over time after surgery would elucidate the features of autonomic nervous activity in patients with delirium. These results could provide a basis for effective nursing intervention and timing for preventing the onset of delirium. Here, we aimed to obtain basic data on effective nursing interventions for preventing the onset of postoperative delirium. Heart rate variability was recorded during the morning and nighttime on the day before surgery until 3 days postoperatively in elderly patients who underwent orthopedic surgery to investigate the manner in which heart rate and autonomic nervous activity changed over time. Data were collected over 11 months from July 2013 to November 2014. Surgical stress led to the maintenance of heart rate at a significantly higher value from the day of the surgery until postoperative day 3 compared to that before surgery. Moreover, the autonomic nervous activity remained unchanged during the morning, and it was significantly lower during the night from postoperative day 1 until postoperative day 3 than before the surgery. These results suggest that there is a decrease in parasympathetic nervous activity during the nighttime postoperatively. PMID:28289270

Treatment of complicated parapneumonic pleural effusion and pleural parapneumonic empyema.

PubMed

Rodríguez Suárez, Pedro; Freixinet Gilart, Jorge; Hernández Pérez, José María; Hussein Serhal, Mohamed; López Artalejo, Antonio

2012-07-01

We performed this observational prospective study to evaluate the results of the application of a diagnostic and therapeutic algorithm for complicated parapneumonic pleural effusion (CPPE) and pleural parapneumonic empyema (PPE). From 2001 to 2007, 210 patients with CPPE and PPE were confirmed through thoracocentesis and treated with pleural drainage tubes (PD), fibrinolytic treatment or surgical intervention (videothoracoscopy and posterolateral thoracotomy). Patients were divided into 3 groups: I (PD); II (PD and fibrinolytic treatment); IIIa (surgery after PD and fibrinolysis), and IIIb (direct surgery). The statistical study was done by variance analysis (ANOVA), χ2 and Fisher exact test. The presence of alcohol or drug consumption, smoking and chronic obstructive pulmonary disease (COPD) were strongly associated with a great necessity for surgical treatment. The IIIa group was associated with increased drainage time, length of stay and complications. No mortality was observed. The selective use of PD and intrapleural fibrinolysis makes surgery unnecessary in more than 75% of cases. The selective use of PD and fibrinolysis avoids surgery in more than 75% of cases. However, patients who require surgery have more complications, longer hospital stay, and more days on PD and they are more likely to require admittance to the Intensive Care Unit.

Refractive surgery in Israel Defense Forces recruits.

PubMed

Horowitz, Josepha; Mezer, Eedy; Shochat, Tzippora; Mandel, Yossi; Buckman, Gila; Sasson, Adi; Geyer, Orna

2008-02-01

To determine the prevalence of refractive surgery history in recruits for military service in the Israel Defense Forces (IDF) between 1998 to 2005 and to evaluate the effect of surgery on the recruits' fitness to serve in combat units. Surgeon General's HQ, Medical Corps, Israel Defense Forces. The computerized medical records of all ametropic Israeli army inductees were reviewed. They included spectacle-wearing, contact lens-wearing, and post refractive-surgery individuals who were examined in the recruitment office before their compulsory military service. The extracted data from the personal files consisted of the assignment to combat units of those who had refractive surgery and those who wore corrective eyewear and the first and last military position of all ametropic recruits who were assigned to combat units. Five hundred ninety-seven inductees (513 men, 84 women) had refractive surgery before their military service during the study period. The prevalence of recruits who had refractive surgery increased from 0.8/1000 ametropes in 1998 to 4.9/1000 ametropes in 2005. Significantly more recruits who had surgery (73.5%) than recruits who wore corrective eyewear were assigned to combat units (P<.001). The dropout rate from combat units of the former was significantly lower than that of the latter (13.1% versus 29.2%) (P<.001). More corrective eyewear users had refractive surgery before their IDF military service, and relatively more of them applied for combat duty. The high percentage of recruits who had refractive surgery who serve uninterruptedly in combat units indicates that the procedure has no deleterious effect on the recruits' fitness.

Roux-en-Y Gastric Bypass Surgery Induces Early Plasma Metabolomic and Lipidomic Alterations in Humans Associated with Diabetes Remission.

PubMed

Arora, Tulika; Velagapudi, Vidya; Pournaras, Dimitri J; Welbourn, Richard; le Roux, Carel W; Orešič, Matej; Bäckhed, Fredrik

2015-01-01

Roux-en-Y gastric bypass (RYGB) is an effective method to attain sustained weight loss and diabetes remission. We aimed to elucidate early changes in the plasma metabolome and lipidome after RYGB. Plasma samples from 16 insulin-resistant morbidly obese subjects, of whom 14 had diabetes, were subjected to global metabolomics and lipidomics analysis at pre-surgery and 4 and 42 days after RYGB. Metabolites and lipid species were compared between time points and between subjects who were in remission and not in remission from diabetes 2 years after surgery. We found that the variables that were most discriminatory between time points were decanoic acid and octanoic acid, which were elevated 42 days after surgery, and sphingomyelins (18:1/21:0 and 18:1/23:3), which were at their lowest level 42 days after surgery. Insulin levels were lower at 4 and 42 days after surgery compared with pre-surgery levels. At 4 days after surgery, insulin levels correlated positively with metabolites of branched chain and aromatic amino acid metabolism and negatively with triglycerides with long-chain fatty acids. Of the 14 subjects with diabetes prior to surgery, 7 were in remission 2 years after surgery. The subjects in remission displayed higher pre-surgery levels of tricarboxylic acid cycle intermediates and triglycerides with long-chain fatty acids compared with subjects not in remission. Thus, metabolic alterations are induced soon after surgery and subjects with diabetes remission differ in the metabolic profiles at pre- and early post-surgery time points compared to patients not in remission.

Roux-en-Y Gastric Bypass Surgery Induces Early Plasma Metabolomic and Lipidomic Alterations in Humans Associated with Diabetes Remission

PubMed Central

Pournaras, Dimitri J.; Welbourn, Richard; le Roux, Carel W.; Orešič, Matej; Bäckhed, Fredrik

2015-01-01

Roux-en-Y gastric bypass (RYGB) is an effective method to attain sustained weight loss and diabetes remission. We aimed to elucidate early changes in the plasma metabolome and lipidome after RYGB. Plasma samples from 16 insulin-resistant morbidly obese subjects, of whom 14 had diabetes, were subjected to global metabolomics and lipidomics analysis at pre-surgery and 4 and 42 days after RYGB. Metabolites and lipid species were compared between time points and between subjects who were in remission and not in remission from diabetes 2 years after surgery. We found that the variables that were most discriminatory between time points were decanoic acid and octanoic acid, which were elevated 42 days after surgery, and sphingomyelins (18:1/21:0 and 18:1/23:3), which were at their lowest level 42 days after surgery. Insulin levels were lower at 4 and 42 days after surgery compared with pre-surgery levels. At 4 days after surgery, insulin levels correlated positively with metabolites of branched chain and aromatic amino acid metabolism and negatively with triglycerides with long-chain fatty acids. Of the 14 subjects with diabetes prior to surgery, 7 were in remission 2 years after surgery. The subjects in remission displayed higher pre-surgery levels of tricarboxylic acid cycle intermediates and triglycerides with long-chain fatty acids compared with subjects not in remission. Thus, metabolic alterations are induced soon after surgery and subjects with diabetes remission differ in the metabolic profiles at pre- and early post-surgery time points compared to patients not in remission. PMID:25946120

Near demise of a child with Prader-Willi syndrome during elective orchidopexy.

PubMed

Mantadakis, Elpis; Spanaki, Anna-Maria; Geromarkaki, Elsa; Vassilaki, Efrosini; Briassoulis, George

2006-07-01

The case of a morbidly obese 3.5-year-old boy, with Prader-Willi syndrome (PWS), who experienced a life-threatening episode of pulmonary edema soon after induction of general anesthesia with sevoflurane and intubation for orchidopexy is presented. The patient who had history of sleep apnea and who had an uneventful laparoscopy under general anesthesia 6 months previously was supported with mechanical ventilation with positive end expiratory pressure but developed hyperthermia, pneumonia, sepsis, and Acute Respiratory Distress Syndrome in the intensive care unit. He recovered fully 11 days after surgery. The possible contributing factors for the development of pulmonary edema are discussed. Arrangements for monitoring in an intensive care setting after surgery are highly recommended for patients with PWS.

Optimising recovery after surgery: Predictors of early discharge and hospital readmission.

PubMed

Carter, Jonathan; Philp, Shannon; Wan, King M

2016-10-01

Fast track surgery (FTS) programs minimise the stress response after surgery and allow for enhanced recovery. To document the frequency and incidence of adverse events in patients enrolled on a FTS program and to investigate factors associated with shorter length of stay and readmission to hospital. A seven-year updated surgical audit of patients undergoing laparotomy for suspected or confirmed malignancy on a FTS program. Five hundred and fifty patients comprise the study group. Average age and body mass index (BMI) were 55 years and 28, respectively. Mean length of stay (LOS) was 3.4 days with 194 (35%) patients discharged on day 2. Six (1%) patients had confirmed venous thromboembolism (VTE), three of whom were diagnosed on pre-operative imaging. Overall, transfusion rate was 5%. Adverse events in decreasing frequency were hospital readmission (4%) and significant wound infection (3%). All other adverse events were uncommon with rates <0.5%. Factors associated with a discharge on or after day 3 include age, pathology, Eastern Cooperative Oncology Group performance status, incision type, operating time, blood transfusion and cyclo-oxygenase 2 inhibitors. Factors associated with hospital readmission include longer operating time, performance of lymph node sampling/dissection, longer LOS, development of wound infection, febrile morbidity, return to the operating room, unplanned intensive care unit admission and presence of other complications. Patients managed by a FTS protocol can expect enhanced outcomes when compared to historical controls. © 2016 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

["Abdominal dressing" - a new method of treatment for open abdomen following secondary peritonitis].

PubMed

Wild, T; Stremitzer, S; Budzanowski, A; Rinder, H; Tamandl, D; Zeisel, C; Hölzenbein, T; Sautner, T

2004-05-01

Treatment of open abdomen following secondary peritonitis is a challenge for surgery and intensive care units (ICU). The aim of this study was to compare three different concurrent treatment strategies. Patients suffering an open abdomen following surgery for secondary peritonitis at the Department of General Surgery from 01/01 to 12/03 were investigated. Factor studied: duration of open abdomen, incidence of multi-organ failure, need for surgical revisions, length of stay (LOS) in ICU, nursing requirements (change of dressing/day), survival and integrity of abdominal wall after discharge. Treatment strategies included: open packing (OP), classic vacuum assisted (V.A.C.(R))-therapy with silicone net protection for the intestine (CV) and V.A.C.(R)-therapy with "abdominal dressing" a newly developed meshed polyvinyl wrap (AD). 21 patients were studied: 5 patients were treated with OP, 8 patients with CV and 8 patients with AD. Mean LOS was 65 (OP) vs. 53 (CV) vs. 42 (AD) days (NS), peritonitis related death was 3 (OP) vs. 1 (CV) vs. 0 (AD) (p < 0.05 Chisquare test). Median nursing effort was 4 dressings/day (OP), 0.5 (CV) and 0.5 (AD) (p < 0.005 OP vs CV, AD Kruskal-Wallis test). The "abdominal dressing"-therapy seems to be a more efficient treatment option in patients suffering from open abdomen following secondary peritonitis. A trend towards shorter ICU-LOS, lower mortality rates and reduced nursing requirements support our hypothesis.

[Where do we stand with benign prostatic hyperplasia day-case surgery: A laser effect?

PubMed

Gury, L; Robert, G; Bensadoun, H

2018-06-12

Despite its feasibility has been proven, Benign Prostatic Hyperplasia (BPH) day-case surgery remains uncommon. Our objective was to describe the evolution of BPH day-case surgery in France according to the surgical technique employed. We extracted data from the Information System of Medicalization Program (PMSI) including all of the hospital stays in France from 2010 to 2016. Patients belonging to the transurethral prostatectomy homogeneous group of patients (GHM 12C04) and having as a main diagnosis prostatic hyperplasia (N40) or benign prostatic tumor (D291) were included in the analysis. From March 2016, specific codes were introduced to differentiate laser surgery and other types of surgery: JGFE023 (resection without laser), JGFE365 (laser resection) and JGNE171 (laser vaporization). We described the rates of day case surgery and the average length of stay from 2010 to 2016. From March 2016 we could study the influence of laser surgery on day-case and length of stay. Regarding the all dataset analysis we found 328,781 hospital stays (318,549 patients) for BPH surgery, of which 2.7% (9047 hospital stays) were day-case. From 2010 to 2016, the lengths of stay decreased from 5.78 to 4.29 days. In the meantime, the number of day-case procedures increased from 14 patients (0.03%) to 3035 patients (5.63%). Regarding the last 9 months of 2016, we found 38,930 hospital stays including 5.4% (2104) day-cases. In total, 92.7% of day-case procedures had been performed with a laser technique, of which 47.9% (1008) were laser vaporization and 44.8% (944) were laser resection. There were only 7.1% (151.8%) of day-case procedures performed without laser. The exponential development of the day-case procedures seems to be linked with the advent of laser technology. This tendency is expected to increase in the coming years according to the spreading of laser surgery. 3. Crown Copyright © 2018. Published by Elsevier Masson SAS. All rights reserved.

Short-term effects of splenectomy on serum fibrosis indexes in liver cirrhosis patients.

PubMed

Kong, Degang; Chen, Xiuli; Lu, Shichun; Guo, Qingliang; Lai, Wei; Wu, Jushan; Lin, Dongdong; Zeng, Daobing; Duan, Binwei; Jiang, Tao; Cao, Jilei

2015-01-01

To determine the changing patterns of 4 liver fibrosis markers pre and post splenectomy (combined with pericardial devascularization [PCDV]) and to examine the short-term effects of splenectomy on liver fibrosis. Four liver fibrosis markers of 39 liver cirrhosis patients were examined pre, immediately post, 2 days post, and 1 week post (15 cases) splenectomy (combined with PCDV). The laminin (LN) level decreased immediately post surgery compared with the preoperative LN level (P < 0.05). The type IV collagen level decreased immediately post surgery compared with that pre surgery (P < 0.05), it significantly increased (P < 0.05) 2 days post surgery and significantly decreased 1 week post surgery (P < 0.05). Hyaluronic acid and the procollagen III N-terminal peptide levels increased significantly 2 days post surgery compared with that pre and immediately post surgery, they significantly decreased 1 week post surgery compared to 2 days post surgery (P < 0.05). In the short-term, the 4 liver fibrosis markers and the FibroScans post splenectomy showed characteristic changes, splenectomy may transiently initiate the degradation process of liver fibrosis.

Comparison of electrocautery incision with scalpel incision in midline abdominal surgery - A double blind randomized controlled trial.

PubMed

Prakash, Lalgudi Dorairajan; Balaji, Nitesh; Kumar, Sathasivam Suresh; Kate, Vikram

2015-07-01

To compare the electrocautery incision with scalpel incision in patients undergoing abdominal surgery using a midline incision with respect to incision time, blood loss during incision, postoperative incision site pain and wound infection. Patients undergoing midline abdominal surgery were randomized into electrocautery and scalpel groups. The incision dimensions, incision time and blood loss during incision were noted intraoperatively. Postoperative pain and wound infection were recorded on every postoperative day for one week. 41 patients in each of the two groups were analyzed. Gender and age distribution was similar in both the groups. The mean incision time per unit wound area in the electrocautery group and scalpel group was 9.40 ± 3.37 s/cm(2) and 9.07 ± 3.40 s/cm(2) (p = 0.87) respectively. The mean blood loss per unit wound area was significantly lower in the electrocautery group at 6.46 ± 3.94 ml when compared to that of 23.40 ± 15.28 ml in the scalpel group (p= < 0.0001, CI = 11.97-21.89). There was no significant difference in pain on any of the postoperative days between the two groups and there was no significant difference in the wound infection rates between the electrocautery and scalpel groups (14.63% vs. 12.19%; p = 0.347). With a comparable Postoperative incision site pain, wound infection rate and significantly lower blood loss with the equal time taken for the incision, electrocautery can be considered safe and effective in making skin incision in midline laparotomy compared to scalpel incision. Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.

Ruptured intracranial aneurysms: the outcome of surgical treatment in experienced hands in the period prior to the advent of endovascular coiling

PubMed Central

Lafuente, J; Maurice-Williams, R

2003-01-01

Objectives: To evaluate the results of treatment of patients with a ruptured intracranial aneurysm treated by a single experienced vascular neurosurgeon in the period prior to the introduction of endovascular coiling. Methods: Over a mean (SD) period of 9 (2) years, between January 1990 and June 1999, 245 consecutive patients with ruptured intracranial aneurysms were treated. Patients' details were obtained from a database that had been constructed prospectively. The patients consisted of all those patients treated by the senior author (Mr Maurice-Williams) over this period—that is, every third day on call at his unit. During this period, all patients under the age of 75 years with a diagnosis of subarachnoid haemorrhage were admitted to the neurosurgical unit as soon as was practicable regardless of clinical grade. Results: Of 245 patients, 190 (77.6%) underwent treatment by open surgery using standard microsurgical techniques. At 1 year, the mortality of the operated patients was 2.6%, while 89.5% of the patients had a Glasgow Outcome Score (GOS) of 4 and 5. The overall management outcome (all patients treated, including operated and non-operated cases) at 1 year was: 17.1 % dead while 74.3% had GOS 4 and 5. Of the 190 patients who underwent surgery, 38 (20%) required additional operations, totalling 72 operations in all. Of these, 32 were for hydrocephalus and 17 for the evacuation of intracranial haematomas/collections. Complications of surgery occurred in 56 patients (29.5%). Conclusion: Open surgery, despite good eventual results, is associated with a significant rate of re-operations and complications that would probably be largely avoided with endovascular treatment. Nevertheless, although endovascular coiling has these immediate advantages over surgery it is still not certain that the long term results will be superior to surgery which leads to permanent obliteration of the aneurysm. There may still be a need for open surgery in the future. PMID:14638889

Robotic cardiac surgery in Brazil

PubMed Central

Toschi, Alisson P.; Pope, Renato B.; Montanhesi, Paola K.; Santos, Ricardo S.; Teruya, Alexandre; Hatanaka, Dina M.; Rusca, Gabriel F.; Fischer, Claudio H.; Vieira, Marcelo C.; Makdisse, Marcia R.

2017-01-01

Background Brazil, the largest country and economy in South America, is a major driving force behind the development of new medical technologies in the region. Robotic cardiac surgery (RCS) has been evolving rapidly since 2010, when the first surgery using the DaVinci® robotic system was performed in Latin America. The aim of this article is to evaluate short and mid-term results in patients undergoing robotic cardiac surgery in Brazil. Methods From March 2010 to December 2015, 39 consecutive patients underwent robotic cardiac surgery. Twenty-seven patients were male (69.2%), with the mean age of 51.3±17.9 years. Participants had a mean ejection fraction of 62±5%. The procedures included in this study were mitral valve surgery, surgical treatment of atrial fibrillation, atrial septal defect closure, resection of intra-cardiac tumors, totally endoscopic coronary artery bypass and pericardiectomy. Results The mean time spent on cardiopulmonary bypass (CPB) during RCS was 154.9±94.2 minutes and the mean aortic cross-clamp time was 114.48±75.66 minutes. Thirty-two patients (82%) were extubated in the operating room immediately after surgery. The median intensive care unit (ICU) length of stay was 1 day (ranging from 0 to 25) and the median hospital length of stay was 5 days (ranging from 3 to 25). For each type of procedure, endpoints were individually reported. There were no conversions to sternotomy and no intra-operative complications. Patient follow-up was complete in 100% of the participants, with two early deaths unrelated to the procedures and no re-operations at mid-term. Conclusions Despite the heterogeneity of this series, RCS appears to be feasible, safe and effective when used for the correction of various intra- and extra-cardiac pathologies. Adopting the robotic system has been a challenge in Brazil, where its limited clinical application may be related to the lack of specific training and the high cost of technology. PMID:28203537

Early and mid-term outcomes of endovascular and open surgical repair of non-dissected aortic arch aneurysm†.

PubMed

Hori, Daijiro; Okamura, Homare; Yamamoto, Takahiro; Nishi, Satoshi; Yuri, Koichi; Kimura, Naoyuki; Yamaguchi, Atsushi; Adachi, Hideo

2017-06-01

With the introduction of endovascular stent graft technology, a variety of surgical options are available for patients with aortic aneurysms. We sought to evaluate early-term and mid-term outcomes of patients undergoing endovascular and open surgical repair for non-dissected aortic arch aneurysm. Overall, 200 patients underwent treatment for isolated non-dissected aortic arch aneurysm between January 2008 and February 2016: 133 patients had open surgery and 67, endovascular repair. Early-term and mid-term outcomes were compared. Seventy percent ( n  = 47) needing endovascular repair underwent fenestrated stent graft and 30% ( n  = 20) underwent the debranched technique. Patients in the open surgery group were younger (71 vs 75 years, P  < 0.001) and had a lower prevalence of ischaemic heart disease (11% vs 35%, P  < 0.001). Intensive care unit stay (1 vs 3 days, P  < 0.001), hospital stay (11 vs 17 days, P  < 0.001) and surgical time (208 vs 390 min, P  < 0.001) were lower in the endovascular repair group than in the open surgery group. There were 3 in-hospital deaths each in the open surgery and endovascular groups (2% vs 5%, respectively, P  = 0.40). Mid-term survival ( P  < 0.001) and freedom from reintervention ( P  = 0.009) were better in the open surgery than in the endovascular repair group. No aneurysm-related deaths were observed. The propensity-matched comparison ( n  = 58) demonstrated that survival was better in the open surgery group ( P  = 0.011); no significant difference was seen in the reintervention rate ( P  = 0.28). Close follow-up for re-intervention may reduce the risk for aneurysm-related deaths and provide acceptable outcomes in patients undergoing endovascular repair. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Robotic cardiac surgery in Brazil.

PubMed

Poffo, Robinson; Toschi, Alisson P; Pope, Renato B; Montanhesi, Paola K; Santos, Ricardo S; Teruya, Alexandre; Hatanaka, Dina M; Rusca, Gabriel F; Fischer, Claudio H; Vieira, Marcelo C; Makdisse, Marcia R

2017-01-01

Brazil, the largest country and economy in South America, is a major driving force behind the development of new medical technologies in the region. Robotic cardiac surgery (RCS) has been evolving rapidly since 2010, when the first surgery using the DaVinci ® robotic system was performed in Latin America. The aim of this article is to evaluate short and mid-term results in patients undergoing robotic cardiac surgery in Brazil. From March 2010 to December 2015, 39 consecutive patients underwent robotic cardiac surgery. Twenty-seven patients were male (69.2%), with the mean age of 51.3±17.9 years. Participants had a mean ejection fraction of 62±5%. The procedures included in this study were mitral valve surgery, surgical treatment of atrial fibrillation, atrial septal defect closure, resection of intra-cardiac tumors, totally endoscopic coronary artery bypass and pericardiectomy. The mean time spent on cardiopulmonary bypass (CPB) during RCS was 154.9±94.2 minutes and the mean aortic cross-clamp time was 114.48±75.66 minutes. Thirty-two patients (82%) were extubated in the operating room immediately after surgery. The median intensive care unit (ICU) length of stay was 1 day (ranging from 0 to 25) and the median hospital length of stay was 5 days (ranging from 3 to 25). For each type of procedure, endpoints were individually reported. There were no conversions to sternotomy and no intra-operative complications. Patient follow-up was complete in 100% of the participants, with two early deaths unrelated to the procedures and no re-operations at mid-term. Despite the heterogeneity of this series, RCS appears to be feasible, safe and effective when used for the correction of various intra- and extra-cardiac pathologies. Adopting the robotic system has been a challenge in Brazil, where its limited clinical application may be related to the lack of specific training and the high cost of technology.

Tranexamic Acid in Patients Undergoing Coronary-Artery Surgery.

PubMed

Myles, Paul S; Smith, Julian A; Forbes, Andrew; Silbert, Brendan; Jayarajah, Mohandas; Painter, Thomas; Cooper, D James; Marasco, Silvana; McNeil, John; Bussières, Jean S; McGuinness, Shay; Byrne, Kelly; Chan, Matthew T V; Landoni, Giovanni; Wallace, Sophie

2017-01-12

Tranexamic acid reduces the risk of bleeding among patients undergoing cardiac surgery, but it is unclear whether this leads to improved outcomes. Furthermore, there are concerns that tranexamic acid may have prothrombotic and proconvulsant effects. In a trial with a 2-by-2 factorial design, we randomly assigned patients who were scheduled to undergo coronary-artery surgery and were at risk for perioperative complications to receive aspirin or placebo and tranexamic acid or placebo. The results of the tranexamic acid comparison are reported here. The primary outcome was a composite of death and thrombotic complications (nonfatal myocardial infarction, stroke, pulmonary embolism, renal failure, or bowel infarction) within 30 days after surgery. Of the 4662 patients who were enrolled and provided consent, 4631 underwent surgery and had available outcomes data; 2311 were assigned to the tranexamic acid group and 2320 to the placebo group. A primary outcome event occurred in 386 patients (16.7%) in the tranexamic acid group and in 420 patients (18.1%) in the placebo group (relative risk, 0.92; 95% confidence interval, 0.81 to 1.05; P=0.22). The total number of units of blood products that were transfused during hospitalization was 4331 in the tranexamic acid group and 7994 in the placebo group (P<0.001). Major hemorrhage or cardiac tamponade leading to reoperation occurred in 1.4% of the patients in the tranexamic acid group and in 2.8% of the patients in the placebo group (P=0.001), and seizures occurred in 0.7% and 0.1%, respectively (P=0.002 by Fisher's exact test). Among patients undergoing coronary-artery surgery, tranexamic acid was associated with a lower risk of bleeding than was placebo, without a higher risk of death or thrombotic complications within 30 days after surgery. Tranexamic acid was associated with a higher risk of postoperative seizures. (Funded by the Australian National Health and Medical Research Council and others; ATACAS Australia New Zealand Clinical Trials Registry number, ACTRN12605000557639 .).

Measles in a South African paediatric intensive care unit: again!

PubMed

Coetzee, Saskia; Morrow, Brenda M; Argent, Andrew C

2014-05-01

The aim of this study is to evaluate the outcomes of children with measles-related disease (MRD) admitted to a paediatric intensive care unit (PICU) and the effect on PICU resources and elective surgery of a recent measles epidemic. This was a retrospective observational study of all patients admitted to the PICU of Red Cross War Memorial Children's Hospital, Cape Town, South Africa, with MRD from January to December 2010. Patient admission characteristics, duration of PICU admission and mortality were recorded. Costs were calculated using bed days utilised and estimated daily PICU admission cost. A total of 1274 children were admitted over the study period, 58 (4.6%) with MRD (median (interquartile range) age 7 (5-9) months). Pneumonia was the most common reason for admission (81%) and the main cause of mortality. Non-MRD mortality was 8.8% compared with MRD mortality of 31% (P < 0.0001). Standardised mortality for non-MRD was 0.7 versus 1.7 in MRD (P = 0.002). HIV comorbidity and being underweight for age were associated with increased mortality. Patients with MRD occupied 379 bed days with a median (interquartile range) duration of stay of 5.5 (3.0-9.0) days at an estimated overall cost of R4,813,300 (approximately $543,900). During the study period, 67 children booked for elective surgery, and 87 other referrals were refused PICU admission. MRD was associated with significant morbidity and mortality, and substantial strain on scarce PICU resources. © 2013 The Authors. Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians).

Converting emergency pilonidal abscess into an elective procedure.

PubMed

Hussain, Zeiad I; Aghahoseini, Assad; Alexander, David

2012-06-01

Improvements in outcome after surgery for elective pilonidal sinus disease have yet to be matched for those presenting with acute disease. Traditional approaches to the management of acute pilonidal abscess have been associated with slow healing and significant loss of working time. The aim of this study was to report our approach in which a temporizing intervention allows subsequent definitive treatment with low morbidity. This article presents a prospective cohort study. This study was performed in acute admissions to the Surgical Unit in York Teaching Hospital. Patients presenting with acute pilonidal abscess, not septic, immune-compromised, or diabetic, and without skin necrosis, underwent aspiration on the surgical ward. Aspiration of pilonidal abscess under local anesthetic was performed with the use of a wide-bore needle. The abscess cavity was drained to dryness, samples were sent to the laboratory for microbiology, and empirical oral antibiotics were commenced, covering anaerobes and aerobes. Review was arranged for within 7 days to plan elective excision and primary closure of the underlying pilonidal sinus. The primary outcomes measured were the number of days required to return to normal activities, response to treatment, and any residual inflammation. Fifty-six patients were referred with acute pilonidal abscess. Forty patients met the criteria for aspiration and empirical antibiotic treatment. All were allowed to go home the same day and were reviewed within a median of 5 days. Thirty-eight (38/40) patients demonstrated complete resolution of acute inflammation and were back to normal activities the following day. Fifteen patients subsequently underwent day-case excision and primary closure at a median of 9 weeks. Another 13 are awaiting surgery, and 10 patients have declined further treatment. Two (2/40) patients did not respond, one of whom did not receive the appropriate antibiotics. Both were managed with incision and drainage. Aspiration and antibiotic management of pilonidal abscess is effective in 95% of acute cases in preventing the need for emergent laying open and allows for subsequent elective surgery.

Can improved quality of care explain the success of orthogeriatric units? A population-based cohort study.

PubMed

Kristensen, Pia Kjær; Thillemann, Theis Muncholm; Søballe, Kjeld; Johnsen, Søren Paaske

2016-01-01

admission to orthogeriatric units improves clinical outcomes for patients with hip fracture; however, little is known about the underlying mechanisms. to compare quality of in-hospital care, 30-day mortality, time to surgery (TTS) and length of hospital stay (LOS) among patients with hip fracture admitted to orthogeriatric and ordinary orthopaedic units, respectively. population-based cohort study. using prospectively collected data from the Danish Multidisciplinary Hip Fracture Registry, we identified 11,461 patients aged ≥65 years admitted with a hip fracture between 1 March 2010 and 30 November 2011. The patients were divided into two groups: (i) those treated at an orthogeriatric unit, where the geriatrician is an integrated part of the multidisciplinary team, and (ii) those treated at an ordinary orthopaedic unit, where geriatric or medical consultant service are available on request. Outcome measures were the quality of care as reflected by six process performance measures, 30-day mortality, the TTS and the LOS. Data were analysed using log-binomial, linear and logistic regression controlling for potential confounders. admittance to orthogeriatric units was associated with a higher chance for fulfilling five out of six process performance measures. Patients who were admitted to an orthogeriatric unit experienced a lower 30-day mortality (adjusted odds ratio (aOR) 0.69; 95% CI 0.54-0.88), whereas the LOS (adjusted relative time (aRT) of 1.18; 95% CI 0.92-1.52) and the TTS (aRT 1.06; 95% CI 0.89-1.26) were similar. admittance to an orthogeriatric unit was associated with improved quality of care and lower 30-day mortality among patients with hip fracture. © The Author 2015. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Comparison of Plastic Surgery Residency Training in United States and China.

PubMed

Zheng, Jianmin; Zhang, Boheng; Yin, Yiqing; Fang, Taolin; Wei, Ning; Lineaweaver, William C; Zhang, Feng

2015-12-01

Residency training is internationally recognized as the only way for the physicians to be qualified to practice independently. China has instituted a new residency training program for the specialty of plastic surgery. Meanwhile, plastic surgery residency training programs in the United States are presently in a transition because of restricted work hours. The purpose of this study is to compare the current characteristics of plastic surgery residency training in 2 countries. Flow path, structure, curriculum, operative experience, research, and evaluation of training in 2 countries were measured. The number of required cases was compared quantitatively whereas other aspects were compared qualitatively. Plastic surgery residency training programs in 2 countries differ regarding specific characteristics. Requirements to become a plastic surgery resident in the United States are more rigorous. Ownership structure of the regulatory agency for residency training in 2 countries is diverse. Training duration in the United States is more flexible. Clinical and research training is more practical and the method of evaluation of residency training is more reasonable in the United States. The job opportunities after residency differ substantially between 2 countries. Not every resident has a chance to be an independent surgeon and would require much more training time in China than it does in the United States. Plastic surgery residency training programs in the United States and China have their unique characteristics. The training programs in the United States are more standardized. Both the United States and China may complement each other to create training programs that will ultimately provide high-quality care for all people.

Surgeons' attitudes to some aspects of day case surgery

PubMed Central

Sloan, D S G; Watson, J D

1986-01-01

The level of day case surgery is much lower in Northern Ireland than in England. A questionnaire was sent to all 55 consultant general surgeons in Northern Ireland to assess attitudes to this form of care and 51 (93%) replied. They were asked about the suitability of five procedures for day surgery. The three minor procedures of vasectomy, cystoscopy and gastroscopy were regarded as suitable or very suitable by 50 (98% of those who replied), 48 (94%) and 48 (94%) respectively. For the two intermediate procedures, 25 (49%) regarded the repair of inguinal hernia as suitable for day case surgery and 22 (43%) ligation of varicose veins. When asked about eight factors limiting their use of day surgery for inguinal hernia repair, the two most frequently rated as important were ‘home conditions’ and ‘level of provision of domiciliary care’ (both by 44 (86%) of the surgeons). Of factors which might promote their use of day surgery for this operation the two most important were ‘more efficient use of health service resources’ (71%) and the ‘ability to convalesce at home’ (67%). The problem of under-reporting of day cases and the importance of accurate statistics are considered. PMID:3739063

Bariatric surgeries performed by the Brazilian National Health System in residents of the Metropolitan Region of Porto Alegre, Rio Grande do Sul, Brazil, 2010-2016.

PubMed

Carvalho, Adriane da Silva; Rosa, Roger Dos Santos

2018-06-11

to characterize caracterize by Brazilian National Health System (SUS) hospitalizations for bariatric surgeries in residents of the Metropolitan Region of Porto Alegre, RS, Brazil, from 2010 to 2016. data analysis of the National Hospital Information System (SIH/SUS); calculation of indicators by sex, age groups, use of Intensive Care Unit and hospitalization expenses; the target population were patients aged 15 years and older. there were 1,249 hospitalizations (178.4/year; 5.4/100 thousand inhab./year), and the average age was 41.3±10.3 years old (average±standard deviation); the female sex was more prevalent (85.0%) and the age group 35-39 years accounted for 234 cases (18.7%); 227 patients (18.2%) needed ICU; there were 2 (0.2%) deaths; the mean for hospital stay was 5.1±3.2 days; the average annual expense was BRL1,073.830.29±223,791.48; and the average cost for hospitalization was BRL6,018.26±851,34 (BRL1,171.03/day). bariatric surgeries were characterized as procedures undergone by young female adults, with relatively frequent use of ICU and low fatality.

Severe Rhabdomyolysis Associated with Staphylococcus aureus Acute Endocarditis Requiring Surgery.

PubMed

Ravry, Céline; Fedou, Anne-Laure; Dubos, Maria; Denes, Éric; Etchecopar, Caroline; Barraud, Olivier; Vignon, Philippe; François, Bruno

2015-12-01

Rhabdomyolysis has multiple etiologies with unclear mechanisms; however, rhabdomyolysis caused by Staphylococcus aureus infection is rare. A case report of severe rhabdomyolysis in a patient who presented with endocarditis caused by methicillin-susceptible S. aureus and review of relevant literature. The patient had a history of cardiac surgery for tetralogy of Fallot. He was admitted to the hospital because of fever and digestive symptoms. Respiratory and hemodynamic status deteriorated rapidly, leading to admission to the intensive care unit (ICU) for mechanical ventilation and vasopressor support. Laboratory tests disclosed severe rhabdomyolysis with a serum concentration of creatine kinase that peaked at 49,068 IU/L; all blood cultures grew methicillin-susceptible S. aureus. Antibiotic therapy was amoxicillin-clavulanic acid, ciprofloxacin, and gentamicin initially and was changed subsequently to oxacillin, clindamycin, and gentamicin. Transesophageal echocardiography showed vegetation on the pulmonary valve, thus confirming the diagnosis of acute endocarditis. Viral testing and computed tomography (CT) scan ruled out any obvious alternative etiology for rhabdomyolysis. Bacterial analysis did not reveal any specificity of the staphylococcal strain. The patient improved with antibiotics and was discharged from the ICU on day 26. He underwent redux surgery for valve replacement on day 53. Staphylococcal endocarditis should be suspected in cases of severe unexplained rhabdomyolysis with acute infectious symptoms.

Day care versus in-patient surgery for age-related cataract.

PubMed

Lawrence, David; Fedorowicz, Zbys; van Zuuren, Esther J

2015-11-02

Age-related cataract accounts for more than 40% of cases of blindness in the world with the majority of people who are blind from cataract living in lower income countries. With the increased number of people with cataract, it is important to review the evidence on the effectiveness of day care cataract surgery. To provide authoritative, reliable evidence regarding the safety, feasibility, effectiveness and cost-effectiveness of day case cataract extraction by comparing clinical outcomes, cost-effectiveness, patient satisfaction or a combination of these in cataract operations performed in day care versus in-patient units. We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2015, Issue 7), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to August 2015), EMBASE (January 1980 to August 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to August 2015), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 17 August 2015. We included randomised controlled trials comparing day care and in-patient surgery for age-related cataract. The primary outcome was the achievement of a satisfactory visual acuity six weeks after the operation. Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected adverse effects information from the trials. We included two trials. One study was conducted in the USA in 1981 (250 people randomised and completed trial) and one study conducted in Spain in 2001 (1034 randomised, 935 completed trial). Both trials used extracapsular cataract extraction techniques that are not commonly used in higher income countries now. Most of the data in this review came from the larger trial, which we judged to be at low risk of bias.The mean change in visual acuity (in Snellen lines) of the operated eye four months postoperatively was similar in people given day care surgery (mean 4.1 lines standard deviation (SD) 2.3, 464 participants) compared to people treated as in-patients (mean 4.1 lines, SD 2.2, 471 participants) (P value = 0.74). No data were available from either study on intra-operative complications.Wound leakage, intraocular pressure (IOP) and corneal oedema were reported in the first day postoperatively and at four months after surgery. There was an increased risk of high IOP in the day care group in the first day after surgery (risk ratio (RR) 3.33, 95% confidence intervals (CI) 1.21 to 9.16, 935 participants) but not at four months (RR 0.61, 95% CI 0.14 to 2.55, 935 participants). The findings for the other outcomes were inconclusive with wide CIs. There were two cases of endophthalmitis observed at four months in the day care group and none in the in-patient group. The smaller study stated that there were no infections or severe hyphaemas.In a subset of participants evaluated for quality of life (VF14 questionnaire) similar change in quality of life before and four months after surgery was observed (mean change in VF14 score: day care group 25.2, SD 21.2, 150 participants; in-patient group: 23.5, SD 25.7, 155 participants; P value = 0.30). Subjective assessment of patient satisfaction in the smaller study suggested that participants preferred to recuperate at home, were more comfortable in their familiar surroundings and enjoyed the family support that they received at home. Costs were 20% more for the in-patient group and this was attributed to higher costs for overnight stay. This review provides evidence that there is cost saving with day care cataract surgery compared to in-patient cataract surgery. Although effects on visual acuity and quality of life appeared similar, the evidence with respect to postoperative complications was inconclusive because the effect estimates were imprecise. Given the wide-spread adoption of day care cataract surgery, future research in cataract clinical pathways should focus on evidence provided by high quality clinical databases (registers), which would enable clinicians and healthcare planners to agree clinical and social indications for in-patient care and so make better use of resources.

[Appropriateness of ketorolac use in a trauma hospital].

PubMed

Angeles González-Fernández, M

2009-06-01

To evaluate the suitability of ketorolac and non-steroidal anti-inflamatory drugs (NSAIDs) and other analgesic drugs currently used in the hospital. We have followed the steps to develop a PDCA cycle (plan, do, check, act) or quality improvement cycle. The quality problem was analysed using an Ishikawa diagram. We defined both qualitative quality indicators, those that measure prescription quality, and quantitative ones (defined daily dose, DDD/100BDs), which measure drug consumption, being the objectives to achieve. The study was conducted in all patients admitted to the hospital and who were admitted to orthopaedic and trauma surgery and plastic surgery departments with unit-dose dispensing systems. The strategy used was to give information to physicians through meetings and documentation. Finally, the results were analysed and compared with the initial objectives. The study was performed on 260 patients in the first study period and 292 in the second. Qualitative indicators: intravenous ketorolac use < or =2 days, increased in 25.5% (p<0.001); in patients > or =65 years old at dose < or =60 mg/day it increased 27.7% (p<0.05). Quantitative indicators: in the second study period, ketorolac use decreased (plastic surgery department: 61.8 DDD/100BDs to 14.8), whereas tramadol, ibuprofen and metamizole increased (plastic surgery department: 0 to 14.1 in tramadol, 8.7 to 48.6 in ibuprofen and 50.1 to 71 in metamizole). Appropriateness of ketorolac, NSAIDs and tramadol use has been achieved, thus improving patient safety. Strategies have been effective.

Obstructive sleep apnea and postoperative complications in patients undergoing coronary artery bypass graft surgery: a need for preventive strategies.

PubMed

Amra, Babak; Niknam, Nasim; Sadeghi, Mohsen Mir Mohammad; Rabbani, Majid; Fietze, Ingo; Penzel, Thomas

2014-11-01

Obstructive sleep apnea (OSA) is very frequent and often unrecognized in surgical patients. OSA is associated with perioperative complications. We evaluated the effects of OSA on postoperative complications and hospital outcomes in patients undergoing coronary artery bypass graft (CABG) surgery. Candidates of elective CABG were evaluated by the Berlin questionnaire for OSA. After surgery, patients were assessed for postoperative complications, re-admission to the Intensive Care Unit (ICU), duration of intubation, re-intubation, days spent in the ICU and the hospital. We studied 61 patients who underwent CABG from which 25 (40.9%) patients had OSA. Patients with OSA had higher body mass index (29.5 ± 3.9 vs. 26.0 ± 3.7 kg/m(2), P = 0.003) and higher frequency of hypertension (68.0% vs. 30.5%, P = 0.003), dyslipidemia (36.0% vs. 5.5%, P = 0.004), and pulmonary disease (16.0 vs. 2.7%, P = 0.08). Regarding the surgical outcomes, OSA patients had longer intubation duration (0.75 ± 0.60 vs. 0.41 ± 0.56 days, P = 0.03). Obstructive sleep apnea is frequent, but unrecognized among patients undergoing CABG. In these patients, OSA is associated with prolonged intubation duration. Preventing these problems may be possible by early diagnosis and management of OSA in cardiac surgery patients. Further studies with larger sample of patients and longer follow-ups are required in this regard.

Risk of Ischemic Stroke and Transient Ischemic Attack Is Increased up to 90 Days after Non-Carotid and Non-Cardiac Surgery.

PubMed

Grau, Armin J; Eicke, Martin; Burmeister, Christoph; Hardt, Roland; Schmitt, Eberhard; Dienlin, Sieghard

2017-01-01

The risk of stroke after cardiac and carotid surgery is well established. In contrast, stroke risk in association with non-cardiac and non-carotid surgery and its time course are insufficiently known. We investigated the prevalence of recent and planned surgery among patients with stroke and transient ischemic attack (TIA), time dependency of stroke risk, stroke etiology, and interruption of antithrombotic medication in association with surgery. Data on type and date of surgery and similar interventions within the last year or planned for the next 2 weeks were anonymously collected together with demographic data, vascular risk factors, stroke severity, handicap before stroke and stroke etiology within a state-wide, mandatory, hospital-based acute stroke care quality monitoring project (Rhineland-Palatinate, Germany) for 1 year (2010). Non-carotid and non-cardiothoracic surgery was reported as performed within 1 year before the index event or as planned for the next 2 weeks thereafter in 532 out of 12,120 patients with ischemic stroke/TIA (4.4%). Compared to 91-365 days before stroke/TIA as reference period, risk of cerebral ischemia (per day analysis) was increased for surgery within 61-90 days before ischemia (rate ratio 2.0, 95% CI 1.5-2.8) and continuously increased along shorter intervals between stroke and surgery (31-60 days: rate ratio 3.6, 95% CI 2.9-4.5; 15-30 days: rate ratio 8.2, 95% CI 6.7-10.1; 8-14 days: rate ratio 13.2, 95% CI 10.3-16.8; 4-7 days: rate ratio 16.5, 95% CI 12.2-22.1) peaking at an interval of 1-3 days before ischemia (rate ratio 34.0, 95% CI 26.9-42.8). On the day of surgery, rate ratio was 14.8 (95% CI 7.8-27.9) and for planned surgery it was 2.7 (95% CI 1.8-4.0). Results were similar for first-ever and for recurrent ischemic stroke. Perioperative stroke/TIA was positively associated with atrial fibrillation and cardioembolic stroke etiology, higher mortality, more severe neurological deficits at discharge, and longer hospital stay; and it was inversely associated with microangiopathic etiology and discharge at home. In 34.5% of patients with recent/planned surgery, prior antithrombotic or anticoagulant medication had been interrupted. Recent or planned surgery imposes a considerable short-term stroke risk particularly by cardioembolism with cessation of medication as an important contributor. Stroke after surgery is associated with poor outcome and high mortality. Better strategies to reduce the burden of perioperative stroke are urgently required. © 2017 S. Karger AG, Basel.

Improvement in Creatinine Clearance after Open Heart Surgery in Infants as an Early Indicator of Surgical Success.

PubMed

Dagan, Amit; Dagan, Ovadia

2016-12-01

Early surgical correction of congenital heart malformations in neonates and small infants may be complicated by acute kidney injury (AKI), which is associated with higher morbidity and mortality rates, especially in patients who require dialysis. Glomerular filtration rate (GFR) is considered the best measurement of renal function which, in neonates and infants, is highly dependent on heart function. To determine whether measurements of creatinine clearance after open heart surgery in neonates and young infants can serve as an early indicator of surgical success or AKI. We conducted a prospective observational study in 19 neonates and small infants (body weight < 5 kg) scheduled for open heart surgery with cardiopulmonary bypass. Urine collection measurement of creatinine clearance and albumin excretion was performed before and during surgery and four times during 48 hours after surgery. Mean creatinine clearance was lowest during surgery (25.2 ± 4. ml/min/1.73 m2) and increased significantly in the first 16 hours post-surgery (45.7 ± 6.3 ml/min/1.73 m2). A similar pattern was noted for urine albumin which was highest during surgery (203 ± 31 µg/min) and lowest (93 ± 20 µg/min) 48 hours post-surgery. AKI occurred in four patients, and two patients even required dialysis. All six showed a decline in creatinine clearance and an increase in urine albumin between 8 and 16 hours post-surgery. In neonates and small infants undergoing open heart surgery, a significant improvement in creatinine clearance in the first 16 hours postoperatively is indicative of a good surgical outcome. This finding has important implications for the early evaluation and treatment of patients in the intensive care unit on the first day post-surgery.

Incidence and predictors of post-thyroidectomy hypocalcaemia in a tertiary endocrine surgical unit

PubMed Central

Prasad, P; Harrison, BJ; Balasubramanian, SP

2014-01-01

Background Post-thyroidectomy hypocalcaemia is a common complication with significant short and long term morbidity. The aim of this study was to determine the incidence and predictors of post-thyroidectomy hypocalcaemia (as defined by a corrected calcium <2.1 mmol/l) in a tertiary endocrine surgical unit. Methods A total of 238 consecutive patients who underwent completion or bilateral thyroid surgery between 2008 and 2011 were included in this retrospective study. Clinical and biochemical data were obtained from electronic and hard copy medical records. Results The incidence of post-thyroidectomy hypocalcaemia on first postoperative day (POD1) was 29.0%. There was variation in the incidence of hypocalcaemia depending on the timing of measurement on the first postoperative day. At six months following surgery, 5.5% of patients were on calcium and/or vitamin D supplementation. Factors associated with post-thyroidectomy hypocalcaemia were lower preoperative corrected calcium (p=0.005) and parathyroid gland (PTG) auto-transplant (p=0.001). Other clinical factors such as central lymph node dissection, inadvertent PTG excision, ethnicity, preoperative diagnosis and Lugol’s iodine were not associated with post-thyroidectomy hypocalcaemia. Conclusion The incidence of post-thyroidectomy hypocalcaemia was underestimated by 6% when only POD1 measurements were considered. The timing of measurement on POD1 has an impact on the incidence of post-thyroidectomy hypocalcaemia. Auto-transplantation and lower preoperative calcium were associated with post-thyroidectomy hypocalcaemia. PMID:24780788

"To See With My Own Eyes": Experiences of Family Visits During Phase 1 Recovery.

PubMed

Wendler, M Cecilia; Smith, Katherine; Ellenburg, Wanda; Gill, Rita; Anderson, Lea; Spiegel-Thayer, Kim

2017-02-01

Long separations are a characteristic of the day of surgery, keeping patients and their family members waiting and apart. At a time of high vulnerability, these separations can cause anxiety and worry. The purpose of this study was to identify the outcomes and experiences of patients and family members who engaged in a 5- to 10-minute supervised family visit during phase I postanesthesia recovery. This was a descriptive, single-group, mixed-methods study. Quantitative data, gathered on the day of surgery, was obtained from patients (vital signs, state anxiety scores) and their designated family members (state anxiety scores); satisfaction with the visit was also measured. An optional second, qualitative phase included a semi-structured interview examining the remembered experiences of patients and family members. A statistically significant drop in state anxiety was discovered after the visit, and satisfaction with the visit was exceedingly high. Qualitatively, patients and family members described their overwhelming relief to be able "to see with my own eyes" how well each was doing. This study supports that family visits in the postanesthesia care unit are safe and profoundly important as an independent nursing intervention. Recommendations include implementation of family visits during postanesthesia care unit recovery for all patients and family members who desire them. Copyright © 2016 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.

Incidence and predictors of post-thyroidectomy hypocalcaemia in a tertiary endocrine surgical unit.

PubMed

Edafe, O; Prasad, P; Harrison, B J; Balasubramanian, S P

2014-04-01

Post-thyroidectomy hypocalcaemia is a common complication with significant short and long term morbidity. The aim of this study was to determine the incidence and predictors of post-thyroidectomy hypocalcaemia (as defined by a corrected calcium <2.1 mmol/l) in a tertiary endocrine surgical unit. A total of 238 consecutive patients who underwent completion or bilateral thyroid surgery between 2008 and 2011 were included in this retrospective study. Clinical and biochemical data were obtained from electronic and hard copy medical records. The incidence of post-thyroidectomy hypocalcaemia on first postoperative day (POD1) was 29.0%. There was variation in the incidence of hypocalcaemia depending on the timing of measurement on the first postoperative day. At six months following surgery, 5.5% of patients were on calcium and/or vitamin D supplementation. Factors associated with post-thyroidectomy hypocalcaemia were lower preoperative corrected calcium (p=0.005) and parathyroid gland (PTG) auto-transplant (p=0.001). Other clinical factors such as central lymph node dissection, inadvertent PTG excision, ethnicity, preoperative diagnosis and Lugol's iodine were not associated with post-thyroidectomy hypocalcaemia. The incidence of post-thyroidectomy hypocalcaemia was underestimated by 6% when only POD1 measurements were considered. The timing of measurement on POD1 has an impact on the incidence of post-thyroidectomy hypocalcaemia. Auto-transplantation and lower preoperative calcium were associated with post-thyroidectomy hypocalcaemia.

The use of dornase alpha for post-operative pulmonary atelectasis after congenital heart surgery.

PubMed

Ozturk, Erkut; Tanidir, Ibrahim C; Haydin, Sertac; Onan, Ismihan S; Odemis, Ender; Bakir, Ihsan

2014-10-01

To investigate the efficacy of dornase alpha, a mucolytic agent, in children who developed pulmonary atelectasis after congenital heart surgery. Retrospective case-control study. Paediatric cardiac intensive care unit at a tertiary care hospital. Between July, 2011 and July, 2012, 41 patients who underwent congenital cardiac operations and developed post-operative pulmonary atelectasis that was resistant to conventional treatment and chest physiotherapy. In all, 26 patients received dornase alpha treatment. As a control group, 15 patients were treated with conventional medications and chest physiotherapy. The median age of patients was 25.5 (3-480) days in the study group and 50.0 (3-480) days in the control group. A total of 15 (57.6%) patients in the study group and 8 (53.3%) patients in the control group were male. The median weight was 4.2 (2.9-14.2) kg and 4.0 (3.5-13.6) kg in the study and control group, respectively. In the study group, pulmonary atelectasis was diagnosed at a median period of 5 (2-18) days after operations, whereas in the control group atelectasis was diagnosed at a median period of post-operative 6 (3-19) days. In the study group, the median atelectasis score decreased from 3.4 (1-6) to 0.8 (0-3) (p = 0.001). The median pO2 level increased from 69 (17-142) mmHg to 89 (30-168) mmHg (p = 0.04). In addition, heart rate and respiratory rate per minute were significantly decreased (p < 0.05). There were no significant changes in these parameters in the control group. The use of dornase alpha can be effective for the management of pulmonary atelectasis that develops following congenital heart surgery.

Hematological complications in children subjected to extracorporeal membrane oxygenation.

PubMed

Santiago, M J; Gómez, C; Magaña, I; Muñoz, V; Saiz, P; Sánchez, A; López-Herce, J

2018-03-29

To analyze the hematological complications and need for transfusions in children receiving extracorporeal life support (ECLS). A retrospective study was carried out. A pediatric intensive care unit. Children under 18 years of age treated with ECLS between September 2006 and November 2015. None. Patient and ECLS characteristics, anticoagulation, hematological and coagulation parameters, transfusions and clinical course. A total of 100 patients (94 with heart disease) with a median age of 11 months were studied. Seventy-six patients presented bleeding. The most frequent bleeding point being the mediastinum and 39 patients required revision surgery. In the first 3days, 97% of the patients required blood transfusion (34.4ml/kg per day), 94% platelets (21.1ml/kg per day) and 90% plasma (26.6ml/kg per day). Patients who were in the postoperative period, those who were bleeding at the start of ECLS, those requiring revision surgery, those who could not suspend extracorporeal circulation, and those subjected to transthoracic cannulation required a greater volume of transfusions than the rest of the patients. Thromboembolism occurred in 14 patients and hemolysis in 33 patients. Mortality among the children who were bleeding at the start of ECLS (57.6%) was significantly higher than in the rest of the patients (37.5%) (P=0.048). Children treated with ECLS present high blood product needs. The main factors related to transfusions were postoperative period, bleeding at the start of ECLS, revision surgery, transthoracic cannulation, and the impossibility of suspending extracorporeal circulation. Children with bleeding suffered greater mortality than the rest of the patients. Copyright © 2018 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.

Assessment of the effect of off-pump coronary artery bypass (OPCAB) surgery on right ventricle function using strain and strain rate imaging.

PubMed

Khani, Mohammad; Hosseintash, Mahsa; Foroughi, Mahnoosh; Naderian, Mohammadreza; Khaheshi, Isa

2016-04-01

Right ventricle function significantly decreases after coronary artery bypass surgery; as one of the likely causes, such a condition is attributed to the use of cardiopulmonary pump (CPB). Because nowadays there is a tendency toward increasing use of off-pump coronary artery bypass (OPCAB) surgery, this study was conducted to evaluate the right ventricle function after this type of surgery using strain and strain rate imaging (SRI) echocardiography. This study was conducted on 30 patients, candidate for elective OPCAB surgery, between 2011 and 2012. Standard echocardiography was performed before the surgery and the right ventricle function was examined using strain and SRI echocardiography. Then patient underwent surgery, 6 days and 3 months after surgery they underwent echocardiography again and the results obtained from the three stages were compared with each other. Participants included 30 patients (23 males and 7 females) with a mean age of 66±11 years. Compared to the prior of the surgery, 6 days and 3 months after the surgery there was a significant decrease in tricuspid annular plane systolic excursion (TAPSE), tissue Doppler imaging (TDI) at the lateral annulus of tricuspid valve, and strain and SRI of right ventricle. However, the values obtained 3 months after surgery were significantly higher than those obtained after 6 days. In other words, the right ventricle function 6 days after the surgery had dropped, however some of the values recovered 3 months after the surgery. The findings of this study are consistent with other studies in this field and showed that after coronary artery surgery a decline occurs in right ventricular function. However, more detailed quantitative strain and SRI parameters which were measured in our study showed that at the early days after the OPCAB surgery there is a decline in the right ventricle function which is relatively reversible at longer intervals (3 months after surgery).

Cosmetic surgery growth and correlations with financial indices: a comparative study of the United Kingdom and United States from 2002-2011.

PubMed

Nassab, Reza; Harris, Paul

2013-05-01

Over the past 10 years, there has been significant fluctuation in the yearly growth rates for cosmetic surgery procedures in both the United States and the United Kingdom. The authors compare cosmetic surgical procedure rates in the United Kingdom and United States with the macroeconomic climate of each region to determine whether there is a direct relationship between cosmetic surgery rates and economic health. The authors analyzed annual cosmetic surgery statistics from the British Association of Aesthetic Plastic Surgeons and the American Society for Aesthetic Plastic Surgery for 2002-2011 against economic indices from both regions, including the gross domestic product (GDP), consumer prices indices (CPI), and stock market reports. There was a 285.9% increase in the United Kingdom and a 1.1% increase in the United States in the number of procedures performed between 2002 and 2011. There were significant positive correlations between the number of cosmetic procedures performed in the United Kingdom and both the GDP (r = 0.986, P < .01) and CPI (r = 0.955, P < .01). Analysis of the US growth rates failed to show a significant relationship with any indices. UK interest rates showed a significant negative correlation (r = -0.668, P < .05) with procedures performed, whereas US interest rates showed a significant positive correlation. Data from the United States and United Kingdom suggest 2 very different growth patterns in the number of cosmetic surgeries being performed as compared with the economy in each region. Economic indices are accurate indicators of numbers of procedures being performed in the United Kingdom, whereas rates in the United States seem independent of those factors.

Day-of-Surgery Mobilization Reduces the Length of Stay After Elective Hip Arthroplasty.

PubMed

Okamoto, Taro; Ridley, Ryan J; Edmondston, Stephen J; Visser, Mariet; Headford, Julie; Yates, Piers J

2016-10-01

To determine the effect of mobilization on the day of surgery on the readiness for discharge and length of stay after elective total hip arthroplasty (THA). We devised a randomized control trial with concealed allocation and intention-to-treat analysis. Overall, 126 patients who underwent THA and met the criteria for mobilization on the day of surgery were randomly allocated into 2 groups; the intervention group was mobilized on the day of surgery, n = 58 and the control group was mobilized on the day after surgery, n = 68. Apart from timing of mobilization, both groups received the same postoperative management. The primary outcome measures were length of hospital stay and time to readiness for discharge. The early mobilization group was ready for discharge 63 hours (standard deviation [SD] = 15 hours) after surgery, compared to 70 hours (SD = 18 hours) for the control group (P = .03, 95% CI, 0.7-12.8). There was no significant difference in hospital stay in the early mobilization group (77 hours [SD = 30 hours]), compared to the control group (87 hours [SD = 35 hours]; P = .11, 95% CI, -2.1 to 21.6). Despite this at any point in time after the surgery, the intervention group was 1.8 times (P = .003, 95% CI, = 1.2-2.7) more likely to have been discharged. Mobilization on the day of THA surgery significantly increases the probability of discharge at any singular point in time compared with mobilization on the day after surgery and decreases the time to readiness for discharge. Crown Copyright © 2016. Published by Elsevier Inc. All rights reserved.

Evaluation of day care versus inpatient cataract surgery performed at a Jiangsu public Tertiary A hospital.

PubMed

Zhuang, Min; Cao, Juan; Cui, Minglan; Yuan, Songtao; Liu, Qinghuai; Fan, Wen

2018-06-05

High cataract incidence and low cataract surgical rate are serious public health problems in China, despite the fact that efficient day care cataract surgery has been implemented in some public Tertiary A hospitals in China. In this study, we compared not only clinical outcomes, hospitalization time and total costs but also payment manners between day care and inpatient procedures for cataract surgery in a Jiangsu public Tertiary A hospital to put forward several instructional suggestions for the improvement of government medical policies. In total, 4151 day care cases and 2509 inpatient cases underwent the same cataract surgery in the day care ward and ordinary ward respectively, and were defined as two groups. General information, complications, postoperative best corrected visual acuity (BCVA), hospitalization time, total costs and especially payment method were analyzed to compare day care versus inpatient. The general data display no significant differences (P > 0.05), and no significant difference between complications and postoperative BCVA were observed between the two groups (P > 0.05). The period of stay in hospital was significantly different (P < 0.001). The total costs were lower for day care than for inpatients (P < 0.001). To avoid sampling error, we analyzed the data of payment manner for each patient among this period. Day care patients tended to pay for the procedure using the Urban Employees Basic Medical Insurance (UEBMI) method, while inpatients tended to use the Out-of-Pocket Medical Treatment (OMT) payment method (P < 0.001). Day surgery of cataract is more cost-effective and efficient than inpatient surgery with equivalent clinical outcomes. As an efficient therapeutic regimen, day care surgery should be further promoted and supported by the government policies.

Evaluation of cardiac surgery mortality rates: 30-day mortality or longer follow-up?

PubMed

Siregar, Sabrina; Groenwold, Rolf H H; de Mol, Bas A J M; Speekenbrink, Ron G H; Versteegh, Michel I M; Brandon Bravo Bruinsma, George J; Bots, Michiel L; van der Graaf, Yolanda; van Herwerden, Lex A

2013-11-01

The aim of our study was to investigate early mortality after cardiac surgery and to determine the most adequate follow-up period for the evaluation of mortality rates. Information on all adult cardiac surgery procedures in 10 of 16 cardiothoracic centres in Netherlands from 2007 until 2010 was extracted from the database of Netherlands Association for Cardio-Thoracic Surgery (n = 33 094). Survival up to 1 year after surgery was obtained from the national death registry. Survival analysis was performed using Kaplan-Meier and Cox regression analysis. Benchmarking was performed using logistic regression with mortality rates at different time points as dependent variables, the logistic EuroSCORE as covariate and a random intercept per centre. In-hospital mortality was 2.94% (n = 972), 30-day mortality 3.02% (n = 998), operative mortality 3.57% (n = 1181), 60-day mortality 3.84% (n = 1271), 6-month mortality 5.16% (n = 1707) and 1-year mortality 6.20% (n = 2052). The survival curves showed a steep initial decline followed by stabilization after ∼60-120 days, depending on the intervention performed, e.g. 60 days for isolated coronary artery bypass grafting (CABG) and 120 days for combined CABG and valve surgery. Benchmark results were affected by the choice of the follow-up period: four hospitals changed outlier status when the follow-up was increased from 30 days to 1 year. In the isolated CABG subgroup, benchmark results were unaffected: no outliers were found using either 30-day or 1-year follow-up. The course of early mortality after cardiac surgery differs across interventions and continues up to ∼120 days. Thirty-day mortality reflects only a part of early mortality after cardiac surgery and should only be used for benchmarking of isolated CABG procedures. The follow-up should be prolonged to capture early mortality of all types of interventions.

A retrospective review comparing two-year patient-reported outcomes, costs, and healthcare resource utilization for TLIF vs. PLF for single-level degenerative spondylolisthesis.

PubMed

Kim, Elliott; Chotai, Silky; Stonko, David; Wick, Joseph; Sielatycki, Alex; Devin, Clinton J

2018-03-01

The purpose of this study was to compare patient-reported outcomes (PROs), morbidity, and costs of TLIF vs PLF to determine whether one treatment was superior in the setting of single-level degenerative spondylolisthesis. Patients undergoing TLIF or PLF for single-level spondylolisthesis were included for retrospective analysis. EQ-5D, ODI, SF-12 MCS/PCS, NRS-BP/LP scores were collected at baseline and 24 months after surgery. 90-day post-operative complications, revision surgery rates, and satisfaction scores were also collected. Two-year resource use was multiplied by unit costs based on Medicare payment amounts (direct cost). Patient and caregiver workday losses were multiplied by the self-reported gross-of-tax wage rate (indirect cost). Total cost was used to assess mean total 2-year cost per QALYs gained after surgery. 62 and 37 patients underwent TLIF and PLF, respectively. Patients in the PLF group were older (p < 0.01). No significant differences were seen in baseline or 24-month PROs between the two groups. There was a significant improvement in all PROs from baseline to 24 months after surgery (p < 0.001). Both groups had similar rates of 90-day complications, revision surgery, satisfaction, and similar gain in QALYs and cost per QALYs gained. There was no significant difference in 24-month direct, indirect, and total cost. Overall costs and health care utilization were similar in both the groups. Both TLIF and PLF for single-level degenerative spondylolisthesis provide improvement in disability, pain, quality of life, and general health.

Feeding the gut after revisional bariatric surgery: The fate of 126 enteral access tubes.

PubMed

Strong, Andrew T; Fayazzadeh, Hana; Sharma, Gautam; El-Hayek, Kevin; Kroh, Matthew; Rodriguez, John

2018-03-09

Revisional bariatric surgery (RBS) is associated with higher complication rates compared with primary bariatric surgery. Feeding tubes (FTs), including gastrostomy and jejunostomy tubes placed during RBS, may serve as a safety net to provide nutrition when oral intake is contraindicated or limited; however, FTs in this setting have not been well investigated. This study aims to determine complications, use, and duration of FTs placed during RBS. A high-volume academic medical center in the United States. Included patients underwent RBS between January 2008 and December 2016 with FTs placed at the time of RBS. There were 126 patients identified (84.9% female, 76.2% Caucasian, mean age 53.4-±10.9 yr). Patients had previously undergone Roux-en-Y gastric bypass (34.1%), vertical banded gastroplasty (27.8%), and adjustable gastric band (14.3%). Indications for RBS included correction of complication of prior bariatric surgeries (50%), weight regain/failure to lose weight (32.3%), or both (17.3%). Most FTs were placed in the excluded stomach (89.7%), and median tube size was 18 F. FTs were used for feeding in 68.2% of patients, with feeding initiated in a median of 2 days. Leakage around the tube (32.5%) and pain (26.8%) were common complaints. Significant tube-related complications included infection (9.1%), dislodgement (5.9%), reintervention (5.8%), and reoperation (2.8%); 16.7% experienced at least 1 significant complication. FTs were removed at a median of 36 days. FTs may aid in prevention of perioperative dehydration and malnutrition after RBS, but should not be considered a benign intervention. FT use should be balanced against institutional outcomes and care goals. Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.

Use of antibiotics for urinary tract infection in women undergoing surgery for urinary incontinence: a cohort study.

PubMed

Guldberg, Rikke; Kesmodel, Ulrik Schiøler; Brostrøm, Søren; Kærlev, Linda; Hansen, Jesper Kjær; Hallas, Jesper; Nørgård, Bente Mertz

2014-02-04

To describe the use of antibiotics for urinary tract infection (UTI) before and after surgery for urinary incontinence (UI); and for those with use of antibiotics before surgery, to estimate the risk of treatment for a postoperative UTI, relative to those without use of antibiotics before surgery. A historical population-based cohort study. Denmark. Women (age ≥18 years) with a primary surgical procedure for UI from the county of Funen and the Region of Southern Denmark from 1996 throughout 2010. Data on redeemed prescriptions of antibiotics ±365 days from the date of surgery were extracted from a prescription database. Use of antibiotics for UTI in relation to UI surgery, and the risk of being a postoperative user of antibiotics for UTI among preoperative users. A total of 2151 women had a primary surgical procedure for UI; of these 496 (23.1%) were preoperative users of antibiotics for UTI. Among preoperative users, 129 (26%) and 215 (43.3%) also redeemed prescriptions of antibiotics for UTI within 0-60 and 61-365 days after surgery, respectively. Among preoperative non-users, 182 (11.0%) and 235 (14.2%) redeemed prescriptions within 0-60 and 61-365 days after surgery, respectively. Presurgery exposure to antibiotics for UTI was a strong risk factor for postoperative treatment for UTI, both within 0-60 days (adjusted OR, aOR=2.6 (95% CI 2.0 to 3.5)) and within 61-365 days (aOR=4.5 (95% CI 3.5 to 5.7)). 1 in 4 women undergoing surgery for UI was treated for UTI before surgery, and half of them had a continuing tendency to UTIs after surgery. Use of antibiotics for UTI before surgery was a strong risk factor for antibiotic use after surgery. In women not using antibiotics for UTI before surgery only a minor proportion initiated use after surgery.

A high risk critical mitral valve stenosis with emergency management at Apollo Hospitals Dhaka.

PubMed

Zahangir, N M; Hoque, K Z; Khan, M H; Haque, M A; Haider, M Z

2013-10-01

Heart valve surgery in high-risk patients with severe jaundice, congestive hepatomegaly and renal impairment is associated with considerable morbidity and mortality. Without operation the consequences are invariably grave. A 35 years old gentleman with congestive cardiac failure was initially treated in coronary care unit (CCU). Mitral valve area was 0.5cm², pulmonary arterial systolic pressure (PASP) was 110mmHg, serum bilirubin was 20mg/dl, SGPT & SGOT were 1024iu/l and 1027iu/l respectively. Serum creatinine was 3.35mmol/l. Serum bilirubin gradually diminished to 3.1mg/dl after 12 days treatment in Coronary Care Unit but next day it increased to 3.6mg/dl. Mitral valve was replaced on an emergency basis. Echocardiogram on the 5th post operative day showed well functioning prosthetic mitral valve in situ. Serum bilirubin decreased to 2.2mg/dl, SGPT, SGOT and serum creatinine to 43iu/l, 40iu/l and 1.34mmol/l respectively. After 8 weeks of postoperative follow up his serum bilirubin decreased to 0.8mg/dl.

Reoperative surgery: a critical risk factor for complications inadequately captured by operative reporting and coding of lysis of adhesions.

PubMed

Aloia, Thomas A; Cooper, Amanda; Shi, Weiming; Vauthey, Jean-Nicolas; Lee, Jeffrey E

2014-07-01

Reoperative surgery is suspected, but not proven, to increase postoperative complication rates. In the absence of a specific definition for reoperative surgery, the American College of Surgeons NSQIP has proposed using procedural coding for lysis of adhesions (LOA) as a surrogate for reoperative surgery to risk adjust hospitals. We hypothesized that coding of reoperative surgery will be associated with worse 30-day outcomes and, for abdominal procedures, will be more accurate than operative dictation and coding of "lysis of adhesions." Reoperative surgery was categorized at the time of data abstraction from February 2012 to December 2012 for all NSQIP cases collected at a single institution by independent surgical clinical reviewers. Reoperative surgery classification and coding of LOA were compared with each other and with 30-day outcomes. The setting was a tertiary cancer center, multispecialty NSQIP model. During the study period, 1,289 operations were classified as nonreoperative (n = 793), regionally reoperative (n = 39; prior surgery in an adjacent area of current operation), or locally reoperative (n = 457; prior surgery at same site or organ). In the multispecialty cohort, the non-risk-adjusted rates of overall 30-day morbidity, serious morbidity, and mortality were 21.5%, 17.7%, and 0.5%. Compared with nonreoperative surgery (overall 30-day morbidity 16.8%, serious morbidity 13.9%, and mortality .38%), both regionally reoperative surgery (overall 30-day morbidity 30.8%, serious morbidity 28.2%, and mortality 2.5%) and locally reoperative surgery (overall 30-day morbidity 28.9%, serious morbidity 23.4%, and mortality .66%) were associated with worse outcomes (p < 0.001). One hundred ninety-nine of the 327 gastrointestinal/laparotomy cases were recorded as reoperative, but only of 20 of these were CPT coded as LOA (sensitivity = 10%). Reoperative surgery is frequent, increases the risk of complications, and can be captured. Operative LOA coding vastly under reports reoperative surgery and, therefore, is not an adequate surrogate for this important risk factor. Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Operative variables are better predictors of postdischarge infections and unplanned readmissions in vascular surgery patients than patient characteristics.

PubMed

Hicks, Caitlin W; Bronsert, Michael; Hammermeister, Karl E; Henderson, William G; Gibula, Douglas R; Black, James H; Glebova, Natalia O

2017-04-01

Although postoperative readmissions are frequent in vascular surgery patients, the reasons for these readmissions are not well characterized, and effective approaches to their reduction are unknown. Our aim was to analyze the reasons for vascular surgery readmissions and to report potential areas for focused efforts aimed at readmission reduction. The 2012 to 2013 American College of Surgeons National Quality Improvement Program (ACS NSQIP) data set was queried for vascular surgery patients. Multivariable models were developed to analyze risk factors for postdischarge infections, the major drivers of unplanned 30-day readmissions. We identified 86,403 vascular surgery patients for analysis. Thirty-day readmission occurred in 8827 (10%), of which 8054 (91%) were unplanned. Of the unplanned readmissions, 61% (n = 4951) were related to the index vascular surgery procedure. Infectious complications were the most common reason for a surgery-related readmission (1940 [39%]), with surgical site infection being the most common type of infection related to unplanned readmission. Multivariable analysis showed the top five preoperative risk factors for postdischarge infections were the presence of a preoperative open wound, inpatient operation, obesity, work relative value unit, and insulin-dependent diabetes (but not diabetes managed with oral medications). Cigarette smoking was a weak predictor and came in tenth in the mode (overall C index, 0.657). When operative and postoperative factors were included in the model, total operative time was the strongest predictor of postdischarge infectious complications (odds ratio [OR] 1.2 for each 1-hour increase in operative time), followed by presence of a preoperative open wound (OR, 1.5), inpatient operation (OR, 2), obesity (OR, 1.8), and discharge to rehabilitation facility (OR, 1.7; P < .001 for all). Insulin-dependent diabetes, cigarette smoking, dialysis dependence, and female gender were also predictive, albeit with smaller effects (OR, 1.1-1.3 for all; P < .001). The overall fit of the multivariable model was fair (C statistic, 0.686). Infectious complications dominate the reasons for unplanned 30-day readmissions in vascular surgery patients. We have identified preoperative, operative, and postoperative risk factors for these infections with the goal of reducing these complications and thus readmissions. Expected patient risk factors, such as diabetes, obesity, renal insufficiency, and cigarette smoking, were less important in predicting infectious complications compared with operative time, presence of a preoperative open wound, and inpatient operation. Our findings suggest that careful operative planning and expeditious operations may be the most effective approaches to reducing infections and thus readmissions in vascular surgery patients. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

How do patient demographics, time-related variables, reasons for cancellation, and clinical procedures affect frequency of same-day operating room surgery cancelation? A maximum likelihood method.

PubMed

Da'ar, Omar B; Al-Mutairi, Talal

2018-06-15

Cancelation of same-day surgery is a common global problem, wasting valuable hospitals' operating room (OR) times and imposing significant economic costs. There is limited evidence to support the association between frequency of same-day surgery cancelation and patient demographics, time-related variables, healthcare provider reasons for cancelation, and clinical procedures in Saudi Arabia. The aim of this study was to explore this relationship, providing an understanding of the local context. A retrospective cross-sectional study that retrieved medical records to examine the association between the frequency of same-day surgery cancelation and covariates including patient demographics, time-related variables, healthcare provider reason for cancelation, and clinical procedures. The data covered from January 2014 to December 2014 at King Fahad National Guard Hospital in Riyadh. We considered 440 patients that met the inclusion criteria for final analysis. The cancelation was regarded less frequent if a patient canceled once in the12 months and more frequent if a patient canceled two times or more in the same period. We used descriptive statistics to summarize data and employed a probit regression to estimate the association of frequency of same-day surgery cancelation and covariates via maximum likelihood method. King Abdullah International Medical Research Center granted the institutional approval. Our study suggests that while reasons of unavailability of OR time were associated with less frequent same-day surgery cancelation, scheduling issues were linked to more frequent cancelations, compared with reasons for patients being unwell on the day of surgery. Waiting time of more than six hours and morning sessions were associated with less frequent cancelations compared to shorter waiting time and afternoon sessions. Compared to general procedures, specialized clinical procedures were associated with cancelations that are more frequent. Further, female patients were more likely to have more cancelations. Finally, being married was associated with the less frequent cancelation of same-day surgery. Our findings provide evidence of determinants of the frequency of same-day surgery cancelations. This study draws several important implications for hospitals, especially on optimal utilization of resources and minimization of same-day surgery cancellations. The study also offers several recommendations that we believe will spur future research.

How can we maximize the use of our operating lists? An analysis of factors influencing theatre efficiency in oculoplastic day surgery.

PubMed

Nagendran, Sonali T; Siah, We Fong; Litwin, Andre; Barbosa, Christine; Jayatilake, Jan; Malhotra, Raman

2016-12-01

Operating theatre utilization has become the principal measure of NHS operating theatre service performance. We analysed data from oculoplastic theatres in a tertiary centre to identify factors influencing theatre efficiency. We conducted three audits on operating theatre utilization in 2011, 2014 and 2015. Data was collected from real time information entered into the hospital database, including time of arrival, induction, first cut and close of operation. The primary outcome measure was the operating list utilization rate, a combined value of anaesthetic and surgical time as a proportion of the total planned session time. The initial 2011 audit recorded an operating list utilization rate of 81.2%. However, this dropped to 64.5% in 2014 following new management and a move to a new theatre suite. Analysis of the factors contributing to poor theatre efficiency led to changes that streamlined the patient pathway, including standardized case scheduling and reducing staggered patient arrival. A 2015 reaudit analyzing the effects of these changes demonstrated an increase in the operating list utilization rate to 78%. It was significantly higher (p < 0.01) for whole-day lists (85%) compared to half-day lists (75%), suggesting that whole-day lists were more efficient. Operating theatres are a valuable resource and the factors affecting theatre efficiency within our unit are common and will be relevant to units elsewhere. Correcting them can lead to significant improvements in patient care. Data from this study may provide a benchmark for other units in the United Kingdom.

Outcome in dogs with advanced (stage 3b) anal sac gland carcinoma treated with surgery or hypofractionated radiation therapy.

PubMed

Meier, V; Polton, G; Cancedda, S; Roos, M; Laganga, P; Emmerson, T; Rohrer Bley, C

2017-09-01

Stage 3b anal sac gland carcinoma (ASGC) can be life-threatening. A surgical approach is not always possible or may be declined. Dogs with stage 3b ASGC treated with surgery or conformal radiation therapy (RT) with 8 × 3.8 Gy (total dose 30.4 Gy, over 2.5 weeks) were retrospectively evaluated. Patient characteristics, median progression-free interval (PFI) and median survival time (MST) were compared. Twenty-eight dogs were included; 15 underwent surgery, 13 underwent RT. At the time of presentation, 21% showed life-threatening obstipation and 25% showed hypercalcaemia. PFI and MST for surgery cases were 159 days (95% CI: 135-184 days) and 182 days (95% CI: 146-218 days), both significantly lower than for RT cases with 347 days (95% CI: 240-454 days) and 447 days (95% CI: 222-672 days), (P = 0.01, P = 0.019). Surgery as well as RT led to a fast relief of symptoms. PFI and survival of surgical patients were significantly inferior to that of a comparable patient group treated with conformal hypofractionated RT. © 2016 John Wiley & Sons Ltd.

[MR cholangiopancreatography in choledochal cysts].

PubMed

Frampas, E; Moussaly, F; Léauté, F; Heloury, Y; Le Neel, J C; Dupas, B

1999-12-01

To assess the value of MR cholangiopancreatography (MRCP) in the diagnosis and preoperative evaluation of choledochal cysts. Five patients (aged between 6 days and 28 years) were investigated by MRCP, referred for ultrasonographic detection of a bile duct dilatation or a cystic structure, of antenatal diagnosis (1 case), for jaundice or abdominal pain (3 cases) or in late follow-up of a choledochal cyst surgery. Two endoscopic-ultrasonographic studies were performed. The five patients underwent surgery without preoperative biliary cholangiography. MRCP was performed using a HASTE sequence in frontal, oblique, axial planes (1,5 Tesla MR unit). MRCP allowed to confirm choledochal cyst, helps to specify the anatomical type (2 type I, 3 type II), detects choledocholithiasis (3 cases). Anatomic correlation was perfect. MRCP allowed to exclude gastrointestinal duplication. Anomalous junction of the pancreaticobiliary duct was found in one case. MRCP diagnoses choledochal cysts, specifies type, helps surgery and can avoid endoscopic retrograde cholangiography or endoscopic sonographic examinations especially for children. It may find an anomalous junction of the pancreaticobiliary duct.

Door openings in the operating room are associated with increased environmental contamination.

PubMed

Perez, Priscilla; Holloway, Julia; Ehrenfeld, Lucy; Cohen, Susan; Cunningham, Linda; Miley, Gerald B; Hollenbeck, Brian L

2018-05-04

Door openings in the operating room (OR) have been hypothesized to increase OR environmental contamination. This study measured average colony-forming units (CFU) in the OR as a function of door openings and other potentially important variables. Bacterial settle plates were placed inside and outside of laminar airflow (LAF) by both exit doors, on the instrument table, and on the back instrument table (if applicable) for 48 orthopedic and general surgery procedures. CFU data were paired to Staphylococcus aureus colonization status, door openings, surgery duration, time of day, OR location, number of staff, use of warming devices, temperature, and humidity. The number of door openings in the OR and surgery duration were significantly associated with increased CFU in the OR overall and outside of LAF. However, under LAF conditions, only the number of OR personnel was significantly associated with increased CFU. Copyright © 2018 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Retrospective cohort study of an enhanced recovery programme in oesophageal and gastric cancer surgery

PubMed Central

Gatenby, PAC; Shaw, C; Hine, C; Scholtes, S; Koutra, M; Andrew, H; Hacking, M; Allum, WH

2015-01-01

Introduction Enhanced recovery programmes have been established in some areas of elective surgery. This study applied enhanced recovery principles to elective oesophageal and gastric cancer surgery. Methods An enhanced recovery programme for patients undergoing open oesophagogastrectomy, total and subtotal gastrectomy for oesophageal and gastric malignancy was designed. A retrospective cohort study compared length of stay on the critical care unit (CCU), total length of inpatient stay, rates of complications and in-hospital mortality prior to (35 patients) and following (27 patients) implementation. Results In the cohort study, the median total length of stay was reduced by 3 days following oesophagogastrectomy and total gastrectomy. The median length of stay on the CCU remained the same for all patients. The rates of complications and mortality were the same. Conclusions The standardised protocol reduced the median overall length of stay but did not reduce CCU stay. Enhanced recovery principles can be applied to patients undergoing major oesophagogastrectomy and total gastrectomy as long as they have minimal or reversible co-morbidity. PMID:26414360

Inflammatory cytokine levels in synovial fluid 3, 4 days postoperatively and its correlation with early-phase functional recovery after anterior cruciate ligament reconstruction: a cohort study.

PubMed

Inoue, Makiko; Muneta, Takeshi; Ojima, Miyoko; Nakamura, Kaori; Koga, Hideyuki; Sekiya, Ichiro; Okazaki, Mutsumi; Tsuji, Kunikazu

2016-12-01

Synovial fluid was collected prior to and at 3 to 4 days after ACL reconstruction to investigate the correlation between inflammatory cytokine levels in the acute phase after surgery and physical functional recovery at 3 months postoperatively.  For this purpose, 79 patients with ACL reconstruction using semitendinosus tendons were included in the study. Median days from injury to surgery were 80 days (13-291 days). Synovial fluid was obtained just before surgery and at 3 to 4 days after surgery. Physical activity of each patient was evaluated at 3 months postoperatively, and scored from 0 (hard to walk) to 5 (run). Patients able to jog (score 4) or run (score 5) were considered as the "quick recovery" group and others (scores 1-3) as the "delayed recovery" group. Physical activity recovery scores in the early surgery group (preoperative period less than 60 days; Group I) were significantly better than those in the delayed surgery group (Group II). Among the cytokines tested, TNF-alpha and IL10 levels in synovial fluid were significantly higher in Group II at 3 to 4 days postoperatively, while levels of these cytokines were quite comparable preoperatively between the groups. Increased IL1-beta expression was noted in the delayed recovery group at 3 to 4 days postoperatively. In addition, levels of IL6, IL10 and IFN-gamma also tended to increase in patients with delayed recovery. Delayed ACL reconstruction increases levels of inflammatory cytokines in synovial fluid after surgery and correlates with a prolonged recovery of short-period physical activity of the patients.

[Management and orientation of a hand laceration].

PubMed

Masmejean, Emmanuel

2013-11-01

The good management and orientation of a hand laceration by the general physician is essential. Anatomical knowledge help to judge, after examination, the opportunity for surgery exploration with local anesthesia. Serious stakes are prognostic and economics. The conclusion identifies three clinical pictures : simple superf cial wound requiring a simple clinical control 2 days follow-up, the dubious wound that need to be sent to a specialized center, and the wound requiring care in an emergency hand unit. Extremely urgent wounds are devascularization, amputation and the pressure injection . Bites and wounds on a tendon way require surgical exploration. Bandage should be as simple as possible in order to allow early motion. No antibiotic is given preventively exept for bite, open fractures and/or delay of treatment. Outpatient surgery under loca anesthesia simplifies management.

Pain progression, intensity and outcomes following tonsillectomy.

PubMed

Warnock, F F; Lander, J

1998-03-01

The objective of this study was to assess outcomes of pediatric day surgery tonsillectomy. A total of 129 children, aged 5-16 years, and their parents were recruited from three urban hospitals which provided pediatric day surgery. Children reported pain on a visual analogue scale (VAS) in day surgery and then daily at home for 7 days. Parents reported outcomes of surgery, including fluid intake, nausea, vomiting and sleep disturbances. They also recorded analgesic administration. Three main results related to extent and duration of pain, quality of management of pain, and effect of pain on utilization of health services. Tonsillectomy caused considerable pain which lasted more than 7 days. Pain followed a trajectory of intense or moderately intense pain for the first 3 days followed by a gradual decline over the next 4 days. In general, post-tonsillectomy pain was poorly managed by health professionals and parents. An unexpected observation was that children who had a bupivacaine infiltration of the tonsil fossa during surgery had significantly more pain in the evening of surgery than children who did not have an infiltration. The increase in postoperative pain experienced by those who had the infiltration was attributed to quality of pain management. Children with persistent pain (those who did not follow the typical trajectory) were likely to be taken to a medical practitioner. One-third of the sample made unscheduled visits to practitioners with most occurring from Day 4 to Day 7 of the follow-up.

Preoperative prediction of intensive care unit stay following cardiac surgery.

PubMed

De Cocker, Jeroen; Messaoudi, Nouredin; Stockman, Bernard A; Bossaert, Leo L; Rodrigus, Inez E R

2011-01-01

Following cardiac surgery, a great variety in intensive care unit (ICU) stay is observed, making it often difficult to adequately predict ICU stay preoperatively. Therefore, a study was conducted to investigate, which preoperative variables are independent risk factors for a prolonged ICU stay and whether a patient's risk of experiencing an extended ICU stay can be estimated from these predictors. The records of 1566 consecutive adult patients who underwent cardiac surgery at our institution were analysed retrospectively over a 2-year period. Procedures included in the analyses were coronary artery bypass grafting, valve replacement or repair, ascending and aortic arch surgery, ventricular rupture and aneurysm repair, septal myectomy and cardiac tumour surgery. For this patient group, ICU stay was registered and 57 preoperative variables were collected for analysis. Descriptives and log-rank tests were calculated and Kaplan-Meier curves drawn for all variables. Significant predictors in the univariate analyses were included in a Cox proportional hazards model. The definitive model was validated on an independent sample of 395 consecutive adult patients who underwent cardiac surgery at our institution over an additional 6-month period. In this patient group, the accuracy and discriminative abilities of the model were evaluated. Twelve independent preoperative predictors of prolonged ICU stay were identified: age at surgery>75 years, female gender, dyspnoea status>New York Heart Association class II (NYHA II), unstable symptoms, impaired kidney function (estimated glomerular filtration rate (eGFR)<60 ml min(-1)), extracardiac arterial disease, presence of arrhythmias, mitral insufficiency>colour flow mapping (CFM) grade II, inotropic support, intra-aortic balloon pumping (IABP), non-elective procedures and aortic surgery. The individual effect of every predictor on ICU stay was quantified and inserted into a mathematical algorithm (called the Morbidity Defining Cardiosurgical (MDC) index), making it possible to calculate a patient's risk of having an extended ICU stay. The model showed very good calibration and very good to excellent discriminative ability in predicting ICU stay >2, >5 and >7 days (C-statistic of 0.78; 0.82 and 0.85, respectively). Twelve independent preoperative risk factors for a prolonged ICU stay following cardiac surgery were identified and constructed into a proportional hazards model. Using this risk model, one can predict whether a patient will have a prolonged ICU stay or not. Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Management of oral and maxillofacial infections in a regional unit: a seven day service?

PubMed

Cabral, Marta; Kapasi, Farhana T; Ameerally, Phillip

2018-05-24

The provision of a seven-day National Health Service (NHS) has been proposed as a means to halt the weekend delay in treatment that has been described in some studies. We tested the emergency services in the Oral and Maxillofacial Surgery Department at Northampton General Hospital to find out whether they provided a seven-day service. Data were collected prospectively and retrospectively for all patients admitted to the Oral and Maxillofacial Department at Northampton General Hospital with infections of the head and neck during a period of 29months (January 2014-May 2016). Duration of hospital stay and waiting time for operation were compared for weekday and weekend admissions to find out if there were changes in either outcomes or waiting times. The severity of infection between the two periods was also assessed using the serum C reactive protein (CRP) concentration as a marker. A total of 293 patients were admitted with head and neck infections, and the mean (range) duration of stay for those admitted on weekdays was 3 (1-14) days and for patients admitted at a weekend was 3 (1-17) days (p=0.14). However, the waiting times for operation were significantly longer during the week (mean (range) 0.6 (0-8) days) than at the weekend (0.5 (0-3) days, p=0.04). We know of no other published studies about provision of a seven-day service in oral and maxillofacial surgery. Our results show that we are already working to that standard, and this raises the question of whether any changes are required to current practice in the NHS, with their associated costs and upheaval. Copyright © 2018 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Short-term Vision Loss Following Whipple Surgery: A Case Report.

PubMed

Gollapalli, Lakshman; Kumar, Aashish J; Sood, Kunal; Muppuri, Rudram

2017-04-15

Occipital seizures may result in visual deficits and may be an ictal or postictal phenomenon. A 71-year-old woman underwent pancreatoduodenectomy (Whipple procedure). During recovery in the postanesthesia care unit, the patient complained of blindness. Upon transfer to the intensive care unit, an electroencephalogram indicated bilateral occipital and hemispheric seizure activity. The patient was treated with antiseizure medication, and vision normalized within 3 days. Subtherapeutic concentration of free phenytoin was confirmed. Our experience suggests that electroencephalogram evaluation should be considered in the workup of postoperative patients who present with acute-onset blindness and in whom the cause remains ambiguous even in the absence of obvious clinical signs of seizures.

Comparison of esophagectomy with and without thoracotomy in a low-resource tertiary care center in a developing country.

PubMed

Kothari, K C; Nair, C Krishnan; George, P S; Patel, M H; Gatti, R C; Gurjar, G C

2011-11-01

Esophageal cancer surgery is traditionally performed by a number of open surgical approaches. Open approaches require thoracotomy and laparotomy. Developments in instrumentation and optics have allowed the use of minimally invasive approaches to esophageal cancer, which had been traditionally managed by open operation. Minimally invasive surgery (MIS) avoids thoracotomy and laparotomy and results in quicker return to normal functions and less morbidity. In this prospective study, we compared the immediate surgical and oncologic outcomes of patients who have undergone MIS with those who have had open surgery. From November 1, 2003 to March 30, 2006, 62 cases of carcinoma esophagus were operated in Surgical unit 3 (MIS unit) in the institute. Out of the 62 patients, 34 (54.8%) underwent minimally invasive esophagectomy (MIE), and the remaining 28 patients (45.2%) underwent open surgery. Both operations were done by the same team of surgeons. The groups were compared in terms of perioperative outcomes, morbidity, mortality, and adequacy of oncologic excision. The average duration for MIS was 312.35 min (60-480 min), which was more than that of open group surgery whose average duration was 261.96 min (60-360 min). This difference was found to be not significant (P < 0.110). The average blood loss was 275.74 mL (200-500 mL) in minimally invasive group compared with 312.50 (200-500 mL) in open group (P-value 0.33). Four patients (11.76%) in MIS group had been converted to open surgery. Average duration of hospitalization was 11.9 (4-24) days in MIS group compared with 12.19 (5-24) days in open group (P-value 0.282). Nine (26.47%) patients in MIS group had developed major or minor morbidity. Similarly, eight (28.57%) patients in open group had morbidity. One patient each expired in each group. The morbidity and mortality rates were not statistically significant. There were four leaks (11.76%) in MIS group and three leaks (10.71%) in open group (P-value 0.85). Regarding the extent of nodal clearance, an average number of 9.5 (0-19) nodes were removed in MIS group compared with an average of 7.26 (0-12) nodes in open group (P-value 0.05). Better visibility and magnification enabled more number of lymph nodes to be removed in MIS group. MIE is oncologically safe compared with open surgery. It has almost similar postoperative course, morbidity pattern, and duration of hospital stay as open surgery. Increased duration of procedure compared with open surgery is a disadvantage of MIS, especially in the early part of learning curve. © 2011 Copyright the Authors. Journal compilation © 2011, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus.

Ambulatory surgery and anaesthesia in HUKM, a teaching hospital in Malaysia: the first two years experience.

PubMed

Norsidah, A M; Yahya, N; Adeeb, N; Lim, A L

2001-03-01

Ambulatory or day care surgery is still in its infancy in this part of the world. Our newly built university affiliated hospital started its Day Surgery Centre in February 1998. It is the first multidisciplinary ambulatory surgery centre in a teaching hospital in the country. It caters for Orthopaedic surgery, Urology, Plastic surgery, Otorhinolaryngology, General surgery, Paediatric surgery and Ophthalmology. We have done 2,604 cases and our unanticipated admission rate is less than 2%. There has been no major morbidity or mortality. The problems of setting up a multidisciplinary ambulatory centre in a teaching hospital are discussed.

Winged scapula incidence and upper limb morbidity after surgery for breast cancer with axillary dissection.

PubMed

Rizzi, Samantha Karlla Lopes de Almeida; Haddad, Cinira Assad Simão; Giron, Patricia Santolia; Pinheiro, Thaís Lúcia; Nazário, Afonso Celso Pinto; Facina, Gil

2016-06-01

The aim of this study was to determine the incidence of winged scapula after breast cancer surgery, its impact on shoulder morbidity and difference in incidence according to surgery type. Patients with breast cancer and surgical indication for axillary dissection were included. A total of 112 patients were surveyed with one physical evaluation before the surgery and others 15, 30, 90, and 180 days after. Winged scapula was assessed with test proposed by Hoppenfeld. Shoulder range of motion (ROM) was assessed with goniometer for flexion, extension, adduction, abduction, internal rotation, and external rotation. A verbal scale from 0 to 10 was used to assess pain. Winged scapula incidence was 8.0 % 15 days after surgery. Two patients recovered from winged scapula 90 days after surgery and four more 180 days after surgery, while three patients still had winged scapula at this time. The incidence after 15 days from surgery was 20.9 and 22.6 % among patients submitted to sentinel node biopsy or axillary lymphadenectomy (AL), respectively (p < 0.01). There was no statistical difference of incidence according to breast surgery type. Operated side shoulder flexion, adduction, and abduction ROM changes were statistically different in patients with or without winged scapula. The mean reduction was higher in patients with winged scapula. Both groups showed the same pattern over time in pain. Winged scapula incidence was 8.0 % and was higher in AL, and prevalence decreased during 6 months after surgery. Patients who developed winged scapula had more shoulder flexion, adduction, and abduction limitation.

Secular trends in acute dialysis after elective major surgery — 1995 to 2009

PubMed Central

Siddiqui, Nausheen F.; Coca, Steven G.; Devereaux, Philip J.; Jain, Arsh K.; Li, Lihua; Luo, Jin; Parikh, Chirag R.; Paterson, Michael; Philbrook, Heather Thiessen; Wald, Ron; Walsh, Michael; Whitlock, Richard; Garg, Amit X.

2012-01-01

Background: Acute kidney injury is a serious complication of elective major surgery. Acute dialysis is used to support life in the most severe cases. We examined whether rates and outcomes of acute dialysis after elective major surgery have changed over time. Methods: We used data from Ontario’s universal health care databases to study all consecutive patients who had elective major surgery at 118 hospitals between 1995 and 2009. Our primary outcomes were acute dialysis within 14 days of surgery, death within 90 days of surgery and chronic dialysis for patients who did not recover kidney function. Results: A total of 552 672 patients underwent elective major surgery during the study period, 2231 of whom received acute dialysis. The incidence of acute dialysis increased steadily from 0.2% in 1995 (95% confidence interval [CI] 0.15–0.2) to 0.6% in 2009 (95% CI 0.6–0.7). This increase was primarily in cardiac and vascular surgeries. Among patients who received acute dialysis, 937 died within 90 days of surgery (42.0%, 95% CI 40.0–44.1), with no change in 90-day survival over time. Among the 1294 patients who received acute dialysis and survived beyond 90 days, 352 required chronic dialysis (27.2%, 95% CI 24.8–29.7), with no change over time. Interpretation: The use of acute dialysis after cardiac and vascular surgery has increased substantially since 1995. Studies focusing on interventions to better prevent and treat perioperative acute kidney injury are needed. PMID:22733671

The role of Rajyoga meditation for modulation of anxiety and serum cortisol in patients undergoing coronary artery bypass surgery: A prospective randomized control study.

PubMed

Kiran, Usha; Ladha, Suruchi; Makhija, Neeti; Kapoor, Poonam Malhotra; Choudhury, Minati; Das, Sambhunath; Gharde, Parag; Malik, Vishwas; Airan, Balram

2017-01-01

Rajyoga meditation is a form of mind body intervention that is promoted by the Brahma Kumaris World Spiritual University. This form of meditation can be easily performed without rituals or mantras and can be practiced anywhere at any time. The practice of Rajyoga meditation can have beneficial effects on modulating anxiety and cortisol level in patients undergoing major cardiac surgery. A prospective randomized control study was carried out in a single tertiary care center. One hundred and fifty patients undergoing elective coronary artery bypass surgery were enrolled in the study. The patients were randomized in two groups namely, Group 1 (Rajyoga group) and Group 2 (Control Group). Anxiety was measured on a visual analog scale 1-10 before the start of Rajyoga training or patient counseling (T1), on the morning of the day of surgery (T2), on the 2nd postoperative day (T3), and on the 5th postoperative day (T4). The serum cortisol level was measured in the morning of the day of surgery (T1), on the 2nd postoperative day (T2) and on the 5th postoperative day (T3), respectively. In the study, it was seen that the anxiety level of the patients before the surgery (T1) and on the day of surgery (T2) were comparable between the two groups. However on the 2nd postoperative day (T3), the patients who underwent Rajyoga training had lower anxiety level in comparison to the control group (3.12 ± 1.45 vs. 6.12 ± 0.14, P < 0.05) and on the 5th postoperative day (T4) it was seen that Rajyoga practice had resulted in significant decline in anxiety level (0.69 ± 1.1 vs. 5.6 ± 1.38, P < 0.05). The serum cortisol level was also favorably modulated by the practice of Rajyoga meditation. Mindbody intervention is found to effective in reducing the anxiety of the patients and modulating the cortisol level in patients undergoing wellknown stressful surgery like coronary artery bypass surgery.

The Role of Rajyoga Meditation for Modulation of Anxiety and Serum Cortisol in Patients Undergoing Coronary Artery Bypass Surgery: A Prospective Randomized Control Study

PubMed Central

Kiran, Usha; Ladha, Suruchi; Makhija, Neeti; Kapoor, Poonam Malhotra; Choudhury, Minati; Das, Sambhunath; Gharde, Parag; Malik, Vishwas; Airan, Balram

2017-01-01

Introduction: Rajyoga meditation is a form of mind body intervention that is promoted by the Brahma Kumaris World Spiritual University. This form of meditation can be easily performed without rituals or mantras and can be practiced anywhere at any time. The practice of Rajyoga meditation can have beneficial effects on modulating anxiety and cortisol level in patients undergoing major cardiac surgery. Materials and Methods: A prospective randomized control study was carried out in a single tertiary care center. One hundred and fifty patients undergoing elective coronary artery bypass surgery were enrolled in the study. The patients were randomized in two groups namely, Group 1 (Rajyoga group) and Group 2 (Control Group). Anxiety was measured on a visual analog scale 1–10 before the start of Rajyoga training or patient counseling (T1), on the morning of the day of surgery (T2), on the 2nd postoperative day (T3), and on the 5th postoperative day (T4). The serum cortisol level was measured in the morning of the day of surgery (T1), on the 2nd postoperative day (T2) and on the 5th postoperative day (T3), respectively. Results: In the study, it was seen that the anxiety level of the patients before the surgery (T1) and on the day of surgery (T2) were comparable between the two groups. However on the 2nd postoperative day (T3), the patients who underwent Rajyoga training had lower anxiety level in comparison to the control group (3.12 ± 1.45 vs. 6.12 ± 0.14, P < 0.05) and on the 5th postoperative day (T4) it was seen that Rajyoga practice had resulted in significant decline in anxiety level (0.69 ± 1.1 vs. 5.6 ± 1.38, P < 0.05). The serum cortisol level was also favorably modulated by the practice of Rajyoga meditation. Conclusion: Mindbody intervention is found to effective in reducing the anxiety of the patients and modulating the cortisol level in patients undergoing wellknown stressful surgery like coronary artery bypass surgery. PMID:28393774

[Survey of pain after ambulatory surgery: An internet-based instrument].

PubMed

Schwarze, C; Zenz, D; Orlowski, O; Wempe, C; Van Aken, H; Zahn, P; Maier, C; Pogatzki-Zahn, E M

2016-04-01

Pain after surgery continues to be undermanaged. Studies and initiatives aiming to improve the management of postoperative pain are growing; however, most studies focus on inpatients and pain on the first day after surgery. The management of postoperative pain after ambulatory surgery and for several days thereafter is not yet a major focus. One reason is the low return rate of the questionnaires in the ambulatory sector. This article reports the development and feasibility of a web-based electronic data collection system to examine pain and pain-related outcome on predefined postoperative days after ambulatory surgery. In this prospective pilot study 127 patients scheduled for ambulatory surgery were asked to participate in a survey to evaluate aspects related to pain after ambulatory surgery. The data survey was divided in (1) a preoperative, intraoperative and postoperative part and (2) a postoperative internet-based electronic questionnaire which was sent via e-mail link to the patient on days 1, 3 and 7 after surgery. A software was developed using a PHP-based platform to send e-mails and retrieve the data after web-based entries via a local browser. Feasibility, internet-based hitches and compliance were assessed by an additional telephone call after day 7. A total of 100 patients (50 female) between 18 and 71 years (mean 39.1 ± 12.7 years) were included in the pilot study. Return rates of the electronic questionnaires were 86% (days 3 and 7) and 91% (day 1 after surgery). All 3 electronic questionnaires were answered by 82% of patients. Aspects influencing the return rate of questionnaires were work status but not age, gender, education level and preoperative pain. Telephone interviews were performed with 81 patients and revealed high operability of the internet-based survey without any major problems. The user-friendly feasibility and operability of this internet-based electronic data survey system explain the high compliance and return rate of electronic questionnaires by patients at home after ambulatory surgery. This survey tool therefore provides unique opportunities to evaluate and improve postoperative pain management after ambulatory surgery.

Cost Implications of Primary Versus Revision Surgery in Adult Spinal Deformity.

PubMed

Qureshi, Rabia; Puvanesarajah, Varun; Jain, Amit; Kebaish, Khaled; Shimer, Adam; Shen, Francis; Hassanzadeh, Hamid

2017-08-01

Adult spinal deformity (ASD) is an important problem to consider in the elderly. Although studies have examined the complications of ASD surgery and have compared functional and radiographic results of primary surgery versus revision, no studies have compared the costs of primary procedures with revisions. We assessed the in-hospital costs of these 2 surgery types in patients with ASD. The PearlDiver Database, a database of Medicare records, was used in this study. Mutually exclusive groups of patients undergoing primary or revision surgery were identified. Patients in each group were queried for age, sex, and comorbidities. Thirty-day readmission rates, 30-day and 90-day complication rates, and postoperative costs of care were assessed with multivariate analysis. For analyses, significance was set at P < 0.001. The average reimbursement of the primary surgery cohort was $57,078 ± $30,767. Reimbursement of revision surgery cohort was $52,999 ± $27,658. The adjusted difference in average costs between the 2 groups is $4773 ± $1069 (P < 0.001). The 30-day and 90-day adjusted difference in cost of care when sustaining any of the major medical complications in primary surgery versus revision surgery was insignificant. Patients undergoing primary and revision corrective procedures for ASD have similar readmission rates, lengths of stays, and complication rates. Our data showed a higher cost of primary surgery compared with revision surgery, although costs of sustaining postoperative complications were similar. This finding supports the decision to perform revision procedures in patients with ASD when indicated because neither outcomes nor costs are a hindrance to correction. Copyright © 2017 Elsevier Inc. All rights reserved.

Robotic thoracic surgery results in shorter hospital stay and lower postoperative pain compared to open thoracotomy: a matched pairs analysis.

PubMed

Darr, Christopher; Cheufou, Danjouma; Weinreich, Gerhard; Hachenberg, Thomas; Aigner, Clemens; Kampe, Sandra

2017-10-01

To evaluate postoperative pain intensity and length of hospital stay after open or robotic thoracic surgery in a standardized postoperative pain therapy setting. In the present retrospective (oberservation period: January 2015 until January 2016) study we matched data of 38 patients with robotic thoracic surgery ("robotic patients"; age: 62.2 years, male gender: 42.1%) with 38 patients with open thoracic surgery ("open patients"; age: 62.5 years, male gender: 42.1%). Power analysis indicated that 36 patients per group would be required. 68% of all patients received an epidural catheter, and 32% a systemic opioid based analgesia. Postoperative pain intensity in "robotic patients" was lower at rest on postoperative day 3-5 compared to "open patients" (NRS POD 3 robotic surgery 0.5±1.0 vs. open surgery 1.0±1.6, p = 0.04; NRS POD 4 robotic surgery 0,5 ± 1.0 vs. open surgery 1.1±1.3, p=0.04; NRS POD 5 robotic surgery 0.7 ± 1.0 vs. open surgery 1.5±1.5, p=0.003). Chest tube duration was shorter in "robotic patients" (2.9 ± 2.0 days vs. 4.9 ± 2.2 days; p < 0.001). Moreover, length of hospital stay was shorter in "robotic patients" than in "open patients" (6.9 days vs. 8.0 days; p = 0.02). There was no significant difference in postoperative opioid consumption between the groups. Nearly 95% of patients were discharged home with an oral opioid in both groups. Patients after robotic pulmonary resection experience lower postoperative pain and are discharged earlier from hospital than patients after open thoracic surgery. The study design is retrospectively.

Smoking Cessation Can Reduce the Incidence of Postoperative Hypoxemia After On-Pump Coronary Artery Bypass Grafting Surgery.

PubMed

Guan, Zheng; Lv, Yi; Liu, Jingjie; Liu, Lin; Yuan, Hui; Shen, Xin

2016-12-01

To determine whether smoking cessation can reduce the incidence of postoperative hypoxemia (POH) after on-pump coronary artery bypass grafting (CABG) surgery. Prospective, single-center, observational study. Single-center university teaching hospital. The study comprised 300 patients undergoing on-pump CABG surgery who met the inclusion criteria. Patients were divided into the following 3 groups according to smoking status: sustained quitters (n = 132)-smoking cessation for more than 1 month and less than 1 year; quitters (n = 95)-smoking cessation for more than 1 week and less than 1 month; and smokers (n = 73)-smoking at least 1 cigarette per day for at least 1 year. None. The primary outcome was the incidence of POH after on-pump CABG surgery. Secondary outcomes included length of postoperative mechanical ventilation and intensive care unit stay between the POH group and non-POH group. There were significant decreases of POH incidence in the sustained quitters and quitters compared with the smokers both after intensive care unit (ICU) admission and 24 hours after surgery (18.2%, 18.9%, v 32.9%; p = 0.036 and 9.8%, 10.5%, v 26%; p = 0.003, respectively), and there was no significant difference in POH incidence between the sustained quitters and quitters. The length of postoperative mechanical ventilation was longer in smokers than in sustained quitters and quitters (15.9±6.1 h v 11.9±5.3 h and 13.0±5.8 h, respectively; p<0.05), but there were no significant differences in the length of ICU stay among the 3 groups (54.2±7.5 h v 55.1±7.5 h and 53.7±6.6 h, respectively; p = 0.333). Smoking cessation can reduce POH after on-pump CABG surgery, and it also can shorten the length of postoperative mechanical ventilation. Copyright © 2016 Elsevier Inc. All rights reserved.

PKD knockdown inhibits pressure overload-induced cardiac hypertrophy by promoting autophagy via AKT/mTOR pathway.

PubMed

Zhao, Di; Wang, Wei; Wang, Hao; Peng, Honghai; Liu, Xiangjuan; Guo, Weixing; Su, Guohai; Zhao, Zhuo

2017-01-01

Growing evidence shows that protein kinase D (PKD) plays an important role in the development of pressure overload-induced cardiac hypertrophy. However, the mechanisms involved are not clear. This study tested our hypothesis that PKD might mediate cardiac hypertrophy by negatively regulating autophagy using the technique of PKD knockdown by siRNA. Cardiac hypertrophy was induced in 8-week old male C57BL/6 mice by transverse aortic constriction (TAC). TAC mice were then divided into five groups receiving the treatments of vehicle (DMSO), an autophagy inducer rapamycin (1 mg/kg/day, i.p.), control siRNA, lentiviral PKD siRNA (2×10 8 transducing units/0.1 ml, i.v. injection in one day after surgery, and repeated in 2 weeks after surgery), and PKD siRNA plus 3-methyladenine (3-MA, an autophagy inhibitor, 20 mg/kg/day, i.p.), respectively. Four weeks after TAC surgery, echocardiographic study, hematoxylin and eosin (HE) staining, and Masson's staining showed mice with TAC had significantly hypertrophy and remodeling compared with sham animals. Treatments with PKD siRNA or rapamycin significantly ameliorated the cardiac hypertrophy and dysfunction. Moreover, PKD siRNA increased cardiac autophagic activity determined by electron micrographic study and the biomarkers by Western blot, accompanied with the downregulated AKT/mTOR/S6K signaling pathway. All the cardiac effects of PDK knockdown were inhibited by co-treatment with 3-MA. These results suggest that PKD is involved in the development of cardiac hypertrophy by inhibiting cardiac autophagy via AKT/mTOR pathway.

PKD knockdown inhibits pressure overload-induced cardiac hypertrophy by promoting autophagy via AKT/mTOR pathway

PubMed Central

Zhao, Di; Wang, Wei; Wang, Hao; Peng, Honghai; Liu, Xiangjuan; Guo, Weixing; Su, Guohai; Zhao, Zhuo

2017-01-01

Growing evidence shows that protein kinase D (PKD) plays an important role in the development of pressure overload-induced cardiac hypertrophy. However, the mechanisms involved are not clear. This study tested our hypothesis that PKD might mediate cardiac hypertrophy by negatively regulating autophagy using the technique of PKD knockdown by siRNA. Cardiac hypertrophy was induced in 8-week old male C57BL/6 mice by transverse aortic constriction (TAC). TAC mice were then divided into five groups receiving the treatments of vehicle (DMSO), an autophagy inducer rapamycin (1 mg/kg/day, i.p.), control siRNA, lentiviral PKD siRNA (2×108 transducing units/0.1 ml, i.v. injection in one day after surgery, and repeated in 2 weeks after surgery), and PKD siRNA plus 3-methyladenine (3-MA, an autophagy inhibitor, 20 mg/kg/day, i.p.), respectively. Four weeks after TAC surgery, echocardiographic study, hematoxylin and eosin (HE) staining, and Masson's staining showed mice with TAC had significantly hypertrophy and remodeling compared with sham animals. Treatments with PKD siRNA or rapamycin significantly ameliorated the cardiac hypertrophy and dysfunction. Moreover, PKD siRNA increased cardiac autophagic activity determined by electron micrographic study and the biomarkers by Western blot, accompanied with the downregulated AKT/mTOR/S6K signaling pathway. All the cardiac effects of PDK knockdown were inhibited by co-treatment with 3-MA. These results suggest that PKD is involved in the development of cardiac hypertrophy by inhibiting cardiac autophagy via AKT/mTOR pathway. PMID:28367092

The Burden of the Fellowship Interview Process on General Surgery Residents and Programs.

PubMed

Watson, Shawna L; Hollis, Robert H; Oladeji, Lasun; Xu, Shin; Porterfield, John R; Ponce, Brent A

This study evaluated the effect of the fellowship interview process in a cohort of general surgery residents. We hypothesized that the interview process would be associated with significant clinical time lost, monetary expenses, and increased need for shift coverage. An online anonymous survey link was sent via e-mail to general surgery program directors in June 2014. Program directors distributed an additional survey link to current residents in their program who had completed the fellowship interview process. United States allopathic general surgery programs. Overall, 50 general surgery program directors; 72 general surgery residents. Program directors reported a fellowship application rate of 74.4%. Residents most frequently attended 8 to 12 interviews (35.2%). Most (57.7%) of residents reported missing 7 or more days of clinical training to attend interviews; these shifts were largely covered by other residents. Most residents (62.3%) spent over $4000 on the interview process. Program directors rated fellowship burden as an average of 6.7 on a 1 to 10 scale of disruption, with 10 being a significant disruption. Most of the residents (57.3%) were in favor of change in the interview process. We identified potential areas for improvement including options for coordinated interviews and improved content on program websites. The surgical fellowship match is relatively burdensome to residents and programs alike, and merits critical assessment for potential improvement. Published by Elsevier Inc.

Retropharyngeal and Parapharyngeal Abscesses Among Children and Adolescents in the United States: Epidemiology and Management Trends, 2003-2012.

PubMed

Woods, Charles R; Cash, Elizabeth D; Smith, Aaron M; Smith, Michael J; Myers, John A; Espinosa, Claudia M; Chandran, Swapna K

2016-09-01

The epidemiology and hospital course of children with retropharyngeal abscess (RPA) or parapharyngeal abscess (PPA) have not been fully described at the national level in the United States. Pediatric discharges for PPA and RPA were evaluated by using the Kids' Inpatient Database from 2003, 2006, 2009, and 2012. Cases were identified by using International Classification of Disease, Ninth Revision, Clinical Modification codes 478.22 and 478.24 for PPA and RPA, respectively. Nationally representative incidence data were calculated by using weighted case estimates and US census data. Demographic and cost analyses were conducted by using unweighted analyses. There were 2685 hospital discharges for PPA and 6233 hospital discharges for RPA during the 4 study years combined. The incidence of RPA increased from 2.98 per 100 000 population among children <20 years old in 2003 to 4.10 per 100 000 in 2012. The incidence of PPA peaked at 1.49 per 100 000 in 2006. Incidences were highest among children <5 years old and boys in all age groups for PPA and RPA. Winter-to-spring seasonality also was evident for both. PPA was managed surgically in 58.1% of the cases, and RPA was managed surgically in 46.7%. Surgery was performed most often on the day of admission or the following day, was more frequent at teaching hospitals, and was associated with higher hospital charges. The mean hospital length of stay was longer for children who had surgery versus those who did not (4.4 vs 3.1 days [for PPA] and 4.8 vs 3.2 days [for RPA], respectively; both P < .001). The median charges for RPA and PPA were similar. The proportions of children with RPA or PPA covered by Medicaid increased during the study period. PPA and RPA represent relatively common male-predominant childhood infections with similar epidemiologies. The incidence of hospital discharges with a diagnosis of RPA increased during the study period. Substantial proportions of children with PPA or RPA are now managed without surgery. Surgical drainage was associated with higher hospital charges and longer lengths of stay. © The Author 2015. Published by Oxford University Press on behalf of the Pediatric Infectious Diseases Society. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.

Health-hazard evaluation report HETA 87-063-1808, Presbyterian Day Surgery Center, Albuquerque, New Mexico

DOE Office of Scientific and Technical Information (OSTI.GOV)

Daniels, W.J.; Gunter, B.

1987-07-01

In response to a request from employees to evaluate exposures to waste anesthetic gases and vapors at the Presbyterian Day Surgery Unit, located in Albuquerque, New Mexico, personal and area air-sampling and leak-detection testing was carried out for nitrous oxide (N/sub 2/O) and halogenated anesthetic agents in the six operating rooms at the facility. Nitrous oxide concentrations ranged from not detectable to 95 parts per million (ppm) with a mean of 20ppm. Five of the samples exceeded the NIOSH limit of 25ppm for N/sub 2/O during anesthetic administration. Ethrane levels in 14 personal and area air samples ranged from lessmore » than the limit of detection to 3.63ppm with a mean of 0.31ppm. Isoflurane and halothane were below the limits of detection. The ventilation system in use changed the air in excess of 20 times per hour. However, during a portion of surgical procedures the system was not operating, resulting in a higher than normal exposure level in three of the operating rooms.« less

Cataract surgery among Medicare beneficiaries.

PubMed

Schein, Oliver D; Cassard, Sandra D; Tielsch, James M; Gower, Emily W

2012-10-01

To present descriptive epidemiology of cataract surgery among Medicare recipients in the United States. Cataract surgery performed on Medicare beneficiaries in 2003 and 2004. Medicare claims data were used to identify all cataract surgery claims for procedures performed in the United States in 2003-2004. Standard assumptions were used to limit the claims to actual cataract surgery procedures performed. Summary statistics were created to determine the number of procedures performed for each outcome of interest: cataract surgery rates by age, sex, race and state; surgical volume by facility type and surgeon characteristics; time interval between first- and second-eye cataract surgery. The national cataract surgery rate for 2003-2004 was 61.8 per 1000 Medicare beneficiary person-years. The rate was significantly higher for females and for those aged 75-84 years. After adjustment for age and sex, blacks had approximately a 30% lower rate of surgery than whites. While only 5% of cataract surgeons performed more than 500 cataract surgeries annually, these surgeons performed 26% of the total cataract surgeries. Increasing surgical volume was found to be highly correlated with use of ambulatory surgical centers and reduced time interval between first- and second-eye surgery in the same patient. The epidemiology of cataract surgery in the United States Medicare population documents substantial variation in surgical rates by race, sex, age, and by certain provider characteristics.

Cardiac surgery in systemic lupus erythematosus patients: Clinical characteristics and outcomes.

PubMed

Tejeda-Maldonado, Javier; Quintanilla-González, Lauro; Galindo-Uribe, Jaime; Hinojosa-Azaola, Andrea

2017-03-11

To study the clinical characteristics and outcomes in systemic lupus erythematosus (SLE) patients who underwent cardiac surgery. Retrospective analysis of 30 SLE patients who underwent cardiac surgery at a single center. Demographics, comorbidities, clinical and serologic characteristics, cardiovascular risk scores and treatment were recorded. Type of surgery, postoperative complications, mortality and histology were analyzed. Disease duration at surgery was 2 years. Valve replacement was the procedure most frequently performed (53%), followed by pericardial window (37%). At least one postoperative complication developed in 63% (mainly infections). An aortic cross-clamp time≥76minutes was associated with at least one postoperative complication (OR 6.4, 95% CI 1.1-35.4, p=.03). Early death occurred in 5 patients (17%) and late in 3 (10%); main causes were sepsis and heart failure. Disease activity was associated with pericardial window (OR 12.6, 95% CI 1.9-79, p=.007); lymphopenia≤1.200 (OR 10.1, 95% CI 1.05-97, p=.04); age≤30 years (OR 7.7, 95% CI 1.2-46.3, p=.02); and New York Heart Association class III (OR 7.0, 95% CI 1.1-42, p=.03). Postoperative infection was associated with length of hospital stay≥2 weeks (OR 54.9, 95% CI 5.0-602.1, p=.001); intensive care unit stay≥10 days (OR 20, 95% CI 1.6-171.7, p=.01); duration of mechanical ventilation≥5 days (OR 16.9, 95% CI 1.5-171.7, p=.01); and pulmonary artery systolic pressure≥50mmHg (OR 7.8, 95% CI 1.4-41.2, p=.01). Cardiac surgery in SLE confers high morbidity and mortality. SLE-specific preoperative risk scores should be designed to identify prognostic factors. Copyright © 2017 Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología. All rights reserved.

Frequency Rate of Atelectasis in Patients Following Coronary Artery Bypass Graft and Its Associated Factors at Mazandaran Heart Center in 2013-2014.

PubMed

Niyayeh Saffari, Neshat Hasan; Nasiri, Ebrahim; Mousavinasab, Seyed Nouraddin; Ghafari, Rahman; Soleimani, Aria; Esmaeili, Ravanbakhsh

2015-03-26

As the most common postoperative pulmonary complications after cardiac surgery, atelectasis is one of the most important and serious early postoperative complications and one of the most important causes of prolonged hospitalization, increased costs, and mortality rise. Therefore, the present study was aimed at specifying the frequency of atelectasis in patients following coronary artery bypass graft and its associated factors in Mazandaran Heart Center in 2013-2014. The present investigation was a descriptive cross-sectional study in which sequential sampling was used. It was conducted on 375 patients whose coronary artery bypass graft had been performed by the same surgeon and anesthesiologist. For data collection, first the patients' demographic variables and the information of their surgery were retrieved through their profiles, direct observation, patient inquiry, and the collected data were recorded in the data collection forms. Then, atelectasis was measured before the surgery and on the first and second days after it by taking CXR whose results were checked by two radiologists who were not aware of the previous observations. Data were analyzed through t-test, Pearson test, and Chi-square test using SPSS 16.0. The results of the present study indicated that, 123 out of 375 patients (32.8%) were diagnosed with at least one type of tattletales during the first three days after the surgery. The mean age of the patients who were diagnosed with atelectasis was 62.9 and most of them were female. The results also showed that there was a significant relationship between postoperative frequency of atelectasis and the patients' pulmonary diseases and underlying diseases like diabetes and hyperlipidemia, smoking and alcohol use before the surgery, and transfusion of 4 units of packed red blood cells during the surgery (p<0.05). Atelectasis is the most common postoperative complication which emerges more in patients with pulmonary and underlying diseases than other patients.

Frequency Rate of Atelectasis in Patients Following Coronary Artery Bypass Graft and Its Associated Factors at Mazandaran Heart Center in 2013-2014

PubMed Central

Saffari, Neshat Hasan Niyayeh; Nasiri, Ebrahim; Mousavinasab, Seyed Nouraddin; Ghafari, Rahman; Soleimani, Aria; Esmaeili, Ravanbakhsh

2015-01-01

Introduction: As the most common postoperative pulmonary complications after cardiac surgery, atelectasis is one of the most important and serious early postoperative complications and one of the most important causes of prolonged hospitalization, increased costs, and mortality rise. Therefore, the present study was aimed at specifying the frequency of atelectasis in patients following coronary artery bypass graft and its associated factors in Mazandaran Heart Center in 2013-2014. Materials: The present investigation was a descriptive cross-sectional study in which sequential sampling was used. It was conducted on 375 patients whose coronary artery bypass graft had been performed by the same surgeon and anesthesiologist. For data collection, first the patients’ demographic variables and the information of their surgery were retrieved through their profiles, direct observation, patient inquiry, and the collected data were recorded in the data collection forms. Then, atelectasis was measured before the surgery and on the first and second days after it by taking CXR whose results were checked by two radiologists who were not aware of the previous observations. Data were analyzed through t-test, Pearson test, and Chi-square test using SPSS 16.0. Results: The results of the present study indicated that, 123 out of 375 patients (32.8%) were diagnosed with at least one type of tattletales during the first three days after the surgery. The mean age of the patients who were diagnosed with atelectasis was 62.9 and most of them were female. The results also showed that there was a significant relationship between postoperative frequency of atelectasis and the patients’ pulmonary diseases and underlying diseases like diabetes and hyperlipidemia, smoking and alcohol use before the surgery, and transfusion of 4 units of packed red blood cells during the surgery (p<0.05). Conclusion: Atelectasis is the most common postoperative complication which emerges more in patients with pulmonary and underlying diseases than other patients. PMID:26153209

Treatment of complicated parapneumonic pleural effusion and pleural parapneumonic empyema

PubMed Central

Suárez, Pedro Rodríguez; Gilart, Jorge Freixinet; Pérez, José María Hernández; Serhal, Mohamed Hussein; Artalejo, Antonio López

2012-01-01

Summary Background We performed this observational prospective study to evaluate the results of the application of a diagnostic and therapeutic algorithm for complicated parapneumonic pleural effusion (CPPE) and pleural parapneumonic empyema (PPE). Material/Methods From 2001 to 2007, 210 patients with CPPE and PPE were confirmed through thoracocentesis and treated with pleural drainage tubes (PD), fibrinolytic treatment or surgical intervention (videothoracoscopy and posterolateral thoracotomy). Patients were divided into 3 groups: I (PD); II (PD and fibrinolytic treatment); IIIa (surgery after PD and fibrinolysis), and IIIb (direct surgery). The statistical study was done by variance analysis (ANOVA), χ 2 and Fisher exact test. Results The presence of alcohol or drug consumption, smoking and chronic obstructive pulmonary disease (COPD) were strongly associated with a great necessity for surgical treatment. The IIIa group was associated with increased drainage time, length of stay and complications. No mortality was observed. The selective use of PD and intrapleural fibrinolysis makes surgery unnecessary in more than 75% of cases. Conclusions The selective use of PD and fibrinolysis avoids surgery in more than 75% of cases. However, patients who require surgery have more complications, longer hospital stay, and more days on PD and they are more likely to require admittance to the Intensive Care Unit. PMID:22739734

Umbilical hernias: the cost of waiting.

PubMed

Strosberg, David S; Pittman, Matthew; Mikami, Dean

2017-02-01

Umbilical hernias are well described in the literature, but its impact on health care is less understood. The purpose of this study was to investigate the effect of non-operative management of umbilical hernias on cost, work absenteeism, and resource utilization. The Truven Health Database, consisting of 279 employers and over 3000 hospitals, was reviewed for all umbilical hernia patients, aged 18-64 who were enrolled in health plans for 12 months prior to surgery and 12 months after surgery. Patients were excluded if they had a recurrence or had been offered a "no surgery" approach within 1 year of the index date. The remaining patients were separated into surgery (open or laparoscopic repair) or no surgery (NS). Post-cost analysis at 90 and 365 days and estimated days off from work were reviewed for each group. The non-surgery cohort had a higher proportion of females and comorbidity index. Adjusted analysis showed significantly higher 90 and 365 costs for the surgery group (p < 0.0001), though the cost difference did decrease over time. NS group had significantly higher estimated days of health-care utilization at both the 90 (1.99 vs. 3.58 p < 0.0001) and 365 (8.69 vs. 11.04 p < 0.0001) day post-index mark. A subgroup analysis demonstrated laparoscopic repair had higher costs compared to open primarily due to higher index procedure costs (p < 0.05). Though the financial costs were found to be higher in the surgery group, the majority of these were due to the surgery itself. Significantly higher days of health-care utilization and estimated days off work were experienced in the NS group. It is our belief that early operative intervention will lead to decreased costs and resource utilization.

Pre- to Post-operative Changes in Physical Activity: Report from the Longitudinal Assessment of Bariatric Surgery-2

PubMed Central

King, Wendy C; Hsu, Jesse Y; Belle, Steven H; Courcoulas, Anita P; Eid, George M; Flum, David R; Mitchell, James E; Pender, John R; Smith, Mark D; Steffen, Kristine J; Wolfe, Bruce M

2011-01-01

Background Numerous studies report that bariatric surgery patients report more physical activity (PA) after surgery than before, but the quality of PA assessment has been questionable. Methods The Longitudinal Assessment of Bariatric Surgery-2 is a 10-center longitudinal study of adults undergoing bariatric surgery. Of 2458 participants, 455 were given an activity monitor, which records steps/minute, and an exercise diary before and 1 year after surgery. Mean step/day, active minutes/day, and high-cadence minutes/week were calculated for 310 participants who wore the monitor at least 10 hours/day for at least 3 days at both time points. Pre- and post-surgery PA were compared for differences using the Wilcoxon signed-rank test. Generalized Estimating Equations identified independent pre-operative predictors of post-operative PA. Results PA increased significantly (p<.0001) pre- to post-operative for all PA measures. Median values pre- and post-operative were: 7563 and 8788 steps/day; 309 and 340 active minutes/day; and 72 and 112 high-cadence minutes/week, respectively. However, depending on the PA measure, 24–29% of participants were at least 5% less active post-operative than pre-operative. Controlling for surgical procedure, sex, age and BMI, higher PA preoperative independently predicted higher PA post-operative (p<.0001, all PA measures). Less pain, not having asthma and self-report of increasing PA as a weight loss strategy pre-operative also independently predicted more high-cadence minutes/week post-operative (p<.05). Conclusion The majority of adults increase their PA level following bariatric surgery. However, most remain insufficiently active and some become less active. Increasing PA, addressing pain and treating asthma prior to surgery may have a positive impact on post-operative PA. PMID:21944951

Development of the Combined Assessment of Risk Encountered in Surgery (CARES) surgical risk calculator for prediction of postsurgical mortality and need for intensive care unit admission risk: a single-center retrospective study.

PubMed

Chan, Diana Xin Hui; Sim, Yilin Eileen; Chan, Yiong Huak; Poopalalingam, Ruban; Abdullah, Hairil Rizal

2018-03-23

Accurate surgical risk prediction is paramount in clinical shared decision making. Existing risk calculators have limited value in local practice due to lack of validation, complexities and inclusion of non-routine variables. We aim to develop a simple, locally derived and validated surgical risk calculator predicting 30-day postsurgical mortality and need for intensive care unit (ICU) stay (>24 hours) based on routinely collected preoperative variables. We postulate that accuracy of a clinical history-based scoring tool could be improved by including readily available investigations, such as haemoglobin level and red cell distribution width. Electronic medical records of 90 785 patients, who underwent non-cardiac and non-neuro surgery between 1 January 2012 and 31 October 2016 in Singapore General Hospital, were retrospectively analysed. Patient demographics, comorbidities, laboratory results, surgical priority and surgical risk were collected. Outcome measures were death within 30 days after surgery and ICU admission. After excluding patients with missing data, the final data set consisted of 79 914 cases, which was divided randomly into derivation (70%) and validation cohort (30%). Multivariable logistic regression analysis was used to construct a single model predicting both outcomes using Odds Ratio (OR) of the risk variables. The ORs were then assigned ranks, which were subsequently used to construct the calculator. Observed mortality was 0.6%. The Combined Assessment of Risk Encountered in Surgery (CARES) surgical risk calculator, consisting of nine variables, was constructed. The area under the receiver operating curve (AUROC) in the derivation and validation cohorts for mortality were 0.934 (0.917-0.950) and 0.934 (0.912-0.956), respectively, while the AUROC for ICU admission was 0.863 (0.848-0.878) and 0.837 (0.808-0.868), respectively. CARES also performed better than the American Society of Anaesthesiologists-Physical Status classification in terms of AUROC comparison. The development of the CARES surgical risk calculator allows for a simplified yet accurate prediction of both postoperative mortality and need for ICU admission after surgery. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Enhanced Recovery After Surgery: A Review.

PubMed

Ljungqvist, Olle; Scott, Michael; Fearon, Kenneth C

2017-03-01

Enhanced Recovery After Surgery (ERAS) is a paradigm shift in perioperative care, resulting in substantial improvements in clinical outcomes and cost savings. Enhanced Recovery After Surgery is a multimodal, multidisciplinary approach to the care of the surgical patient. Enhanced Recovery After Surgery process implementation involves a team consisting of surgeons, anesthetists, an ERAS coordinator (often a nurse or a physician assistant), and staff from units that care for the surgical patient. The care protocol is based on published evidence. The ERAS Society, an international nonprofit professional society that promotes, develops, and implements ERAS programs, publishes updated guidelines for many operations, such as evidence-based modern care changes from overnight fasting to carbohydrate drinks 2 hours before surgery, minimally invasive approaches instead of large incisions, management of fluids to seek balance rather than large volumes of intravenous fluids, avoidance of or early removal of drains and tubes, early mobilization, and serving of drinks and food the day of the operation. Enhanced Recovery After Surgery protocols have resulted in shorter length of hospital stay by 30% to 50% and similar reductions in complications, while readmissions and costs are reduced. The elements of the protocol reduce the stress of the operation to retain anabolic homeostasis. The ERAS Society conducts structured implementation programs that are currently in use in more than 20 countries. Local ERAS teams from hospitals are trained to implement ERAS processes. Audit of process compliance and patient outcomes are important features. Enhanced Recovery After Surgery started mainly with colorectal surgery but has been shown to improve outcomes in almost all major surgical specialties. Enhanced Recovery After Surgery is an evidence-based care improvement process for surgical patients. Implementation of ERAS programs results in major improvements in clinical outcomes and cost, making ERAS an important example of value-based care applied to surgery.

[Impact of preoperative oral liquid carbohydrate on postoperative insulin resistance in gastric cancer patients and its associated study].

PubMed

Chen, Junyong; Cheng, Liyang; Xie, Zhengyong; Li, Zehang

2015-12-01

To investigate the impact of preoperative oral liquid carbohydrate on postoperative insulin resistance (IR) in gastric cancer patients undergoing elective resection, and to examine the association of IR index (homeostasis model assessment, HOMA-IR) with tumor necrosis factor-α (TNF-α). Between January 2013 and September 2013, 35 patients undergoing elective resection for gastric cancer were prospectively enrolled and randomized into two groups. Patients in trial group (n=18) received oral 500 ml of 10% glucose solution two hours before surgery. Patients in control group (n=17) were asked to fast for 8-12 hours before operation. About 300 mg of rectus abdominis and subcutaneous fatty tissues was removed before the closure of abdominal wall. Blood samples were collected to measure the serum concentration of TNF-α with double antibody sandwich ELISA in perioperative period (3-hour before operation, end of operation, 1-day and 3-day after operation). HOMA-IR was calculated on preoperative 3-hour and postoperative 1-day. Western blotting was used to detect protein expression of TNF-α. Correlation of HOMA-IR with TNF-α was examined. HOMA-IR on the first day after surgery was not different from that at 3-hour before surgery in trial group (P=0.090), which was significantly lower than that in control group (P=0.000). In trial group, serum TNF-α at the end of operation was higher than that at 3-hour before surgery, which declined rapidly on the first day after surgery and had no significant difference compared with that on the third day after surgery. In control group, serum TNF-α at the end of operation was also higher than that before surgery, which rose to the peak on the first day after surgery and was still higher than that at 3-hour before surgery. The TNF-α protein expression in muscle tissues of trial group was higher than that of control group (P=0.001), while no significant difference was observed between two groups in adipose tissues (P=0.987). Correlation analysis showed that HOMA-IR was positively correlated with TNF-α on the first day after surgery (r=0.832, P=0.000). Oral intake of liquid carbohydrate 2 hours before surgery can reduce the level of TNF-α, which is likely to improve the postoperative insulin resistance.

2,3-Diphosphoglycerate Concentrations in Autologous Salvaged Versus Stored Red Blood Cells and in Surgical Patients After Transfusion.

PubMed

Scott, Andrew V; Nagababu, Enika; Johnson, Daniel J; Kebaish, Khaled M; Lipsitz, Joshua A; Dwyer, Ian M; Zuckerberg, Gabriel S; Barodka, Viachaslau M; Berkowitz, Dan E; Frank, Steven M

2016-03-01

Stored red blood cells (RBCs) are deficient in 2,3-diphosphoglycerate (2,3-DPG), but it is unclear how autologous salvaged blood (ASB) compares with stored blood and how rapidly 2,3-DPG levels return to normal after transfusion. Therefore, we compared levels of 2,3-DPG in stored versus ASB RBCs and in patients' blood after transfusion. Twenty-four patients undergoing multilevel spine fusion surgery were enrolled. We measured 2,3-DPG and the oxyhemoglobin dissociation curve (P50) in samples taken from the ASB and stored blood bags before transfusion and in blood samples drawn from patients before and after transfusion. The mean storage duration for stored RBCs was 24 ± 8 days. Compared with fresh RBCs, stored RBCs had decreased 2,3-DPG levels (by approximately 90%; P < 0.0001) and a decreased P50 (by approximately 30%; P < 0.0001). However, ASB RBCs did not exhibit these changes. The mean 2,3-DPG concentration decreased by approximately 20% (P < 0.05) in postoperative blood sampled from patients who received 1 to 3 stored RBC units and by approximately 30% (P < 0.01) in those who received ≥4 stored RBC units. 2,3-DPG was unchanged in patients who received no stored blood or ASB alone. After surgery, 2,3-DPG levels recovered gradually over 3 postoperative days in patients who received stored RBCs. Stored RBCs, but not ASB RBCs, have decreased levels of 2,3-DPG and a left-shift in the oxyhemoglobin dissociation curve. Postoperatively, 2,3-DPG levels remain below preoperative baseline levels for up to 3 postoperative days in patients who receive stored RBCs but are unchanged in those who receive only ASB RBCs.

2,3-Diphosphoglycerate Concentrations in Autologous Salvaged Versus Stored Red Blood Cells and in Surgical Patients After Transfusion

PubMed Central

Scott, Andrew V.; Nagababu, Enika; Johnson, Daniel J.; Kebaish, Khaled M.; Lipsitz, Joshua A.; Dwyer, Ian M.; Zuckerberg, Gabriel S.; Barodka, Viachaslau M.; Berkowitz, Dan E.; Frank, Steven M.

2016-01-01

Background Stored red blood cells (RBCs) are deficient in 2,3-diphosphoglycerate (2,3-DPG), but it is unclear how autologous salvaged blood (ASB) compares to stored blood, and how rapidly 2,3-DPG levels return to normal after transfusion. Therefore, we compared levels of 2,3-DPG in stored versus ASB RBCs, and in patients’ blood following transfusion. Methods Twenty-four patients undergoing multilevel spine fusion surgery were enrolled. We measured 2,3-DPG and the oxyhemoglobin dissociation curve (P50) in samples taken from the ASB and stored blood-bags before transfusion, and in blood samples drawn from patients before and after transfusion. Results The mean storage duration for stored RBCs was 24 ± 8 days. Compared with fresh RBCs, stored RBCs had decreased 2,3-DPG levels (by ≈ 90%; P<0.0001), and a decreased P50 (by ≈ 30%; P<0.0001). However, ASB RBCs did not exhibit these changes. The mean 2,3-DPG concentration decreased by ≈ 20% (P<0.05) in postoperative blood sampled from patients who received 1 – 3 stored RBC units, and by ≈ 30% (P<0.01) in those who received ≥4 stored RBC units. 2,3-DPG was unchanged in patients who received no stored blood or ASB alone. After surgery, 2,3-DPG levels recovered gradually over three postoperative days in patients who received stored RBCs. Conclusions Stored RBCs, but not ASB RBCs, have decreased levels of 2,3-DPG and a left shift in the oxyhemoglobin dissociation curve. Postoperatively, 2,3-DPG levels remain below preoperative baseline levels for up to three postoperative days in patients who receive stored RBCs, but are unchanged in those who receive only ASB RBCs. PMID:26891388

Propranolol reduces the anxiety associated with day case surgery.

PubMed

Mealy, K; Ngeh, N; Gillen, P; Fitzpatrick, G; Keane, F B; Tanner, A

1996-01-01

To find out if propranolol, a non-cardioselective beta-blocker, can reduce the anxiety associated with day case surgery. Prospective randomized double blind trial. University hospital, Ireland. An unselected group of 53 patients undergoing day case surgery. Subjects randomised to receive either propranolol (10 mg) or placebo on the morning of operation. Blood pressure; pulse, anxiety, pain score and patient satisfaction. Mean (SD) Hospital Anxiety and Depression score was significantly lower in the propranolol group than in the control group (2.5 (0.7) compared with 4.6 (0.7), p < 0.0001) before discharge. A low dose of propranolol given on the morning of day case surgery significantly reduced patients' anxiety.

Is the Preoperative Administration of Amiodarone or Metoprolol More Effective in Reducing Atrial Fibrillation: After Coronary Bypass Surgery?

PubMed

Onk, Oruc Alper; Erkut, Bilgehan

2015-10-01

This study examined the influence of preoperative administration of amiodarone and metoprolol in preventing postoperative atrial fibrillation (AF) after coronary artery bypass grafting (CABG) surgery.The study comprised 251 patients who underwent CABG surgery at our hospital between January 2012 and May 2014. The patients were randomly divided into 2 groups: amiodarone therapy group (n = 122 patients) and metoprolol therapy group (n = 129 patients).In the amiodarone group, the patients received amiodarone tablet orally 1 week before coronary bypass surgery and during the postoperative period. In the metoprolol group, the patients received metoprolol tablet orally 1 week before surgery and during the postoperative period. The AF development rate was retrospectively evaluated between the first 3 days and 4 weeks after surgery.AF developed in 14 patients in the amiodarone group and 16 patients in the metoprolol group 4 weeks after the operation (P = 0.612).No significant difference was observed between the groups in terms of intensive care unit and hospital stay. Furthermore, hospital charges were similar in both groups (P = 0.741).The results of the logistic regression analysis showed age, left ventricular ejection fraction, left atrial diameter, and aortic cross-clamping time to be predictors for postoperative AF.This study demonstrates that amiodarone and metoprolol have similar effects in prevention of AF after cardiac surgery. However, larger-scale studies need to be conducted to substantiate these findings.

OUTPATIENT ANTERIOR CERVICAL DISCECTOMY: A FRENCH STUDY AND LITERATURE REVIEW.

PubMed

Gennari, Antoine; Mazas, Simon; Coudert, Pierre; Gille, Olivier; Vital, Jean-Marc

2018-06-11

In France, surgery for lumbar disc herniation is now being done in the outpatient ambulatory setting at select facilities. However, surgery for the cervical spine in this setting is controversial because of the dangers of neck hematoma. We wanted to share our experience with performing ambulatory anterior cervical discectomy in 30 patients at our facility. Since 2014, 30 patients (16 men, 14 women; mean age of 47.2 years) with cervical radiculopathy due to single-level cervical disc disease (19 at C5-C6 and 11 at C6-C7) were operated at our ambulatory surgery center. After anterior cervical discectomy, cervical disc replacement was performed in 13 patients and fusion in 17 patients. The mean operative time was 38minutes and the mean duration of postoperative monitoring was 7hours 30minutes. The patients stayed at the healthcare facility for an average of 10hours 10minutes. One female patient (3%) was transferred to a standard hospital unit due to a neurological deficit requiring surgical revision with no cause identified. Two patients (7%) were rehospitalized on Day 1 due to dysphagia that resolved spontaneously. Thus the "ambulatory success rate" was 90% (27/30). There were no other complications and the overall satisfaction rate was excellent (9.6/10). Outpatient anterior cervical discectomy is now widely performed in the United States. Ours is the first study of French patients undergoing this procedure. The complication rate was very low (< 2%) and even lower than patients treated in an inpatient hospital setting in comparative studies. Note that our patients were carefully selected for outpatient surgery as certain risk factors for complications have previously been identified (age, 3+levels, comorbidities / ASA> 2). No deaths in the first 30 days postoperative have been reported in the literature. Wound hematoma leading to airway compromise is rare in the ambulatory setting (0.2%). The few cases that occurred were detected early and the hematoma drained before the patient was discharged. Dysphagia is actually the most common complication (8% to 30%). Cervical spine surgery can be performed in an ambulatory surgery center in carefully selected patients. Our criteria are patients less than 65 years of age, single-level disease, ASA <2, and standard cervical morphology. The complication and readmission rates are low. Careful hemostasis combined with close postoperative monitoring for at least 6hours helps to reduce the risk of neck hematoma. Prevention of postoperative dysphagia must be a focus of the care provided. Copyright © 2018. Published by Elsevier Masson SAS.

Recombinant activated factor VII in cardiac surgery: single-center experience.

PubMed

Singh, Sarvesh Pal; Chauhan, Sandeep; Choudhury, Minati; Malik, Vishwas; Choudhary, Shiv Kumar

2014-02-01

The widespread off-label use of recombinant activated factor VII for the control of refractory postoperative hemorrhage continues despite a warning from the Food and Drug Administration. Although effective in reducing the need for transfusion of blood and blood products, safety concerns still prevail. To compare the dosing and efficacy of recombinant activated factor VII between pediatric and adult patients, and in the operating room and intensive care unit. The records of 69 patients (33 children and 36 adults) who underwent cardiovascular surgery and received recombinant activated factor VII were reviewed retrospectively. The dose of recombinant activated factor VII, mediastinal drainage, use of blood and blood products, incidence of thrombosis, and 28-day mortality were studied. the efficacy of recombinant activated factor VII was comparable in adults and children, despite the lower dose in adults. Prophylactic use of recombinant activated factor VII decreased the incidence of mediastinal exploration and the duration of intensive care unit stay. A 4.3% incidence of thrombotic complications was observed in this study. The efficacious dose of recombinant activated factor VII is much less in adults compared to children. Prophylactic use of recombinant activated factor VII decreases the dose required, the incidence of mediastinal exploration, and intensive care unit stay, with no survival benefit.

Exposure to high stress in the intensive care unit may have negative effects on health-related quality-of-life outcomes after cardiac surgery.

PubMed

Schelling, Gustav; Richter, Markus; Roozendaal, Benno; Rothenhäusler, Hans-Bernd; Krauseneck, Till; Stoll, Christian; Nollert, Georg; Schmidt, Michael; Kapfhammer, Hans-Peter

2003-07-01

Up to 20% of patients do not show improvements in health-related quality of life (HRQL) after cardiac surgery, despite apparently successful surgical procedures. We sought to determine whether failed improvements in HRQL after cardiac surgery are associated with the development of traumatic memories and chronic stress states as a result of high perioperative stress exposure. Prospective cohort study. A 10-bed cardiovascular intensive care unit of a tertiary care university hospital. A total of 148 cardiac surgical patients. None. The patients were evaluated for traumatic memories from postoperative treatment in the cardiovascular intensive care unit (defined as the subjective recollection of pain, respiratory distress, anxiety/panic, and nightmares), symptoms of chronic stress, including those of posttraumatic stress disorder, and HRQL preoperatively (at baseline) and at 6 months after cardiac surgery. A state of chronic stress was defined as the development of posttraumatic stress disorder at 6 months after surgery. Factors predicting the decline in HRQL were determined by multivariable linear regression. Twenty-seven patients (18.2%) had posttraumatic stress disorder at 6 months after cardiac surgery; seven of these patients (4.8%) had evidence of preexisting posttraumatic stress disorder before undergoing cardiac surgery. Patients with new posttraumatic stress disorder at 6 months after cardiac surgery had a significantly higher number of traumatic memories from postoperative treatment in the cardiovascular intensive care unit (p =.01). A multiple regression model included the number of traumatic memories from the intensive care unit and stress symptom scores at 6 months after heart surgery as predictors for variations in physical HRQL outcome scores (R2 =.30, p <.04). Stress symptom scores were the most significant predictors of mental health HRQL outcomes (R2 =.52, p <.01). Exposure to high stress in the cardiovascular intensive care unit can have negative effects on HRQL outcomes of cardiac surgery.

[Better communication between surgery and anesthesia may provide safer surgery. The exchange of information has been mapped within the framework of "Safe abdominal surgery"].

PubMed

Göransson, Katarina; Lundberg, Johan; Ljungqvist, Olle; Ohlsson, Elisabet; Sandblom, Gabriel

2015-09-01

Poor communication between surgical and anesthesia unit personnel may jeopardize patient safety.  Review reports from a national survey on patient safety performed at 17 units 2011-2013 were analyzed in order to identify strategies to reduce risks related to the interaction between surgery and anesthesia. The reports were reviewed in this study by an independent group in order to extract findings related to communication between anesthesia and surgical unit personnel. Suggested strategies to improve patient safety included: uniform national health declaration forms; consistent use of admission notes; uniform systems for documenting medical information; multidisciplinary forum for evaluation of high-risk patients; weekly and daily scheduling of surgical programs; application of the WHO check list; open dialog during surgery; oral and written reports from the surgeon to the postoperative unit; and combined mortality and morbidity conferences.

Complication and recurrence rate in laser CO2 versus traditional surgery in the treatment of Bartholin's gland cyst.

PubMed

Frega, Antonio; Schimberni, Mauro; Ralli, Eleonora; Verrone, Antonella; Manzara, Federica; Schimberni, Matteo; Nobili, Flavia; Caserta, Donatella

2016-08-01

The treatment of Bartholin's gland cysts by traditional surgery is characterized by some disadvantages and complications such as hemorrhage, postoperative dyspareunia, infections, necessity for a general anesthesia. Contrarily, CO2 laser surgery might be less invasive and more effective as it solves many problems of traditional surgery. The aim of our study is to describe CO2 laser technique evaluating its feasibility, complication rate and results vs traditional surgery. Among patients treated for Bartholin's gland cyst, we enrolled 62 patients comparing traditional surgical excision vs CO2 laser surgery of whom 27 patients underwent traditional surgery, whereas 35 patients underwent CO2 laser surgery. Mean operative time, complication rate, recurrence rate and short- and long-term outcomes were assessed. The procedures required a mean operative time of 9 ± 5.3 min for CO2 laser surgery and 42.2 ± 13.8 for traditional surgery. Two patients (5.7 %) needed an hemostatic suture for intraoperative bleeding in the laser CO2 laser technique against 14.8 % for traditional surgery. Carbon dioxide allows a complete healing in a mean time of 22 days without scarring, hematomas or wound infections and a return to daily living in a mean time of 2 days. Instead, patients undergone traditional surgery required a mean time of 14 days to return to daily life with a healing mean time completed in 28 days. The minimum rate of intra- and post-operative complications, the ability to perform it under local anesthesia in an outpatient setting make CO2 laser surgery more cost-effective than traditional surgery.

Is day-case cataract surgery an attractive alternative from the patients' point of view? A questionnaire survey.

PubMed

Weingessel, Birgit; Richter-Mueksch, Sibylla; Weingessel, Andreas; Gnad, Hans; Vécsei-Marlovits, Pia Veronika

2008-01-01

Cataract surgery is the most common elective surgical procedure undertaken in elderly people. In many European countries and in the USA cataract surgery is normally a day-case procedure without an overnight stay in hospital, unlike the situation in Austria where fewer than 2% of patients are day cases. However, there is a lack of prospective studies on patients' need for and acceptance of day-case surgery. The aim of our study was therefore to evaluate patients' demand and suitability for outpatient surgery, based on analysis of preoperative questionnaires on availability of family and/or social support and on preoperative ophthalmologic examination. Among 500 consecutive patients with cataract, 154 (41.8%) chose a day-case procedure and 256 (58.2%) preferred inpatient admission. Patients preferring full admission were older (mean age 76.4+/-8.1 vs. 72.73+/-9.5 years, P<0.001), had worse visual acuity (0.55+/-0.20 vs. 0.66+/-0.23, P<0.001), were more likely to be female (63.9% vs. 47.0%, P=0.001), to live more than one hour away from the hospital (26.5% vs. 12.5%, P<0.001) and have no carer at home (43.0% vs. 6.5%, P<0.001). Patients favoring day-case surgery were more likely to be able to attend an ophthalmologic check-up 24 h after surgery (96.7% vs. 59.6%, p<0.001). The majority of patients indicated a preference for inpatient care, but this may be a reflection of their previous hospital experience and a matter of custom in the elderly population. Information, education and better organization of after-surgery services could help increase the attractiveness of cataract surgery as an outpatient procedure in Austria. Our findings could also be relevant to day-case services in medical care in general.

One-day quantitative cross-sectional study of family information time in 90 intensive care units in France.

PubMed

Fassier, Thomas; Darmon, Michel; Laplace, Christian; Chevret, Sylvie; Schlemmer, Benoit; Pochard, Frédéric; Azoulay, Elie

2007-01-01

Providing family members with clear, honest, and timely information is a major task for intensive care unit physicians. Time spent informing families has been associated with effectiveness of information but has not been measured in specifically designed studies. To measure time spent informing families of intensive care unit patients. One-day cross-sectional study in 90 intensive care units in France. Clocked time spent by physicians informing the families of each of 951 patients hospitalized in the intensive care unit during a 24-hr period. Median family information time was 16 (interquartile range, 8-30) mins per patient, with 20% of the time spent explaining the diagnosis, 20% on explaining treatments, and 60% on explaining the prognosis. One third of the time was spent listening to family members. Multivariable analysis identified one factor associated with less information time (room with more than one bed) and seven factors associated with more information time, including five patient-related factors (surgery on the study day, higher Logistic Organ Dysfunction score, coma, mechanical ventilation, and worsening clinical status) and two family-related factors (first contact with family and interview with the spouse). Median information time was 20 (interquartile range, 10-39) mins when three factors were present and 106.5 (interquartile range, 103-110) mins when five were present. This study identifies factors associated with information time provided by critical care physicians to family members of critically ill patients. Whether information time correlates with communication difficulties or communication skills needs to be evaluated. Information time provided by residents and nurses should be studied.

Acellular Flowable Matrix in the Treatment of Tunneled or Cavity Ulcers in Diabetic Feet: A Preliminary Report.

PubMed

Campitiello, Ferdinando; Mancone, Manfredi; Della Corte, Angela; Guerniero, Raffaella; Canonico, Silvestro

2018-06-01

The authors aimed to explore the feasibility and safety of an advanced, acellular, flowable wound matrix (FWM) in patients with diabetes-related cavity or tunnel lesions involving deep structures. Patients with diabetic foot ulcers were hospitalized at the General and Geriatric Surgery Unit of the University of Campania in Naples, Italy, between March 2015 and December 2015. Twenty-three patients with tunneled or cavity ulcers were treated. The lesions were filled with the FWM. Surgical wound edges were either approximated with stitches or left to heal by secondary intention. After 6 weeks, 78.26% of patients completely healed after a single application of the FWM. The healing time for all healed wounds was 30.85 ± 12.62 days, or 26.11 ± 5.43 days in patients for whom wound edges were approximated by stitches, and 57.66 ± 3.05 days in the patients who healed by secondary intention (P = .01). Permanent tissue regeneration was observed in a high percentage of patients, and shorter healing time was achieved. Study authors observed a low rate of complications such as major amputation and increased hospitalization. The FWM seems ideal for tunneled and cavity ulcers with irregular geometry. This new porous matrix allows closure of the lesion while reducing healing time and demolition surgery.

[Orthopaedic day surgery in Emilia-Romagna].

PubMed

Rolli, M; Rodler, M; Petropulacos, K; Baldi, R

2001-09-01

It is well known that the organizational model of day surgery, concerning surgical problems defined by the literature as minor, has the aim of optimising the use of hospital resources and facilitating patients and their families, from a psychological and social point of view, by reducing hospitalisation time and the associated complications, and ensuring the same efficacy and more appropriateness of treatment. This study is firstly aimed at analysing the impact that the healthcare policy of the Emilia Romagna Region has had on the development of day surgery practice. Secondly, it compares the patients treated in orthopaedic day surgery in the hospitals of Bologna, Modena, Ferrara, Parma, Reggio Emilia, Maggiore hospital of Bologna and Rizzoli Orthopaedic Institute of Bologna (II.OO.R). In the period 1997-2000 there was a marked increase in the number of operations carried out in day surgery in all of the above-mentioned hospitals. Also in the unispecialistic orthopaedic hospital there was a surprising increase in the percentage of operations carried out in day surgery with respect to the total number of operations performed. The aim of the Rizzoli Orthopaedic Institute and the Emilia Romagna Region is to further implement this form of healthcare, contextually potentiating the appropriateness of hospital admission and avoiding, when not necessary, other forms of healthcare.

[Case of neuroleptic malignant syndrome following open heart surgery for thoracic aortic aneurysm with parkinson's disease].

PubMed

Shinoda, Maiko; Sakamoto, Mik; Shindo, Yuki; Ando, Yumi; Tateda, Takeshi

2013-12-01

An 80-year-old woman with Parkinson's disease was scheduled for open heart surgery to repair thoracic aortic aneurysm. Parkinson's symptoms were normally treated using oral levodopa (200 mg), selegiline-hydrochloride (5 mg), bromocriptine-mesilate (2 mg), and amantadine-hydrochloride (200 mg) daily. On the day before surgery, levodopa 50mg was infused intravenously. Another 25 mg of levodopa was infused immediately after surgery. Twenty hours later, the patient developed tremors, heyperventilation, but no obvious muscle rigidity. Two days after surgery, the patient exhibited high fever, hydropoiesis, elevated creatine kinase, and a rise in blood leukocytes. She was diagnosed with neuroleptic malignant syndrome. She was intubated, and received dantrolene sodium. Symptoms of neuroleptic malignant syndrome disappeared on the fourth postoperative day. The stress of open heart surgery, specifically extracorporeal circulation and concomitant dilution of levodopa, triggered neuroleptic malignant syndrome in this patient. Parkinson's patients require higher doses of levodopa prior to surgery to compensate and prevent neuroleptic malignant syndrome after surgery.

Thoracic corpectomy for neoplastic vertebral bodies using a navigated lateral extracavitary approach-a single-center consecutive case series: technique and analysis.

PubMed

Hartmann, Sebastian; Wipplinger, Christoph; Tschugg, Anja; Kavakebi, Pujan; Örley, Alexander; Girod, Pierre Pascal; Thomé, Claudius

2018-04-01

Thoracic myelopathy is often caused by vertebral body fractures resulting from neoplastic conditions, traumatic events, or infectious diseases. One of the preferred procedures for treating it is the lateral extracavitary approach (LECA) with single-level or multilevel decompressive corpectomy and reconstruction. The aim of this retrospective study was to analyze the thoracic lateral extracavitary approach with corpectomy using vertebral body replacement systems (VBR-S) and dorsal reconstruction. Twenty-four patients with metastatic or primary lesions of thoracic vertebrae T2-T12 underwent spinal decompression and ventral column reconstruction with correction of spinal deformity via a LECA. One-level to four-level corpectomies were performed with additional navigated dorsal pedicle screw fixation at an average of two levels above and below the corpectomy lesion. None of the patients received preoperative spinal embolization, and the majority of the patients were admitted to radiotherapy postoperatively. Their mean age was 56 years (± 15), with a female-to-male sex ratio of 8 to 16. Patients with a minimum follow-up period of 16 months were included. The Karnofsky index, preoperative and postoperative numeric rating scale (NRS), and Frankel scale were measured. In addition, intraoperative loss of blood (LOB), units of packed red blood cell (PRBC) transfusions, the duration of the operation, and the hospitalization period were evaluated and correlated with preoperative and postoperative values. The majority of the patients were suffering from metastatic lesions and were treated with a 1 level corpectomy (median 1 level, range 1 to 4). The mean duration of surgery was 288 min (± 121) and the mean LOB was 1626 mL (± 1486 mL), with approximately two PRBC units per patient used. All patients were transferred to the intensive care unit (ICU) postoperatively, with a mean ICU stay of 2.0 days (± 1 day). The mean hospitalization period was 13 days (± 7 days). No implant-related failures or procedure-related deaths were observed. Significant differences were noted between the preoperative and postoperative Karnofsky index (74 vs. 84%) and NRS (4 vs. 2). One patient required revision surgery due to a superficial wound infection, and another needed revision surgery due to a dural tear. In another patient, an iatrogenic dural tear was repaired during the same surgical procedure and did not lead to postoperative complications. Four pleural effusions and one pneumothorax were observed, so that the overall complication rate was approximately 33%. Four of the patients died within 2 years of the operation due to progression of the primary disease. Lateral corpectomy and sagittal reconstruction of the thoracic spine using VBR-S conducted via a navigated LECA approach yields favorable results, despite the burden of neoplastic disease. These challenging procedures are accompanied by increased LOB and hospitalization periods, with moderate transfusion requirements. Surgery-related complications are low and local tumor control is satisfactory, despite the progression of the underlying neoplastic disease. However, optimal surgical therapy does not ensure long-term survival.Study design Retrospective analysis of thoracic corpectomiesLevel of evidence 4.

Active Ankle Movement May Prevent Deep Vein Thrombosis in Patients Undergoing Lower Limb Surgery.

PubMed

Wang, Zhe; Chen, Qian; Ye, Mao; Shi, Guang-Hui; Zhang, Bo

2016-04-01

Our aim is to investigate the effect of active ankle movement to prevent deep vein thrombosis (DVT) in patients who received lower limb surgery, and to provide a theory of evidence for rehabilitation nursing of patients after orthopedic surgery. Between January 2012 and December 2013, a total of 174 patients were randomized as case group (n = 96) and control group (n = 78). Case group received routine nursing and active ankle movement (30 times/min, 1-7 days after surgery), while control group only received routine nursing. The symptoms and signs of DVT were in real-time observation during the experiment. Thigh and crus circumference, maximum venous outflow (MVO), maximum venous capacity (MVC), and MVO ratio (MVO ratio = MVO/MVC) in the two groups were measured 1-7 days after surgery. Six-month follow-up study was also conducted to observe the occurrence of DVT. Our study revealed that thigh circumference in the case group decreased compared with the control group in 5-7 days (fifth day: 39.98 ± 3.25 vs. 41.01 ± 3.38, P = 0.043; sixth day: 38.21 ± 3.81 vs. 39.49 ± 3.79, P = 0.029; seventh day: 37.13 ± 3.15 vs. 38.76 ± 3.31, P = 0.001), and crus circumference in the case group also decreased compared with the control group in 5-7 days (fifth day: 26.35 ± 2.11 vs. 27.01 ± 2.19, P = 0.045; sixth day: 25.99 ± 2.31 vs. 26.88 ± 3.12, P = 0.032; seventh day: 25.56 ± 1.99 vs. 26.38 ± 2.89, P = 0.028). MVO and MVC in the case group increased compared with the control group 7 days after surgery (MVO: 15.01 ± 2.56 vs. 14.12 ± 2.56, P = 0.024; MVC: 10.18 ± 3.15 vs. 8.91 ± 2.78, P = 0.006). Significant difference in the incidence of thrombus and DVT were found between the case group and the control group 1-7 days after surgery (thrombus: 1.0% and 7.7%, P = 0.027; DVT: 7.6% and 18.4%, P = 0.032). Our result manifested that active ankle movement can relieve the swelling of patients after lower limb surgery, and improve the MVO and MVC of patients to prevent formation of DVT after lower limb surgery. Copyright © 2016 Elsevier Inc. All rights reserved.

Dexamethasone in head and neck cancer patients with microvascular reconstruction: No benefit, more complications.

PubMed

Kainulainen, S; Törnwall, J; Koivusalo, A M; Suominen, A L; Lassus, P

2017-02-01

Glucocorticoids are widely used in association with major surgery of the head and neck to improve postoperative rehabilitation, shorten intensive care unit and hospital stay, and reduce neck swelling. This study aimed to clarify whether peri- and postoperative use of dexamethasone in reconstructive head and neck cancer surgery is associated with any advantages or disadvantages. This prospective double-blind randomized controlled trial comprised 93 patients. A total dose of 60mg of dexamethasone was administered to 51 patients over three days peri- and postoperatively. The remaining 42 patients served as controls. The main primary outcome variables were neck swelling, length of intensive care unit and hospital stay, duration of intubation or tracheostomy, and delay to start of possible radiotherapy. Complications were also recorded. No statistical differences emerged between the two groups in any of the main primary outcome variables. However, there were more major complications, especially infections, needing secondary surgery within three weeks of the operation in patients receiving dexamethasone than in control patients (27% vs. 7%, p=0.012). The use of dexamethasone in oral cancer patients with microvascular reconstruction did not provide a benefit. More major complications, especially infections, occurred in patients receiving dexamethasone. Our data thus do not support the use of peri- and postoperative dexamethasone in oropharyngeal cancer patients undergoing microvascular reconstruction. Copyright © 2016 Elsevier Ltd. All rights reserved.

White paper of Italian Gastroenterology: delivery of services for digestive diseases in Italy: weaknesses and strengths.

PubMed

Buscarini, Elisabetta; Conte, Dario; Cannizzaro, Renato; Bazzoli, Franco; De Boni, Michele; Delle Fave, Gianfranco; Farinati, Fabio; Ravelli, Paolo; Testoni, Pier Alberto; Lisiero, Manola; Spolaore, Paolo

2014-07-01

In 2011 the three major Italian gastroenterological scientific societies (AIGO, the Italian Society of Hospital Gastroenterologists and Endoscopists; SIED, the Italian Society of Endoscopy; SIGE, the Italian Society of Gastroenterology) prepared their official document aimed at analysing medical care for digestive diseases in Italy, on the basis of national and regional data (Health Ministry and Lombardia, Veneto, Emilia-Romagna databases) and to make proposals for planning of care. Digestive diseases were the first or second cause of hospitalizations in Italy in 1999-2009, with more than 1,500,000 admissions/year; however only 5-9% of these admissions was in specialized Gastroenterology units. Reported data show a better outcome in Gastroenterology Units than in non-specialized units: shorter average length of stay, in particular for admissions with ICD-9-CM codes proxying for emergency conditions (6.7 days versus 8.4 days); better case mix (higher average diagnosis-related groups weight in Gastroenterology Units: 1 vs 0.97 in Internal Medicine units and 0.76 in Surgery units); lower inappropriateness of admissions (16-25% versus 29-87%); lower in-hospital mortality in urgent admissions (2.2% versus 5.1%); for patients with urgent admissions due to gastrointestinnal haemorrhage, in-hospital mortality was 2.3% in Gastroenterology units versus 4.0% in others. The present document summarizes the scientific societies' official report, which constitutes the "White paper of Italian Gastroenterology". Copyright © 2014 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

Effects of listening to music on pain intensity and pain distress after surgery: an intervention.

PubMed

Vaajoki, Anne; Pietilä, Anna-Maija; Kankkunen, Päivi; Vehviläinen-Julkunen, Katri

2012-03-01

To evaluate the effects of music listening on pain intensity and pain distress on the first and second postoperative days in abdominal surgery patients and the long-term effects of music on the third postoperative day. Music has been found to relieve pain intensity in surgery patients. There are only a few studies on music intervention in abdominal surgery. Music intervention studies assessing multidimensional pain such as pain intensity and pain distress are also scarce. Prospective clinical study with two parallel groups. Patients undergoing elective abdominal surgery (n = 168) were divided into either a music group (n = 83) or a control group (n = 85). Patients assessed pain intensity and pain distress in bed rest, during deep breathing and in shifting position once in the evening of the operation day and on the first and second postoperative days in the morning, at noon and in the evening. On the third postoperative day, the patients assessed their pain intensity and pain distress only once. In the music group, the patients' pain intensity and pain distress in bed rest, during deep breathing and in shifting position were significantly lower on the second postoperative day compared with control group of patients. On the third postoperative day, when long-term effects of music on pain intensity and pain distress were assessed, there were no significant differences between music and control groups. This study demonstrates that the use of music alleviates pain intensity and pain distress in bed rest, during deep breathing and in shifting position after abdominal surgery on the second postoperative day. Music intervention is safe, inexpensive and easily used to improve the healing environment for abdominal surgery patients. Music intervention should be offered as an adjunct alternative to pharmacological pain relief after abdominal surgery in nursing practice. © 2011 Blackwell Publishing Ltd.

Urinary incontinence - retropubic suspension

MedlinePlus

... the same day as surgery. Or, you may stay for 2 or 3 days after this surgery. Follow instructions about how to care for yourself after you go home. Keep all follow-up appointments. Outlook (Prognosis) Urinary leakage decreases for most women who have this surgery. But you may still ...

Trend, Risk Factors, and Costs of Clostridium difficile Infections in Vascular Surgery.

PubMed

Egorova, Natalia N; Siracuse, Jeffrey J; McKinsey, James F; Nowygrod, Roman

2015-01-01

Starting in December 2013, the Hospital Inpatient Quality Reporting Program included Clostridium difficile infection (CDI) rates as a new publically reported quality measure. Our goal was to review the trend, hospital variability in CDI rates, and associated risk factors and costs in vascular surgery. The rates of CDI after major vascular procedures including aortic abdominal aneurysm (AAA) repair, carotid endarterectomy or stenting, lower extremity revascularization (LER), and LE amputation were identified using Nationwide Inpatient Sample database for 2000-2011. Risk factors associated with CDI were analyzed with hierarchical multivariate logistic regression. Extra costs, length of stay (LOS), and mortality were assessed for propensity-matched hospitalizations with and without CDI. During the study period, the rates of CDI after vascular procedures had increased by 74% from 0.6 in 2000 to 1.05% in 2011, whereas the case fatality rate was stable at 9-11%. In 2011, the highest rates were after ruptured aortic abdominal aneurysm (rAAA) repair (3.3%), followed by lower extremity amputations (2.3%) and elective open AAA (1.3%). The rates of CDI increased after all vascular procedures during the 12 years. The highest increase was after endovascular LER (151.8%) and open rAAA repair (135.7%). In 2011, patients who had experienced CDI had median LOS of 15 days (interquartile range, 9-25 days) compared with 8.3 days for matched patients without CDI, in-hospital mortality 9.1% (compared with 5.0%), and $13,471 extra cost per hospitalization. The estimated cost associated with CDI in vascular surgery in the United States was ∼$98 million in 2011. Hospital rates of CDI varied from 0 to 50% with 3.5% of hospitals having infection rates ≥5%. Factors associated with CDI included multiple chronic conditions, female gender, surgery type, emergent and weekend hospitalizations, hospital transfers, and urban locations. Despite potential reduction of infection rates as evidenced by the experience of hospitals with effective interventions, CDI is increasing among vascular surgery patients. It is associated with prolonged LOS, increased mortality, and higher costs. Copyright © 2015 Elsevier Inc. All rights reserved.

Effect of specialized diagnostic assessment units on the time to diagnosis in screen-detected breast cancer patients.

PubMed

Jiang, L; Gilbert, J; Langley, H; Moineddin, R; Groome, P A

2015-05-26

The duration of the cancer diagnostic process has considerable influence on patients' psychosocial well-being. Breast diagnostic assessment units (DAUs) in Ontario, Canada are designed to improve the quality and timeliness of care during a breast cancer diagnosis. We compared the diagnostic duration of patients diagnosed through a DAU vs usual care (UC). Retrospective population-based cohort study of 2499 screen-detected breast cancers (2011) using administrative health-care databases linked to the Ontario Cancer Registry. The diagnostic interval was measured from the initial screen to cancer diagnosis. Diagnostic assessment unit use was based on the biopsy and/or surgery hospital. We compared the length of the diagnostic interval between the DAU groups using multivariable quantile regression. Diagnostic assessment units had a higher proportion of patients diagnosed within the 7-week target compared with UC (79.1% vs 70.2%, P<0.001). The median time to diagnosis at DAUs was 26 days, which was 9 days shorter compared with UC (95% CI: 6.4-11.6). This effect was reduced to 8.3 days after adjusting for all study covariates. Adjusted DAU differences were similar at the 75th and 90th percentiles of the diagnostic interval distribution. Diagnosis through an Ontario DAU was associated with a reduced time to diagnosis for screen-detected breast cancer patients, which likely reduces the anxiety and distress associated with waiting for a diagnosis.

A Case Study of Infant Physiologic Response to Skin-to-Skin Contact After Surgery for Complex Congenital Heart Disease.

PubMed

Harrison, Tondi M; Ludington-Hoe, Susan

2015-01-01

Infants with complex congenital heart disease requiring surgical intervention within the first days or weeks of life may be the most seriously ill infants needing intensive nursing and medical care. Skin-to-skin contact (SSC) is well accepted and practiced as a positive therapeutic intervention in premature infants but is not routinely offered to infants in cardiac intensive care units. The physiologic effects of SSC in the congenital heart disease population must be examined before recommending incorporation of SSC into standard care routines. The purpose of this case study was to describe the physiologic response to a single session of SSC in an 18-day-old infant with hypoplastic left heart syndrome. Repeated measures of heart rate, respiratory rate, oxygen saturation, blood pressure, and temperature were recorded 30 minutes before SSC, during SSC (including interruptions for bottle and breast feedings), and 10 minutes after SSC was completed. All physiologic parameters were clinically acceptable throughout the 135-minute observation. This case study provides beginning evidence that SSC is safe in full-term infants after surgery for complex congenital heart disease. Further research with a larger sample is needed to examine the effects of SSC on infant physiology before surgery and earlier in the postoperative time period as well as on additional outcomes such as length of stay, maternal-infant interaction, and neurodevelopment.

Fast-track cardiac anesthesia in patients with sickle cell abnormalities.

PubMed

Djaiani, G N; Cheng, D C; Carroll, J A; Yudin, M; Karski, J M

1999-09-01

We conducted a retrospective review of 10 patients with sickle cell trait (SCT) and 30 patients (cohort control) without SCT undergoing first-time coronary artery bypass graft surgery with cardiopulmonary bypass. Demographic, perioperative management, and outcome data were collected. Both groups were matched according to age, weight, duration of surgery, and preoperative hemoglobin (Hb) concentration. Distribution of gender, medical conditions, pharmacological treatment, and preoperative left ventricular function were similar between the groups. The comparisons were analyzed in respect to postoperative blood loss and transfusion rates, as well as duration of intubation, intensive care unit, and hospital length of stay (LOS). All patients underwent fast-track cardiac anesthesia. A combination of cold crystalloid and blood cardioplegia was used. The lowest nasopharyngeal temperature was 33 degrees C. There were no episodes of significant hypoxemia, hypercarbia, or acidosis. None of the patients had sickling crisis during the perioperative period. The postoperative blood loss was 687 +/- 135 vs 585 +/-220 mL in the SCT and control groups, respectively. The trigger for blood transfusion during cardiopulmonary bypass was hematocrit <20% and Hb <75 g/L postoperatively. Three SCT patients (30%) and 10 control patients (33%) received a blood transfusion. Median extubation time was 4.0 vs 3.9 h; intensive care unit LOS was 27 vs 28 h; and hospital LOS was 6.0 vs 5.5 days in the SCT and control groups, respectively. There were no intraoperative deaths. One patient in the SCT group died from multiorgan failure 2 mo after surgery. Fast-track cardiac anesthesia can be used safely in patients with sickle cell trait undergoing first-time coronary artery bypass graft surgery. Extubation time and intensive care unit and hospital length of stay are comparable to those of matched controls, and blood loss and transfusion requirements are not increased. A hematocrit of 20% seems to be a safe transfusion trigger during cardiopulmonary bypass in these patients.

Plastic Surgery Training Worldwide: Part 1. The United States and Europe

PubMed Central

Kamali, Parisa; van Paridon, Maaike W.; Ibrahim, Ahmed M. S.; Paul, Marek A.; Winters, Henri A.; Martinot-Duquennoy, Veronique; Noah, Ernst Magnus; Pallua, Norbert

2016-01-01

Background: Major differences exist in residency training, and the structure and quality of residency programs differ between different countries and teaching centers. It is of vital importance that a better understanding of the similarities and differences in plastic surgery training be ascertained as a means of initiating constructive discussion and commentary among training programs worldwide. In this study, the authors provide an overview of plastic surgery training in the United States and Europe. Methods: A survey was sent to select surgeons in 10 European countries that were deemed to be regular contributors to the plastic surgery literature. The questions focused on pathway to plastic surgery residency, length of training, required pretraining experience, training scheme, research opportunities, and examinations during and after plastic surgery residency. Results: Plastic surgery residency training programs in the United States differ from the various (selected) countries in Europe and are described in detail. Conclusions: Plastic surgery education is vastly different between the United States and Europe, and even within Europe, training programs remain heterogeneous. Standardization of curricula across the different countries would improve the interaction of different centers and facilitate the exchange of vital information for quality control and future improvements. The unique characteristics of the various training programs potentially provide a basis from which to learn and to gain from one another. PMID:27257571

A 1470-nm laser combined with foam sclerotherapy in day surgery: a better choice for lower limb varicose veins.

PubMed

Zhang, Xing; Wang, Xin; Gao, Cheng; Qin, Jinbao; Zhao, Haiguang; Li, Weimin; Lu, Xinwu

2018-04-23

Day surgery is being more and more adopted by clinicians. Higher wavelength lasers give patients better experience than lower wavelength lasers, which makes it more suitable for day surgery. This study compares the short- and mid-term efficacy, postoperative morbidity, and patient satisfaction of "1470-nm endovenous laser ablation (EVLA) combining foam sclerotherapy in day surgery" with "810-nm EVLA with high ligation combining foam sclerotherapy in hospital surgery" on great saphenous vein (GSV) insufficiency postoperatively. A single-institution historical cohort study of 194 patients was performed in Shanghai Ninth People's Hospital, China. Ninety-seven patients received 1470-nm EVLA combining foam sclerotherapy in day surgery ("1470-nm group"), and 97 patients received 810-nm EVLA with high ligation combining foam sclerotherapy in hospital surgery recommended by guidelines ("810-nm group"). No significant difference was found between the 1470-nm group and the 810-nm group in terms of GSV occlusion rate (both 100%), complication rate, and recurrence rate (8.2 vs. 11.3%) during the period of 1-12 months after surgery. Serious complications in the 1470-nm group and 810-nm group were 0 and 1.0%. Minor complications in the 1470-nm group and 810-nm group were ecchymosis at 20.6 and 18.6%, edema at 69.1 and 63.9%, and paresthesia around ankle at 0 and 3.1%, respectively. Advantage of the 1470-nm group over the 810-nm group was statistically significant considering the patient perioperative comfort and economic cost. Treatment of 1470-nm EVLA combining foam sclerotherapy in day surgery has similar efficacy as the 810-nm EVLA with high ligation combining foam sclerotherapy in hospital surgery in GSV insufficiency and is more comfortable with less incision, hospitalization procedure, and medical costs. It may be a new option for patients who are afraid or unable to be hospitalized.

Q10 supplementation effects on cardiac enzyme CK-MB and troponin in patients undergoing coronary artery bypass graft: a randomized, double-blinded, placebo-controlled clinical trial

PubMed Central

Moludi, Jalal; Keshavarz, Seyedali; Tabaee, Ali Sadeghpour; Safiri, Saeid; Pakzad, Reza

2016-01-01

Introduction: Coronary artery bypass surgery (CABG) is associated with ischemia-reperfusion injury and tissue damage. CoQ10 as an antioxidant has an important role and may have cardio-protective effects after myocardial dysfunction and CABG. We aimed to evaluate whether CoQ10 has a myocardial cardio protective impact on cardiac biomarkers after CABG. Methods: In this double-blind study, 80 patients with coronary artery disease (CAD) who underwent CABG surgery were divided into intervention and control groups and received Q10 supplement or placebo, respectively. The surgical characteristics of the patients in the two groups were similar. The intervention group received 150 mg of Q10 supplement per day for 7 days before the surgery. The control group received placebo capsule. After operation the inter- and intra-group blood levels of CK-MB and troponin, before and after supplementation and 12 hours after the CABG, and postoperative outcomes such as intensive care unit (ICU) stay and hospital stay were compared. Results: In this study, 40 subjects were located in each group. The participation rate was 97.5% and men and women accounted for 52.5% and 47.5% respectively. The mean age of the subjects was 58.17 ± 8.55. The two groups were not significantly different in terms of basic variables. Within-group comparison showed a significant increase in the level of troponin enzymes over time (P < 0.001) and CK-MB (P < 0.001). However, between-group comparison showed no significant difference between the two groups in terms of CK-MB (P = 0.384) and troponin (P = 0.115). In the end, no interaction was observed between the intervention and time on CK-MB (P = 0.095) and troponin (P = 0.198) variables. Conclusion: Q10 supplementation 7 days before surgery was not effective in reducing CK-MB and troponin after CABG. PMID:27069560

Association between Socioeconomic Status and 30-Day and One-Year All-Cause Mortality after Surgery in South Korea.

PubMed

Oh, Tak Kyu; Kim, Kooknam; Do, Sang-Hwan; Hwang, Jung-Won; Jeon, Young-Tae

2018-03-10

Preoperative socioeconomic status (SES) is associated with outcomes after surgery, although the effect on mortality may vary according to region. This retrospective study evaluated patients who underwent elective surgery at a tertiary hospital from 2011 to 2015 in South Korea. Preoperative SES factors (education, religion, marital status, and occupation) were evaluated for their association with 30-day and one-year all-cause mortality. The final analysis included 80,969 patients who were ≥30 years old, with 30-day mortality detected in 339 cases (0.4%) and one-year mortality detected in 2687 cases (3.3%). As compared to never-married patients, those who were married or cohabitating (odds ratio (OR): 0.678, 95% confidence interval (CI): 0.462-0.995) and those divorced or separated (OR: 0.573, 95% CI: 0.359-0.917) had a lower risk of 30-day mortality after surgery. Similarly, the risk of one-year mortality after surgery was lower among married or cohabitating patients (OR: 0.857, 95% CI: 0.746-0.983) than it was for those who had never married. Moreover, as compared to nonreligious patients, Protestant patients had a decreased risk of 30-day mortality after surgery (OR: 0.642, 95% CI: 0.476-0.866). The present study revealed that marital status and religious affiliation are associated with risk of 30-day and one-year all-cause mortality after surgery.

Association between Socioeconomic Status and 30-Day and One-Year All-Cause Mortality after Surgery in South Korea

PubMed Central

Oh, Tak Kyu; Kim, Kooknam; Do, Sang-Hwan; Hwang, Jung-Won; Jeon, Young-Tae

2018-01-01

Preoperative socioeconomic status (SES) is associated with outcomes after surgery, although the effect on mortality may vary according to region. This retrospective study evaluated patients who underwent elective surgery at a tertiary hospital from 2011 to 2015 in South Korea. Preoperative SES factors (education, religion, marital status, and occupation) were evaluated for their association with 30-day and one-year all-cause mortality. The final analysis included 80,969 patients who were ≥30 years old, with 30-day mortality detected in 339 cases (0.4%) and one-year mortality detected in 2687 cases (3.3%). As compared to never-married patients, those who were married or cohabitating (odds ratio (OR): 0.678, 95% confidence interval (CI): 0.462–0.995) and those divorced or separated (OR: 0.573, 95% CI: 0.359–0.917) had a lower risk of 30-day mortality after surgery. Similarly, the risk of one-year mortality after surgery was lower among married or cohabitating patients (OR: 0.857, 95% CI: 0.746–0.983) than it was for those who had never married. Moreover, as compared to nonreligious patients, Protestant patients had a decreased risk of 30-day mortality after surgery (OR: 0.642, 95% CI: 0.476–0.866). The present study revealed that marital status and religious affiliation are associated with risk of 30-day and one-year all-cause mortality after surgery. PMID:29534463

Cataract Surgery among Medicare Beneficiaries

PubMed Central

Schein, Oliver D.; Cassard, Sandra D.; Tielsch, James M.; Gower, Emily W.

2014-01-01

Purpose To present descriptive epidemiology of cataract surgery among Medicare recipients in the United States. Setting Cataract surgery performed on Medicare beneficiaries in 2003 and 2004. Methods Medicare claims data were used to identify all cataract surgery claims for procedures performed in the United States in 2003-2004. Standard assumptions were used to limit the claims to actual cataract surgery procedures performed. Summary statistics were created to determine the number of procedures performed for each outcome of interest: cataract surgery rates by age, race, and gender; surgical volume by facility type, surgeon characteristics, and state; time interval between first- and second-eye cataract surgery. Results The national cataract surgery rate for 2003-2004 was 61.8 per 1000 Medicare beneficiary person-years. The rate was significantly higher for females and for those 75-84. After adjustment for age and gender, blacks had approximately a 30% lower rate of surgery than whites. While only 5% of cataract surgeons performed more than 500 cataract surgeries annually, these surgeons performed 26% of the total cataract surgeries. Increasing surgical volume was found to be highly correlated with use of ambulatory surgical centers and reduced time interval between first- and second-eye surgery in the same patient. Conclusions The epidemiology of cataract surgery in the United States Medicare population documents substantial variation in surgical rates by race, gender, age, and by certain provider characteristics. PMID:22978526

FRAIL Questionnaire Screening Tool and Short-Term Outcomes in Geriatric Fracture Patients.

PubMed

Gleason, Lauren Jan; Benton, Emily A; Alvarez-Nebreda, M Loreto; Weaver, Michael J; Harris, Mitchel B; Javedan, Houman

2017-12-01

There are limited screening tools to predict adverse postoperative outcomes for the geriatric surgical fracture population. Frailty is increasingly recognized as a risk assessment to capture complexity. The goal of this study was to use a short screening tool, the FRAIL scale, to categorize the level of frailty of older adults admitted with a fracture to determine the association of each frailty category with postoperative and 30-day outcomes. Retrospective cohort study. Level 1 trauma center. A total of 175 consecutive patients over age 70 years admitted to co-managed orthopedic trauma and geriatrics services. The FRAIL scale (short 5-question assessment of fatigue, resistance, aerobic capacity, illnesses, and loss of weight) classified the patients into 3 categories: robust (score = 0), prefrail (score = 1-2), and frail (score = 3-5). Postoperative outcome variables collected were postoperative complications, unplanned intensive care unit admission, length of stay (LOS), discharge disposition, and orthopedic follow-up after surgery. Thirty-day outcomes measured were 30-day readmission and 30-day mortality. Analysis of variance (1-way) and Kruskal-Wallis tests were used to compare continuous variables across the 3 FRAIL categories. Fisher exact tests were used to compare categorical variables. Multiple regression analysis, adjusted by age, sex, and Charlson index, was conducted to study the association between frailty category and outcomes. FRAIL scale categorized the patients into 3 groups: robust (n = 29), prefrail (n = 73), and frail (n = 73). There were statistically significant differences between groups in terms of age, comorbidity, dementia, functional dependency, polypharmacy, and rate of institutionalization, being higher in the frailest patients. Hip fracture was the most frequent fracture, and it was more frequent as the frailty of the patient increased (48%, 61%, and 75% in robust, prefrail, and frail groups, respectively). The American Society of Anesthesiologists preoperative risk significantly correlated with the frailty of the patient (American Society of Anesthesiologists score 3-4: 41%, 82% and 86%, in robust, prefrail, and frail groups, P < .001). After adjustment by age, sex, and comorbidity, there was a statistically significant association between frailty and both LOS and the development of any complication after surgery (LOS: 4.2, 5.0, and 7.1 days, P = .002; any complication: 3.4%, 26%, and 39.7%, P = .03; in robust, prefrail, and frail groups). There were also significant differences in discharge disposition (31% of robust vs 4.1% frail, P = .008) and follow-up completion (97% of robust vs 69% of the frail ones). Differences in time to surgery, unplanned intensive care unit admission, and 30-day readmission and mortality, although showing a trend, did not reach statistical significance. Frailty, measured by the FRAIL scale, was associated with increase LOS, complications after surgery, and discharge to rehabilitation facility in geriatric fracture patients. The FRAIL scale is a promising short screen to stratify and help operationalize the perioperative care of older surgical patients. Copyright © 2017 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Night-time care routine interaction and sleep disruption in adult cardiac surgery.

PubMed

Casida, Jesus M; Davis, Jean E; Zalewski, Aaron; Yang, James J

2018-04-01

To explore the context and the influence of night-time care routine interactions (NCRIs) on night-time sleep effectiveness (NSE) and daytime sleepiness (DSS) of patients in the cardiac surgery critical-care and progressive-care units of a hospital. There exists a paucity of empirical data regarding the influence of NCRIs on sleep and associated outcomes in hospitalised adult cardiac surgery patients. An exploratory repeated-measures research design was employed on the data provided by 38 elective cardiac surgery patients (mean age 60.0 ± 15.9 years). NCRI forms were completed by the bedside nurses and patients completed a 9-item Visual Analogue Sleep Scale (100-mm horizontal lines measuring NSE and DSS variables). All data were collected during postoperative nights/days (PON/POD) 1 through 5 and analysed with IBM SPSS software. Patient assessment, medication administration and laboratory/diagnostic procedures were the top three NCRIs reported between midnight and 6:00 a.m. During PON/POD 1 through 5, the respective mean NSE and DSS scores ranged from 52.9 ± 17.2 to 57.8 ± 13.5 and from 27.0 ± 22.6 to 45.6 ± 16.5. Repeated-measures ANOVA showed significant changes in DSS scores (p < .05). NSE and DSS were negatively correlated (r = -.44, p < .05), but changes in NSE scores were not significant (p > .05). Finally, of 8 NCRIs, only 1 (postoperative exercises) was significantly related to sleep variables (r > .40, p < .05). Frequent NCRIs are a common occurrence in cardiac surgery units of a hospital. Further research is needed to make a definitive conclusion about the impact of NCRIs on sleep/sleep disruptions and daytime sleepiness in adult cardiac surgery. Worldwide, acute and critical-care nurses are well positioned to lead initiatives aimed at improving sleep and clinical outcomes in cardiac surgery. © 2018 John Wiley & Sons Ltd.

Intrawound Vancomycin Decreases the Risk of Surgical Site Infection After Posterior Spine Surgery: A Multicenter Analysis.

PubMed

Devin, Clinton J; Chotai, Silky; McGirt, Matthew J; Vaccaro, Alexander R; Youssef, Jim A; Orndorff, Douglas G; Arnold, Paul M; Frempong-Boadu, Anthony K; Lieberman, Isador H; Branch, Charles; Hedayat, Hirad S; Liu, Ann; Wang, Jeffrey C; Isaacs, Robert E; Radcliff, Kris E; Patt, Joshua C; Archer, Kristin R

2018-01-01

Secondary analysis of data from a prospective multicenter observational study. The aim of this study was to evaluate the occurrence of surgical site infection (SSI) in patients with and without intrawound vancomycin application controlling for confounding factors associated with higher SSI after elective spine surgery. SSI is a morbid and expensive complication associated with spine surgery. The application of intrawound vancomycin is rapidly emerging as a solution to reduce SSI following spine surgery. The impact of intrawound vancomycin has not been systematically studied in a well-designed multicenter study. Patients undergoing elective spine surgery over a period of 4 years at seven spine surgery centers across the United States were included in the study. Patients were dichotomized on the basis of whether intrawound vancomycin was applied. Outcomes were occurrence of SSI within postoperative 30 days and SSI that required return to the operating room (OR). Multivariable random-effect log-binomial regression analyses were conducted to determine the relative risk of having an SSI and an SSI with return to OR. .: A total of 2056 patients were included in the analysis. Intrawound vancomycin was utilized in 47% (n = 966) of patients. The prevalence of SSI was higher in patients with no vancomycin use (5.1%) than those with use of intrawound vancomycin (2.2%). The risk of SSI was higher in patients in whom intrawound vancomycin was not used (relative risk (RR) -2.5, P < 0.001), increased number of levels exposed (RR -1.1, P = 0.01), and those admitted postoperatively to intensive care unit (ICU) (RR -2.1, P = 0.005). Patients in whom intrawound vancomycin was not used (RR -5.9, P < 0.001), increased number of levels were exposed (RR-1.1, P = 0.001), and postoperative ICU admission (RR -3.3, P < 0.001) were significant risk factors for SSI requiring a return to the OR. The intrawound application of vancomycin after posterior approach spine surgery was associated with a reduced risk of SSI and return to OR associated with SSI. 2.

Simultaneous bilateral cataract surgery: economic analysis; Helsinki Simultaneous Bilateral Cataract Surgery Study Report 2.

PubMed

Leivo, Tiina; Sarikkola, Anna-Ulrika; Uusitalo, Risto J; Hellstedt, Timo; Ess, Sirje-Linda; Kivelä, Tero

2011-06-01

To present an economic-analysis comparison of simultaneous and sequential bilateral cataract surgery. Helsinki University Eye Hospital, Helsinki, Finland. Economic analysis. Effects were estimated from data in a study in which patients were randomized to have bilateral cataract surgery on the same day (study group) or sequentially (control group). The main clinical outcomes were corrected distance visual acuity, refraction, complications, Visual Function Index-7 (VF-7) scores, and patient-rated satisfaction with vision. Health-care costs of surgeries and preoperative and postoperative visits were estimated, including the cost of staff, equipment, material, floor space, overhead, and complications. The data were obtained from staff measurements, questionnaires, internal hospital records, and accountancy. Non-health-care costs of travel, home care, and time were estimated based on questionnaires from a random subset of patients. The main economic outcome measures were cost per VF-7 score unit change and cost per patient in simultaneous versus sequential surgery. The study comprised 520 patients (241 patients included non-health-care and time cost analyses). Surgical outcomes and patient satisfaction were similar in both groups. Simultaneous cataract surgery saved 449 Euros (€) per patient in health-care costs and €739 when travel and paid home-care costs were included. The savings added up to €849 per patient when the cost of lost working time was included. Compared with sequential bilateral cataract surgery, simultaneous bilateral cataract surgery provided comparable clinical outcomes with substantial savings in health-care and non-health-care-related costs. No author has a financial or proprietary interest in any material or method mentioned. Copyright © 2011 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.

Plastic Surgery Undergraduate Training: How a Single Local Event Can Inspire and Educate Medical Students.

PubMed

Khatib, Manaf; Soukup, Benjamin; Boughton, Oliver; Amin, Kavit; Davis, Christopher R; Evans, David M

2015-08-01

Plastic surgery teaching has a limited role in the undergraduate curriculum. We held a 1-day national course in plastic surgery for undergraduates. Our aim was to introduce delegates to plastic surgery and teach basic plastic surgical skills. We assessed change in perceptions of plastic surgery and change in confidence in basic plastic surgical skills. The day consisted of consultant-led lectures followed by workshops in aesthetic suturing, local flap design, and tendon repair. A questionnaire divided into 3 sections, namely, (1) career plans, (2) perceptions of plastic surgery, and (3) surgical skills and knowledge, was completed by 39 delegates before and after the course. Results were presented as mean scores and the standard error of the mean used to calculate data spread. Data were analyzed using the Mann-Whitney U test for nonparametric data. Career plans: Interest in pursuing a plastic surgery career significantly increased over the course of the day by 12.5% (P < 0.0005).Perceptions: Statistically significant changes were observed in many categories of plastic surgery, including the perception of the role of plastic surgeons in improving patient quality of life, increased by 18.31% (P = 0.063). Before the course 10% of delegates perceived plastic surgery to be a superficial discipline and 20% perceived that plastic surgeons did not save lives. After completing the course, no delegates held those views.Surgical skills: Confidence to perform subcuticular and deep dermal sutures improved by 53% (P < 0.0001) and 57% (P < 0.0001), respectively. Delegates' subjective understanding of the basic geometry of local flaps improved by 94% (P < 0.0001). Interestingly, before the course, 2.5% of delegates drew an accurate modified Kessler suture compared with 87% of on completion of the course. A 1-day intensive undergraduate plastic surgery course can significantly increase delegates' desire to pursue a career in plastic surgery, dispel common misconceptions about this field, and increase their confidence in performing the taught skills. The results of this course demonstrate that a 1-day course is an effective means of teaching basic plastic surgery skills to undergraduates and highlights the potential role for local plastic surgery departments in advancing plastic surgery education.

MILS in a general surgery unit: learning curve, indications, and limitations.

PubMed

Patriti, Alberto; Marano, Luigi; Casciola, Luciano

2015-06-01

Minimally invasive liver surgery (MILS) is going to be a method with a wide diffusion even in general surgery units. Organization, learning curve effect, and the environment are crucial issues to evaluate before starting a program of minimally invasive liver resections. Analysis of a consecutive series of 70 patients has been used to define advantages and limits of starting a program of MILS in a general surgery unit. Seventeen MILS have been calculated with the cumulative sum method as the number of cases to complete the learning curve. Operative times [270 (60-480) vs. 180 (15-550) min; p 0.01] and rate of conversion (6/17 vs. 5/53; p 0.018) decrease after this number of cases. More complex cases can be managed after a proper optimization of all steps of liver resection. When a high confidence of the medical and nurse staff with MILS is reached, economical and strategic issues should be evaluated in order to establish a multidisciplinary hepatobiliary unit independent from the general surgery unit to manage more complex cases.

Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery.

PubMed

Devereaux, P J; Chan, Matthew T V; Alonso-Coello, Pablo; Walsh, Michael; Berwanger, Otavio; Villar, Juan Carlos; Wang, C Y; Garutti, R Ignacio; Jacka, Michael J; Sigamani, Alben; Srinathan, Sadeesh; Biccard, Bruce M; Chow, Clara K; Abraham, Valsa; Tiboni, Maria; Pettit, Shirley; Szczeklik, Wojciech; Lurati Buse, Giovanna; Botto, Fernando; Guyatt, Gordon; Heels-Ansdell, Diane; Sessler, Daniel I; Thorlund, Kristian; Garg, Amit X; Mrkobrada, Marko; Thomas, Sabu; Rodseth, Reitze N; Pearse, Rupert M; Thabane, Lehana; McQueen, Matthew J; VanHelder, Tomas; Bhandari, Mohit; Bosch, Jackie; Kurz, Andrea; Polanczyk, Carisi; Malaga, German; Nagele, Peter; Le Manach, Yannick; Leuwer, Martin; Yusuf, Salim

2012-06-06

Of the 200 million adults worldwide who undergo noncardiac surgery each year, more than 1 million will die within 30 days. To determine the relationship between the peak fourth-generation troponin T (TnT) measurement in the first 3 days after noncardiac surgery and 30-day mortality. A prospective, international cohort study that enrolled patients from August 6, 2007, to January 11, 2011. Eligible patients were aged 45 years and older and required at least an overnight hospital admission after having noncardiac surgery. Patients' TnT levels were measured 6 to 12 hours after surgery and on days 1, 2, and 3 after surgery. We undertook Cox regression analysis in which the dependent variable was mortality until 30 days after surgery, and the independent variables included 24 preoperative variables. We repeated this analysis, adding the peak TnT measurement during the first 3 postoperative days as an independent variable and used a minimum P value approach to determine if there were TnT thresholds that independently altered patients' risk of death. A total of 15,133 patients were included in this study. The 30-day mortality rate was 1.9% (95% CI, 1.7%-2.1%). Multivariable analysis demonstrated that peak TnT values of at least 0.02 ng/mL, occurring in 11.6% of patients, were associated with higher 30-day mortality compared with the reference group (peak TnT ≤ 0.01 ng/mL): peak TnT of 0.02 ng/mL (adjusted hazard ratio [aHR], 2.41; 95% CI, 1.33-3.77); 0.03 to 0.29 ng/mL (aHR, 5.00; 95% CI, 3.72-6.76); and 0.30 ng/mL or greater (aHR, 10.48; 95% CI, 6.25-16.62). Patients with a peak TnT value of 0.01 ng/mL or less, 0.02, 0.03-0.29, and 0.30 or greater had 30-day mortality rates of 1.0%, 4.0%, 9.3%, and 16.9%, respectively. Peak TnT measurement added incremental prognostic value to discriminate those likely to die within 30 days for the model with peak TnT measurement vs without (C index = 0.85 vs 0.81; difference, 0.4; 95% CI, 0.2-0.5; P < .001 for difference between C index values). The net reclassification improvement with TnT was 25.0% (P < .001). Among patients undergoing noncardiac surgery, the peak postoperative TnT measurement during the first 3 days after surgery was significantly associated with 30-day mortality.

Effects of intensivist coverage in a post-anaesthesia care unit on surgical patients' case mix and characteristics of the intensive care unit.

PubMed

Kastrup, Marc; Seeling, Matthes; Barthel, Stefan; Bloch, Andy; le Claire, Marie; Spies, Claudia; Scheller, Matthias; Braun, Jan

2012-07-18

There is an increasing demand for intensive care in hospitals, which can lead to capacity limitations in the intensive care unit (ICU). Due to postponement of elective surgery or delayed admission of emergency patients, outcome may be negatively influenced. To optimize the admission process to intensive care, the post-anaesthesia care unit (PACU) was staffed with intensivist coverage around the clock. The aim of this study is to demonstrate the impact of the PACU on the structure of ICU-patients and the contribution to overall hospital profit in terms of changes in the case mix index for all surgical patients. The administrative data of all surgical patients (n = 51,040) 20 months prior and 20 months after the introduction of a round-the-clock intensivist staffing of the PACU were evaluated and compared. The relative number of patients with longer length of stay (LOS) (more than seven days) in the ICU increased after the introduction of the PACU. The average monthly number of treatment days of patients staying less than 24 hours in the ICU decreased by about 50% (138.95 vs. 68.19 treatment days, P <0.005). The mean LOS in the PACU was 0.45 (± 0.41) days, compared to 0.27 (± 0.2) days prior to the implementation. The preoperative times in the hospital decreased significantly for all patients. The case mix index (CMI) per hospital day for all surgical patients was significantly higher after the introduction of a PACU: 0.286 (± 0.234) vs. 0.309 (± 0.272) P <0.001 CMI/hospital day. The introduction of a PACU and the staffing with intensive care staff might shorten the hospital LOS for surgical patients. The revenues for the hospital, as determined by the case mix index of the patients per hospital day, increased after the implementation of a PACU and more patients can be treated in the same time, due to a better use of resources.

The impact of mental health disorders on 30-day readmission after bariatric surgery.

PubMed

Litz, Megan; Rigby, Andrea; Rogers, Ann M; Leslie, Douglas L; Hollenbeak, Christopher S

2018-03-01

Mental health disorders are common among bariatric surgery patients. Mental health disorders, particularly depression, have been associated with poorer surgical outcomes, indicating the bariatric surgery patient population warrants special clinical attention. Our study sought to examine the effect of diagnosed mental health disorders on 30-day readmission for those undergoing bariatric surgery in hospitals across Pennsylvania from 2011 to 2014. We used Pennsylvania Healthcare Cost Containment Council data to perform this analysis. Inclusion criteria encompassed patients aged>18 years who underwent bariatric surgery at any hospital or freestanding surgical facility in Pennsylvania between 2011 and 2014. Mental health disorders were identified using predetermined International Classification of Disease, Ninth Revision codes. Logistic regression was used to model the risk of 30-day readmission and estimate the effect of mental health disorders on 30-day readmission. Of the 19,259 patients who underwent bariatric surgery, 40.3% had a diagnosed mental health disorder; 6.51% of all patients were readmitted within 30 days. Patients with a diagnosed mental health disorder had 34% greater odds of readmission (odds ratio = 1.34, 95% confidence interval: 1.19-1.51) relative to patients with no diagnosed mental health disorder. Patients with major depressive disorder/bipolar disorder had 46% greater odds of being readmitted compared with patients with no major depressive disorder/bipolar disorder diagnosis. Study findings imply the need for risk assessment of patients before postoperative discharge. Given that patients with mental health diagnoses are at increased risk of 30-day readmission after bariatric surgery, they may benefit from additional discharge interventions designed to attenuate potential readmissions. Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.

Parecoxib relieves pain and has an opioid-sparing effect following major gastrointestinal surgery.

PubMed

Essex, Margaret Noyes; Xu, Hao; Parsons, Bruce; Xie, Li; Li, Chunming

2017-01-01

Parecoxib provides analgesia following a variety of surgeries, including minor gastrointestinal procedures. To our knowledge, there is no data on parecoxib following major gastrointestinal surgery. This study assessed the efficacy and opioid-sparing effects of parecoxib following major gastrointestinal surgeries. Patients in this analysis were a subset from a large, randomized, double-blind, placebo-controlled trial of parecoxib following noncardiac surgeries and consisted of those undergoing a variety of major gastrointestinal surgeries via laparotomy. Pain, pain interference with function, supplemental opioid utilization, opioid-related symptoms, and Patient/Physician Global Evaluation of Study Medication were compared between placebo and parecoxib groups in the 2-3 days following surgery. Significantly ( p <0.001) lower pain scores were observed in the parecoxib group (n=111), relative to placebo (n=126), on Day 2 (-33%) and Day 3 (-35%). Pain interference with function scores was also significantly ( p <0.001) lower among patients receiving parecoxib compared with placebo on Day 2 (-29%) and Day 3 (-36%). At 24, 48, and 72 hours, the cumulative amount of supplemental morphine consumed was 45%, 41%, and 40% less in patients receiving parecoxib compared with placebo (all p <0.001). The risk of experiencing ≥1 opioid-related symptoms was also significantly lower with parecoxib than with placebo on Day 2 (relative risk=0.75; p <0.001). Specifically, the risks of fatigue and drowsiness were significantly (both p <0.05) lower in patients receiving parecoxib compared to those receiving placebo. Patient and Physician Global Evaluation of Study Medication scores were significantly better in the parecoxib group than in the placebo group ( p <0.001). This study is the first to demonstrate that multiple-dose parecoxib, initiated upon recovery from anesthesia, provides analgesia and opioid-sparing effects following a variety of major gastrointestinal surgeries employing laparotomy.

[Use of C response protein in predicting postoperative anastomotic leakage in patients with rectal cancer].

PubMed

Lyu, Zejian; Wu, Deqing; Cai, Guanfu; Luo, Yuwen; Yang, Zifeng; Zhai, Yanyun; Yao, Chuli; Hu, Weixian; Wang, Junjiang; Li, Yong

To investigate the value and feasibility of C reactive protein (CRP) in predicting postoperative anastomotic leakage in rectal cancer patients with enhanced recovery after surgery (ERAS) for safer implementation of this ERAS. A cohort study on serum CRP of 455 rectal cancer patients undergoing laparoscopic radical resection according to the ERAS procedure at Gastrointestinal Unit of General Surgery Department, Guangdong General Hospital from August 2014 to June 2017 was retrospectively carried out. The serum CRP level was measured before operation and at postoperative days 1-7, and the serum CRP level of the groups with and without anastomotic leakage was compared to analyze its prediction for anastomotic leakage. Diagnostic standard of anastomotic leakage was based on the definition of postoperative anastomotic leakage in rectal cancer from International Study Group of Rectal Cancer (ISREC): (1) Postoperative localized or diffuse peritonitis occurred, or fecal liquid was found from the abdominal drainage tube; (2) When anastomotic leakage was uncertain, peritoneal or pelvic computed tomography scan should be used to confirm. All the 455 patients underwent surgery successfully, and 41 patients (9.0%) had anastomotic leakage postoperatively. Patients with anastomotic leakage were diagnosed (4.0±2.0) days postoperatively, of whom 8 cases (19.5%) were diagnosed more than 5 days postoperatively. Serum CRP levels in patients with anastomotic leakage continued to increase within 1-4 days postoperatively [(50.04±27.98) mg/L to (122.75±52.98) mg/L] and decreased 5 days postoperatively [(92.02±58.26) mg/L], both were higher than those of non-anastomotic leakage group, and the difference was statistically significant (all P<0.05, except postoperative day 2). The serum CRP level of non-anastomotic leakage group reached the peak on the second postoperative day [(83.10±37.45) mg/L] and decreased 3 days postoperatively [(48.01±27.59) mg/L]. The ROC curve was drawn with the anastomotic leakage as the state variable, and the CRP level as the detection variable. The area under the curve (AUC) at postoperative 1, 2, 4, 5, 6 and 7 days was 0.74, 0.58, 0.83, 0.82, 0.65, and 0.70, respectively. The maximum was at postoperative day 3 [0.93(95%CI: 0.86-0.99)]. The Youden index was 0.72, and the threshold of CRP was 80.09 mg/L, as the cut-off point to predict anastomotic leakage, with sensitivity, specificity, and positive predictive value of 79.3%, 92.3%, and 74.2%, respectively. Monitoring the postoperative serum CRP level can help predict the occurrence of anastomotic leakage after laparoscopic surgery for rectal cancer. When the serum CRP level is >80.09 mg/L on the third postoperative day, the CRP level has the largest value in predicting postoperative anastomotic leakage, and the safety of ERAS has a certain clinical significance as well.

Soluble Suppression of Tumorigenicity-2 Predicts Hospital Mortality in Burn Patients: An Observational Prospective Cohort Pilot Study.

PubMed

Ruiz-Castilla, Mireia; Bosacoma, Pau; Dos Santos, Bruce; Baena, Jacinto; Guilabert, Patricia; Marin-Corral, Judith; Masclans, Joan R; Roca, Oriol; Barret, Juan P

2018-04-10

The IL33/ST2 pathway has been implicated in the pathogenesis of different inflammatory diseases. Our aim was to analyze whether plasma levels of biomarkers involved in the IL33/ST2 axis might help to predict mortality in burn patients. Single-center prospective observational cohort pilot study performed at the Burns Unit of the Plastic and Reconstructive Surgery Department of the Vall d'Hebron University Hospital (Barcelona). All patients aged ≥18 years old with second or third-degree burns requiring admission to the Burns Unit were considered for inclusion. Blood samples were taken to measure levels of interleukins (IL)6, IL8, IL33, and soluble suppression of tumorigenicity-2 (sST2) within 24 h of admission to the Burns Unit and at day 3. Results are expressed as medians and interquartile ranges or as frequencies and percentages. Sixty-nine patients (58 [84.1%] male, mean age 52 [35-63] years, total body surface area burned 21% [13%-30%], Abbreviated Burn Severity Index 6 [4-8]) were included. Thirteen (18.8%) finally died in the Burns Unit. Plasma levels of sST2 measured at day 3 after admission demonstrated the best prediction accuracy for survival (area under the ROC curve 0.85 [0.71-0.99]; P < 0.001). The best cutoff point for the AUROC index was estimated to be 2,561. In the Cox proportional hazards model, after adjusting for potential confounding, a plasma sST2 level ≥2,561 measured at day 3 was significantly associated with mortality (HR 6.94 [1.73-27.74]; P = 0.006). Plasma sST2 at day 3 predicts hospital mortality in burn patients.

Depression 12-months after coronary artery bypass graft is predicted by cortisol slope over the day.

PubMed

Poole, Lydia; Kidd, Tara; Ronaldson, Amy; Leigh, Elizabeth; Jahangiri, Marjan; Steptoe, Andrew

2016-09-01

Alterations in the diurnal profile of cortisol have been associated with depressed mood in patients with coronary heart disease. The relationship between cortisol output and depressed mood has not been investigated prospectively in coronary artery bypass graft (CABG) patients before. We aimed to study the relationship between cortisol measured pre- and post-operatively and depression symptoms measured 12 months after CABG surgery. We analysed data from 171 patients awaiting first-time, elective CABG surgery from the pre-assessment clinic at St. George's Hospital, London. The Beck Depression Inventory (BDI) was used to assess depression symptoms and saliva samples were collected to measure diurnal cortisol. Baseline assessments of depression and cortisol were obtained an average 29days before surgery, short-term follow-up of cortisol occurred 60days after surgery and long-term follow-up of depression was assessed 378days after surgery. Baseline cortisol slope was not associated with depression at 12-month follow-up. However, a steeper cortisol slope measured 60days after surgery predicted reduced odds of depression (BDI≥10) 12 months after surgery (odds ratio 0.661, 95% confidence interval 0.437-0.998, p=0.049) after controlling for covariates. These findings suggest interventions aimed at improving adaptation in the early recovery period may have long-term benefits in this patient group. Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.

Effect of Intraperitoneal Bupivacaine on Postoperative Pain in the Gynecologic Oncology Patient

PubMed Central

Rivard, Colleen; Vogel, Rachel Isaksson; Teoh, Deanna

2015-01-01

Study Objective To evaluate if the administration of intraperitoneal bupivacaine decreased postoperative pain in patients undergoing minimally invasive gynecologic and gynecologic cancer surgery. Design Retrospective cohort study (Canadian Task Force classification II-3). Setting University-based gynecologic oncology practice operating at a tertiary medical center. Patients All patients on the gynecologic oncology service undergoing minimally invasive surgery between September 2011 and June 2013. Interventions Starting August 2012, intraperitoneal administration of .25% bupivacaine was added to all minimally invasive surgeries. These patients were compared with historical control subjects who had surgery between September 2011 and July 2012 but did not receive intraperitoneal bupivacaine. Measurements and Main Results One-hundred thirty patients were included in the study. The patients who received intraperitoneal bupivacaine had lower median narcotic use on the day of surgery and the first postoperative day compared with those who did not receive intraperitoneal bupivacaine (day 0: 7.0 mg morphine equivalents vs 11.0 mg, p = .007; day 1: .3 mg vs 1.7 mg, p = .0002). The median patient-reported pain scores were lower on the day of surgery in the intraperitoneal bupivacaine group (2.7 vs 3.2, p = .05) Conclusions The administration of intraperitoneal bupivacaine was associated with improved postoperative pain control in patients undergoing minimally invasive gynecologic and gynecologic cancer surgery and should be further evaluated in a prospective study. PMID:26216095

Drivers of 30-Day Readmission in Elderly Patients (>65 Years Old) After Spine Surgery: An Analysis of 500 Consecutive Spine Surgery Patients.

PubMed

Adogwa, Owoicho; Elsamadicy, Aladine A; Han, Jing; Karikari, Isaac O; Cheng, Joseph; Bagley, Carlos A

2017-01-01

Early readmission after spine surgery is being used as a proxy for quality of care. One-fifth of patients are rehospitalized within 30 days after spine surgery, and more than one-third within 90 days; however, there is a paucity of data about the cause of early readmissions in elderly patients after elective spine surgery. A total of 500 elderly patients (>65 years old) undergoing elective spine surgery at a major academic hospital were included in the study. We identified all unplanned readmissions within 30 days of discharge. Unplanned readmissions were defined to have occurred as a result of either a surgical or a nonsurgical complication. Patient records were reviewed to determine the cause of readmission and the length of hospital stay. A total of 50 (10%) unplanned early readmissions were identified. The mean ± SD age was 72.54 ± 5.84 years. The mean ± SD number of days from discharge to readmission was 11.02 ± 7.25 days, and the average length of hospital stay for the readmissions was 7.7 days. The majority of patients that were readmitted presented to the emergency department from home (46%), whereas 38% were readmitted from a skilled nursing facility. The most common causes for readmission were infection or a concern for infection (42%) and pain (14%), with 32% of readmissions requiring a return to the operating room. Our study suggests that in elderly patients undergoing elective spine surgery, infection or a concern for infection, pain, and altered mental status were the most common primary reasons for unplanned readmission. Copyright © 2016 Elsevier Inc. All rights reserved.

30-Day Readmission After Spine Surgery: An Analysis of 1400 Consecutive Spine Surgery Patients.

PubMed

Adogwa, Owoicho; Elsamadicy, Aladine A; Han, Jing L; Karikari, Isaac O; Cheng, Joseph; Bagley, Carlos A

2017-04-01

Retrospective cohort review. To identify the rates, causes, and risk factors for 30-day unplanned readmissions in after elective spine surgery at our institution. Early readmission after spine surgery is being used as a proxy for quality of care. One-fifth of patients are rehospitalized within 30 days after spine surgery. Nearly 60% of these readmissions are unplanned, which translates into billions of dollars in healthcare costs. A total of 1400 patients undergoing elective spine surgery at Duke University Hospital between 2008 and 2010 were included in the study. We identified all unplanned readmissions within 30 days of discharge. Unplanned readmissions were defined to have occurred as a result of either a surgical or a nonsurgical complication. Patient records were reviewed to determine the cause of readmission and the length of hospital stay. A total of 132 (9.4%) unplanned early readmissions were identified. The mean ± SD age was 58.6 ± 15.1 years. Lumbar decompression and fusion was the most common procedure The most common causes for readmission were infection or a concern for infection (34.8%) and pain (19.7%), and 26.5% of readmissions required a return to the operating room. The majority of patients that were readmitted presented to the emergency department from home (58.0%) whereas 25.2% were readmitted from a skilled nursing facility. The mean ± SD number of days from discharge to readmission was 9.8 ± 7.9 days and the average length of hospital stay for the readmissions was 7.5 days. This study suggests that infection and refractory pain were the most common primary reasons for unplanned readmission. Efforts at reducing unplanned early readmission after elective spine surgery should be focused on more effective post discharge care.

Risk model of thoracic aortic surgery in 4707 cases from a nationwide single-race population through a web-based data entry system: the first report of 30-day and 30-day operative outcome risk models for thoracic aortic surgery.

PubMed

Motomura, Noboru; Miyata, Hiroaki; Tsukihara, Hiroyuki; Takamoto, Shinichi

2008-09-30

The objective of this study was to collect integrated data from nationwide hospitals using a web-based national database system to build up our own risk model for the outcome from thoracic aortic surgery. The Japan Adult Cardiovascular Surgery Database was used; this involved approximately 180 hospitals throughout Japan through a web-based data entry system. Variables and definitions are almost identical to the STS National Database. After data cleanup, 4707 records were analyzed from 97 hospitals (between January 1, 2000, and December 31, 2005). Mean age was 66.5 years. Preoperatively, the incidence of chronic lung disease was 11%, renal failure was 9%, and rupture or malperfusion was 10%. The incidence of the location along the aorta requiring replacement surgery (including overlapping areas) was: aortic root, 10%; ascending aorta, 47%; aortic arch, 44%; distal arch, 21%; descending aorta, 27%; and thoracoabdominal aorta, 8%. Raw 30-day and 30-day operative mortality rates were 6.7% and 8.6%, respectively. Postoperative incidence of permanent stroke was 6.1%, and renal failure requiring dialysis was 6.7%. OR for 30-day operative mortality was as follows: emergency or salvage, 3.7; creatinine >3.0 mg/dL, 3.0; and unexpected coronary artery bypass graft, 2.6. As a performance metric of the risk model, C-index of 30-day and 30-day operative mortality was 0.79 and 0.78, respectively. This is the first report of risk stratification on thoracic aortic surgery using a nationwide surgical database. Although condition of these patients undergoing thoracic aortic surgery was much more serious than other procedures, the result of this series was excellent.

[Indicators of healthcare quality in day surgery (2010-2012)].

PubMed

Martínez Rodenas, F; Codina Grifell, J; Deulofeu Quintana, P; Garrido Corchón, J; Blasco Casares, F; Gibanel Garanto, X; Cuixart Vilamajó, L; de Haro Licer, J; Vazquez Dorrego, X

2014-01-01

Monitoring quality indicators in Ambulatory Surgery centers is fundamental in order to identify problems, correct them and prevent them. Given their large number, it is essential to select the most valid ones. The objectives of the study are the continuous improvement in the quality of healthcare of day-case surgery in our center, by monitoring selective quality parameters, having periodic information on the results and taking corrective measures, as well as achieving a percentage of unplanned transfer and cancellations within quality standards. Prospective, observational and descriptive study of the day-case surgery carried out from January 2010 to December 2012. Unplanned hospital admissions and cancellations on the same day of the operation were selected and monitored, along with their reasons. Hospital admissions were classified as: inappropriate selection, medical-surgical complications, and others. The results were evaluated each year and statistically analysed using χ(2) tests. A total of 8,300 patients underwent day surgery during the 3 years studied. The day-case surgery and outpatient index increased by 5.4 and 6.4%, respectively (P<.01). Unexpected hospital admissions gradually decreased due to the lower number of complications (P<.01). Hospital admissions, due to an extended period of time in locoregional anaesthesia recovery, also decreased (P<.01). There was improved prevention of nausea and vomiting, and of poorly controlled pain. The proportion of afternoon admissions was significantly reduced (P<.01). The cancellations increased in 2011 (P<.01). The monitoring of quality parameters in day-case surgery has been a useful tool in our clinical and quality management. Globally, the unplanned transfer and cancellations have been within the quality standards and many of the indicators analysed have improved. Copyright © 2013 SECA. Published by Elsevier Espana. All rights reserved.

Impact of minimally invasive surgery on healthcare utilization, cost, and workplace absenteeism in patients with Incisional/Ventral Hernia (IVH).

PubMed

Mikami, Dean J; Melvin, W Scott; Murayama, Michael J; Murayama, Kenric M

2017-11-01

Incisional hernia repair is one of the most common general surgery operations being performed today. With the advancement of laparoscopy since the 1990s, we have seen vast improvements in faster return to normal activity, shorter hospital stays and less post-operative narcotic use, to name a few. The key aims of this review were to measure the impact of minimally invasive surgery versus open surgery on health care utilization, cost, and work place absenteeism in the patients undergoing inpatient incisional/ventral hernia (IVH) repair. We analyzed data from the Truven Health Analytics MarketScan ® Commercial Claims and Encounters Database. Total of 2557 patients were included in the analysis. Of the patient that underwent IVH surgery, 24.5% (n = 626) were done utilizing minimally invasive surgical (MIS) techniques and 75.5% (n = 1931) were done open. Ninety-day post-surgery outcomes were significantly lower in the MIS group compared to the open group for total payment ($19,288.97 vs. $21,708.12), inpatient length of stay (3.12 vs. 4.24 days), number of outpatient visit (5.48 vs. 7.35), and estimated days off (11.3 vs. 14.64), respectively. At 365 days post-surgery, the total payment ($27,497.96 vs. $30,157.29), inpatient length of stay (3.70 vs. 5.04 days), outpatient visits (19.75 vs. 23.42), and estimated days off (35.71 vs. 41.58) were significantly lower for MIS group versus the open group, respectively. When surgical repair of IVH is performed, there is a clear advantage in the MIS approach versus the open approach in regard to cost, length of stay, number of outpatient visits, and estimated days off.

Racial Disparities in 30-Day Readmission Rates After Elective Spine Surgery: A Single Institutional Experience.

PubMed

Adogwa, Owoicho; Elsamadicy, Aladine A; Mehta, Ankit I; Cheng, Joseph; Bagley, Carlos A; Karikari, Isaac O

2016-11-01

Retrospective cohort review. The aim of this study is to investigate whether patient race is an independent predictor of unplanned 30-day hospital readmission after elective spine surgery. Racial disparities are known to exist for many aspects of surgical care. However, it is unknown if disparities exist in 30-day readmissions after elective spine surgery, an area that is becoming a prime focus for clinical leaders and policymakers. Records of 600 patients undergoing elective spine surgery at a major academic medical center were reviewed. We identified all unplanned readmissions within 30 days of discharge. Unplanned readmissions were defined to have occurred as a result of either a surgical or a nonsurgical complication. Patient's records were reviewed to determine the cause of readmission and the length of hospital stay. The main outcome measure was risk-adjusted odds of all-cause 30-day readmission. We used multivariate logistic regression to determine if Black patients had an increased likelihood of 30-day readmission compared with White patients. Baseline characteristics were similar between both groups. Black patients had higher readmission rates than White patients (10.56% vs. 7.86%, P = 0.04). In a univariate analysis, race, body mass index, sex, patient age, smoking, diabetes, and fusion levels were associated with increased 30-day readmission rates. However, in a multivariate logistic regression model, race was an independent predictor of 30-day readmission after elective spine surgery. In addition, no significant differences in baseline, 1-year and 2-year patient reported outcomes measures were observed between both groups. This study suggests that Black patients are more likely to be readmitted within 30-days of discharge after elective spine surgery. Efforts at reducing disparities should focus not only on race-based measures but also effective post discharge care. 3.

Disparities in breast cancer surgery delay: the lingering effect of race.

PubMed

Sheppard, Vanessa B; Oppong, Bridget A; Hampton, Regina; Snead, Felicia; Horton, Sara; Hirpa, Fikru; Brathwaite, Echo J; Makambi, Kepher; Onyewu, S; Boisvert, Marc; Willey, Shawna

2015-09-01

Delays to surgical breast cancer treatment of 90 days or more may be associated with greater stage migration. We investigated racial disparities in time to receiving first surgical treatment in breast cancer patients. Insured black (56 %) and white (44 %) women with primary breast cancer completed telephone interviews regarding psychosocial (e.g., self-efficacy) and health care factors (e.g., communication). Clinical data were extracted from medical charts. Time to surgery was measured as the days between diagnosis and definitive surgical treatment. We also examined delays of more than 90 days. Unadjusted hazard ratios (HRs) examined univariate relationships between delay outcomes and covariates. Cox proportional hazard models were used for multivariate analyses. Mean time to surgery was higher in blacks (mean 47 days) than whites (mean 33 days; p = .001). Black women were less likely to receive therapy before 90 days compared to white women after adjustment for covariates (HR .58; 95 % confidence interval .44, .78). Health care process factors were nonsignificant in multivariate models. Women with shorter delay reported Internet use (vs. not) and underwent breast-conserving surgery (vs. mastectomy) (p < .01). Prolonged delays to definitive breast cancer surgery persist among black women. Because the 90-day interval has been associated with poorer outcomes, interventions to address delay are needed.

Is lack of surgery for older breast cancer patients in the UK explained by patient choice or poor health? A prospective cohort study.

PubMed

Lavelle, K; Sowerbutts, A M; Bundred, N; Pilling, M; Degner, L; Stockton, C; Todd, C

2014-02-04

Older women have lower breast cancer surgery rates than younger women. UK policy states that differences in cancer treatment by age can only be justified by patient choice or poor health. We investigate whether lack of surgery for older patients is explained by patient choice/poor health in a prospective cohort study of 800 women aged ≥70 years diagnosed with operable (stage 1-3a) breast cancer at 22 English breast cancer units in 2010-2013. interviews and case note review. surgery for operable (stage 1-3a) breast cancer <90 days of diagnosis. Logistic regression adjusts for age, health measures, tumour characteristics, socio-demographics and patient's/surgeon's perceived responsibility for treatment decisions. In the univariable analyses, increasing age predicts not undergoing surgery from the age of 75 years, compared with 70-74-year-olds. Adjusting for health measures and choice, only women aged ≥85 years have reduced odds of surgery (OR 0.18, 95% CI: 0.07-0.44). Each point increase in Activities of Daily Living score (worsening functional status) reduced the odds of surgery by over a fifth (OR 0.23, 95% CI: 0.15-0.35). Patient's role in the treatment decisions made no difference to whether they received surgery or not; those who were active/collaborative were as likely to get surgery as those who were passive, that is, left the decision up to the surgeon. Lower surgery rates, among older women with breast cancer, are unlikely to be due to patients actively opting out of having this treatment. However, poorer health explains the difference in surgery between 75-84-year-olds and younger women. Lack of surgery for women aged ≥85 years persists even when health and patient choice are adjusted for.

Alfuzosin to relieve ureteral stent discomfort: a prospective, randomized, placebo controlled study.

PubMed

Beddingfield, Richard; Pedro, Renato N; Hinck, Bryan; Kreidberg, Carly; Feia, Kendall; Monga, Manoj

2009-01-01

We assessed the impact of alfuzosin on ureteral stent discomfort. A total of 66 patients scheduled for unilateral retrograde ureteroscopy with stent placement provided consent for the study. Patients were randomized between placebo and the study medication, and investigators and patients were blinded to the randomization scheme. To evaluate pain and urinary symptoms patients were asked to complete the Ureteral Stent Symptom Questionnaire (Stone Management Unit, Southmead Hospital, Westbury-on-Trym, United Kingdom) before ureteroscopy and 3 days after the procedure to minimize the confounding impact of procedural discomfort due to surgery. Patients were also asked to maintain a use log of pain medication each day that the ureteral stent was in place. Procedure outcome and complications were recorded, as were patient study medication use and vital health information before the procedure and at the time of stent removal. Statistical analysis was performed using the Student t, chi-square and Wilcoxon rank sum tests, as appropriate, with p <0.05 considered significant. Of 66 patients who provided consent 55 successfully completed the study. In 3 of the 11 failed cases surgery was not done due to spontaneous stone passage, surgery was performed in 3 but no ureteral stent was placed, 4 were excluded from study after obtaining consent due to exclusion criteria and 1 was voluntarily removed from study after obtaining consent but before surgery. Regarding stent type, procedure complications and baseline questionnaire results there were no significant differences between the placebo and alfuzosin arms. When comparing post-procedure questionnaire results, patients in the alfuzosin arm reported less overall pain in the kidney/back/loin area and less pain in the kidney area while passing urine (p = 0.017 and 0.007, respectively). Men in the alfuzosin arm also reported a lesser incidence of excessive urination (p = 0.040). When comparing changes from baseline questionnaire results, the alfuzosin arm experienced a decrease in kidney pain during sleep (p = 0.017), less frequent use of painkillers to control kidney pain (p = 0.020) and a decrease in how much kidney associated pain interfered with life (p = 0.045). There was no significant difference in the amount of narcotics used per day, as reported in patient medication logs. Alfuzosin improves the patient discomfort associated with ureteral stents by decreasing urinary symptoms and kidney pain but it does not affect the amount of narcotics that patients use while the stent is in place.

Traumeel S® for pain relief following hallux valgus surgery: a randomized controlled trial

PubMed Central

2010-01-01

Background In spite of recent advances in post-operative pain relief, pain following orthopedic surgery remains an ongoing challenge for clinicians. We examined whether a well known and frequently prescribed homeopathic preparation could mitigate post-operative pain. Method We performed a randomized, double blind, placebo-controlled trial to evaluate the efficacy of the homeopathic preparation Traumeel S® in minimizing post-operative pain and analgesic consumption following surgical correction of hallux valgus. Eighty consecutive patients were randomized to receive either Traumeel tablets or an indistinguishable placebo, and took primary and rescue oral analgesics as needed. Maximum numerical pain scores at rest and consumption of oral analgesics were recorded on day of surgery and for 13 days following surgery. Results Traumeel was not found superior to placebo in minimizing pain or analgesic consumption over the 14 days of the trial, however a transient reduction in the daily maximum post-operative pain score favoring the Traumeel arm was observed on the day of surgery, a finding supported by a treatment-time interaction test (p = 0.04). Conclusions Traumeel was not superior to placebo in minimizing pain or analgesic consumption over the 14 days of the trial. A transient reduction in the daily maximum post-operative pain score on the day of surgery is of questionable clinical importance. Trial Registration This study was registered at ClinicalTrials.gov. # NCT00279513 PMID:20380750

Low-dose strontium-90 irradiation is effective in preventing the recurrence of pterygia: a ten-year study.

PubMed

Qin, Xue-jiao; Chen, Hong-mei; Guo, Liang; Guo, Yong-yuan

2012-01-01

To study the long-term effects of low-dosage strontium-90 (Sr90) irradiation on the recurrence of pterygium. One hundred twenty eyes from 104 patients with primary or recurrent pterygia were treated with surgery followed by Sr90 irradiation. In brief, starting on the sixth day after surgery, patients were treated with irradiation three times every other day at a total combined dosage of 2000 cGy to 3000 cGy. Corneal topography was used to evaluate ocular surface regularity before and after treatment. Patient follow-up was performed 2 days, 5 days, 2 weeks, 1 month, 3 months, 1 year, 5 years, and 10 years after surgery. Recurrence of pterygium was not observed in any of the patients in this study. Obvious cataract progression was observed in 6 eyes, which may be due to aging. During follow-up studies, only one eye was reported with dryness and foreign-body sensation. Significant pterygium-induced astigmatism was observed in corneal topography, which decreased after surgery. Sr90 irradiation is effective in preventing the recurrence of primary and recurrent pterygia. We recommend delivering a total combined dosage of 2000 cGy to 3000 cGy of Sr90 irradiation administered in three batches every other day starting from the sixth day after surgery. Surgery is important in the rapid recovery of the cornea from pterygium-induced astigmatism.

Setting up pre-admission visits for children undergoing day surgery: a practice development initiative.

PubMed

O'Shea, Maria; Cummins, Ann; Kelleher, Ann

2010-06-01

The hospital experience can bring about a range of negative emotions for children. The literature clearly states that children who are prepared for surgery recover faster and have fewer negative effects. Pre-admission programmes seek to prepare children (and their parents) for surgery. This paper describes in detail how a pre-admission programme was established for children and their families who were scheduled for day case surgery.

Treatment of Chryseobacterium indologenes ventilator-associated pneumonia in a critically ill trauma patient.

PubMed

Monteen, Megan R; Ponnapula, Supriya; Wood, G Christopher; Croce, Martin A; Swanson, Joseph M; Boucher, Bradley A; Fabian, Timothy C

2013-12-01

To report a case of Chryseobacterium indologenes ventilator-associated pneumonia (VAP) in a critically ill trauma patient. This report describes a 66-year-old critically ill trauma patient who developed VAP, which was caused by C indologenes. The patient was injured in a riding lawn mower accident that trapped him underwater in a pond. The patient required surgery for intra-abdominal injuries and was mechanically ventilated in the trauma intensive care unit. On hospital day 5, the patient developed signs and symptoms of VAP. A diagnosis of C indologenes VAP was confirmed based on a quantitative culture from a bronchoscopic bronchoalveolar lavage. The patient's infection was successfully treated with moxifloxacin for 2 days followed by cefepime for 7 days. Formally known as Flavobacterium indologenes, C indologenes is a Gram-negative bacillus normally found in plants, soil, foodstuffs, and fresh and marine water sources. Recently, worldwide reports of C indologenes infections in humans have been increasing, though reports from the United States are still rare. Bacteremia and pneumonia are the most commonly reported infections, and most patients are immunocompromised. The current case differs from most previous reports because this patient was in the United States and did not have any traditional immunocompromised states (eg, transplant, cancer, HIV/AIDS, or corticosteroid use). This case report demonstrates that C indologenes can cause VAP in a trauma ICU patient.

Effect of a perioperative, cardiac output-guided hemodynamic therapy algorithm on outcomes following major gastrointestinal surgery: a randomized clinical trial and systematic review.

PubMed

Pearse, Rupert M; Harrison, David A; MacDonald, Neil; Gillies, Michael A; Blunt, Mark; Ackland, Gareth; Grocott, Michael P W; Ahern, Aoife; Griggs, Kathryn; Scott, Rachael; Hinds, Charles; Rowan, Kathryn

2014-06-04

Small trials suggest that postoperative outcomes may be improved by the use of cardiac output monitoring to guide administration of intravenous fluid and inotropic drugs as part of a hemodynamic therapy algorithm. To evaluate the clinical effectiveness of a perioperative, cardiac output-guided hemodynamic therapy algorithm. OPTIMISE was a pragmatic, multicenter, randomized, observer-blinded trial of 734 high-risk patients aged 50 years or older undergoing major gastrointestinal surgery at 17 acute care hospitals in the United Kingdom. An updated systematic review and meta-analysis were also conducted including randomized trials published from 1966 to February 2014. Patients were randomly assigned to a cardiac output-guided hemodynamic therapy algorithm for intravenous fluid and inotrope (dopexamine) infusion during and 6 hours following surgery (n=368) or to usual care (n=366). The primary outcome was a composite of predefined 30-day moderate or major complications and mortality. Secondary outcomes were morbidity on day 7; infection, critical care-free days, and all-cause mortality at 30 days; all-cause mortality at 180 days; and length of hospital stay. Baseline patient characteristics, clinical care, and volumes of intravenous fluid were similar between groups. Care was nonadherent to the allocated treatment for less than 10% of patients in each group. The primary outcome occurred in 36.6% of intervention and 43.4% of usual care participants (relative risk [RR], 0.84 [95% CI, 0.71-1.01]; absolute risk reduction, 6.8% [95% CI, -0.3% to 13.9%]; P = .07). There was no significant difference between groups for any secondary outcomes. Five intervention patients (1.4%) experienced cardiovascular serious adverse events within 24 hours compared with none in the usual care group. Findings of the meta-analysis of 38 trials, including data from this study, suggest that the intervention is associated with fewer complications (intervention, 488/1548 [31.5%] vs control, 614/1476 [41.6%]; RR, 0.77 [95% CI, 0.71-0.83]) and a nonsignificant reduction in hospital, 28-day, or 30-day mortality (intervention, 159/3215 deaths [4.9%] vs control, 206/3160 deaths [6.5%]; RR, 0.82 [95% CI, 0.67-1.01]) and mortality at longest follow-up (intervention, 267/3215 deaths [8.3%] vs control, 327/3160 deaths [10.3%]; RR, 0.86 [95% CI, 0.74-1.00]). In a randomized trial of high-risk patients undergoing major gastrointestinal surgery, use of a cardiac output-guided hemodynamic therapy algorithm compared with usual care did not reduce a composite outcome of complications and 30-day mortality. However, inclusion of these data in an updated meta-analysis indicates that the intervention was associated with a reduction in complication rates. isrctn.org Identifier: ISRCTN04386758.

Capturing Plastic Surgery on Film-Making Reconstruction Visible.

PubMed

Lunger, Alexander; Ismail, Tarek; Sarraf, Namita; Epple, Christian; Schaefer, Kristin Marit; Schaefer, Dirk J

2017-09-01

The Swiss Plastic Surgery Association (https://plasticsurgery.ch/en/) decided to produce a corporate video to illustrate the concept of "plastic surgery of confidence" to the public. We show the diversity of specializations and the vast range of tasks that surgeons passionately handle day in and day out. We wanted to convey 2 main messages: first, that plastic surgery is more than just cosmetic surgery, and second, that plastic surgery in Switzerland is synonymous with quality and confidence. We selected 17 topics that we felt had good filmic potential and would best explain to the public what plastic surgery is about. This included the selection of appropriate patients, experts, and locations from all over the country. We thought it crucial to show the initial preoperative situation, as only in this case would the achievement of reconstruction be evident and comprehensive to the layman audience. The actual production was filmed in 5 different locations and took 5 days of shooting. We recorded 17 surgeons, 9 patients, and about 30 voluntary background actors. From 23 hours of footage, we created a 7 minute, 22 second corporate video, recorded in 3 of the Swiss national languages. The video was presented to the public online in June 2016, on the same day as the National Open Day of Plastic Surgery in Switzerland. The video is available online. We evaluated the impact of the video using a questionnaire for lay people and observed that it could substantially improve the perception of our specialty, especially regarding the reconstructive aspect. We feel that a freely available corporate video is a very useful means to promote plastic surgery and help patients better understand what it is all about.

Capturing Plastic Surgery on Film—Making Reconstruction Visible

PubMed Central

Ismail, Tarek; Sarraf, Namita; Epple, Christian; Schaefer, Kristin Marit; Schaefer, Dirk J.

2017-01-01

Summary: The Swiss Plastic Surgery Association (https://plasticsurgery.ch/en/) decided to produce a corporate video to illustrate the concept of "plastic surgery of confidence" to the public. We show the diversity of specializations and the vast range of tasks that surgeons passionately handle day in and day out. We wanted to convey 2 main messages: first, that plastic surgery is more than just cosmetic surgery, and second, that plastic surgery in Switzerland is synonymous with quality and confidence. We selected 17 topics that we felt had good filmic potential and would best explain to the public what plastic surgery is about. This included the selection of appropriate patients, experts, and locations from all over the country. We thought it crucial to show the initial preoperative situation, as only in this case would the achievement of reconstruction be evident and comprehensive to the layman audience. The actual production was filmed in 5 different locations and took 5 days of shooting. We recorded 17 surgeons, 9 patients, and about 30 voluntary background actors. From 23 hours of footage, we created a 7 minute, 22 second corporate video, recorded in 3 of the Swiss national languages. The video was presented to the public online in June 2016, on the same day as the National Open Day of Plastic Surgery in Switzerland. The video is available online. We evaluated the impact of the video using a questionnaire for lay people and observed that it could substantially improve the perception of our specialty, especially regarding the reconstructive aspect. We feel that a freely available corporate video is a very useful means to promote plastic surgery and help patients better understand what it is all about. PMID:29062635

Beta-blocker withdrawal among patients presenting for surgery from home

PubMed Central

Schonberger, Robert B.; Lukens, Carrie L.; Turkoglu, O. Dicle; Feinleib, Jessica L.; Haspel, Kenneth L.; Burg, Matthew M.

2012-01-01

Structured Abstract Objective This study sought to measure the incidence of perioperative beta-blocker non-compliance by patients who were prescribed chronic beta blocker therapy and presented for surgery from home. The effect of patient non-compliance on day of surgery presenting heart rate was also examined. Design Prospective observational study with outcome data obtained from review of the medical record. Setting The preoperative clinic and operating rooms of a Veterans Administration hospital. Participants Patients on chronic beta blocker therapy who presented from home for surgery. Interventions None. Measurements and Main Results Demographic and comorbidity data as well as data on self-reported compliance to beta-blocker therapy, initial day of surgery vital signs, and recent ambulatory vital signs were collected. Ten out of fifty subjects (20%; 95% CI = 9-31%) reported not taking their day of surgery beta-blocker. These self-reported non-adherers demonstrated a higher presenting heart rate on the day of surgery vs. adherent subjects (median of 78 beats per minute vs. 65 beats per minute, p=0.02 by Wilcoxon Rank-Sum Test). The difference-in-difference between baseline primary care and day of surgery heart rate was also statistically significant between compliant and non-compliant subjects (-7 beats per minute vs. +12.5 beats per minute, p<0.00001). Conclusions Patient self-report and physiologic data documented failure to take beta-blockers and possible beta-blocker withdrawal in 20% of patients who presented for surgery from home. If these findings are confirmed in larger studies, improved patient understanding of and compliance with medication instructions during preoperative visits should be a focus of future quality improvement initiatives. PMID:22418043

[Correlations of plasma concentrations of β-amyloid peptide and S-100β with postoperative cognitive dysfunction in patients undergoing oral and maxillofacial cancer surgery].

PubMed

Liang, Bing; Sun, Yuan-Qing; Jiang, Jue; Xu, Hui

2016-12-01

To evaluate the changes of perioperative plasma concentrations of Aβ 1-40 and S-100β to determine the relationship with postoperative cognitive dysfunction in elderly patients undergoing oral and maxillofacial cancer surgeries. One hundred and fifteen patients aged at least 60 years undergoing oral and maxillofacial tumor resection were investigated between May 2014 to December 2014.Neuropsychological tests for detecting postoperative cognitive dysfunction(POCD) were performed one day before surgery and 7 days postoperatively. According to the results of neuropsychological tests on day 7, patients were divided into POCD group and non-POCD group.Plasma values of Aβ 1-40 and S-100β were determined with enzyme linked immunosorbent assay (ELISA) before anesthesia induction, 24 h and 7 days after surgery. The data were analyzed using SPSS 19.0 software package. According to the definition, POCD was present in 37 of 115 (32.3%) patients 1 week after surgery. Compared with pre-anesthesia, S-100β levels in POCD group were significantly increased (P<0.05); the level of Aβ 1-40 was significantly higher 24 h after surgery (P<0.05). Compared with non-POCD group, S-100β levels were significantly increased 24 h postoperatively (P<0.05); Aβ1-40 levels were significantly higher 24 h and 7 days postoperatively (P<0.05). POCD was present in 32.2% of patients on day 7 after oral and maxillofacial surgeries with general anesthesia. The increasing levels of Aβ 1-40 , S-100β may be associated with the occurence of POCD. Patients with long-lasting operation and high concentrations of Aβ 1-40 and S-100β after surgeries were at a higher risk of POCD. The clinical values of Aβ 1-40 and S-100 as predictive measurements of POCD after oral and maxillofacial cancer surgery appear to be reasonable.

Accelerated recovery after cardiac operations.

PubMed

Kaplan, Mehmet; Kut, Mustafa Sinan; Yurtseven, Nurgul; Cimen, Serdar; Demirtas, Mahmut Murat

2002-01-01

The accelerated-recovery approach, involving early extubation, early mobility, decreased duration of intensive care unit stay, and decreased duration of hospitalization has recently become a controversial issue in cardiac surgery. We investigated timing of extubation, length of intensive care unit stay, and duration of hospitalization in 225 consecutive cardiac surgery patients. Of the 225 patients, 139 were male and 86 were female; average age was 49.73 +/- 16.95 years. Coronary artery bypass grafting was performed in 127 patients; 65 patients underwent aortic and/or mitral or pulmonary valvular operations; 5 patients underwent valvular plus coronary artery operations; and in 28 patients surgical interventions for congenital anomalies were carried out. The accelerated-recovery approach could be applied in 169 of the 225 cases (75.11%). Accelerated-recovery patients were extubated after an average of 3.97 +/- 1.59 hours, and the average duration of stay in the intensive care unit was 20.93 +/- 2.44 hours for these patients. Patients were discharged if they met all of the following criteria: hemodynamic stability, cooperativeness, ability to initiate walking exercises within wards, lack of pathology in laboratory investigations, and psychological readiness for discharge. Mean duration of hospitalization for accelerated-recovery patients was 4.24 +/- 0.75 days. Two patients (1.18%) who were extubated within the first 6 hours required reintubation. Four patients (2.36%) who were sent to the wards returned to intensive care unit due to various reasons and 6 (3.55%) of the discharged patients were rehospitalized. Approaches for decreasing duration of intubation, intensive care unit stay and hospitalization may be applied in elective and uncomplicated cardiac surgical interventions with short duration of aortic cross-clamping and cardiopulmonary bypass, without risking patients. Frequencies of reintubation, return to intensive care unit, and rehospitalization are quite low with this approach.

Sedative and analgesic use on night and day shifts in a pediatric cardiovascular intensive care unit.

PubMed

Staveski, Sandra L; Tesoro, Tiffany M; Cisco, Michael J; Roth, Stephen J; Shin, Andrew Y

2014-01-01

The use of sedative and analgesic medications is directly linked to patient outcomes. The practice of administering as-needed sedative or analgesic medications deserves further exploration. We hypothesized that important variations exist in the practice of administering as-needed medications in the intensive care unit (ICU). We aimed to determine the influence of time of day on the practice of administering as-needed sedative or analgesic medications to children in the ICU. Medication administration records of patients admitted to our pediatric cardiovascular ICU during a 4-month period were reviewed to determine the frequency and timing of as-needed medication usage by shift. A total of 152 ICU admissions (1854 patient days) were reviewed. A significantly greater number of as-needed doses were administered during the night shift (fentanyl, P = .005; lorazepam, P = .03; midazolam, P = .0003; diphenhydramine, P = .0003; and chloral hydrate, P = .0006). These differences remained statistically significant after excluding doses given during the first 6 hours after cardiovascular surgery. Morphine administration was similar between shifts (P = .08). We identified a pattern of increased administration of as-needed sedative or analgesic medications during nights. Further research is needed to identify the underlying causes of this practice variation.

Oral nutrition or water loading before hip replacement surgery; a randomized clinical trial.

PubMed

Ljunggren, Stefan; Hahn, Robert G

2012-07-02

Surgery induces insulin resistance that might be alleviated by a nutritional drink given preoperatively. The authors hypothesized that some of the beneficial effects of the drink could be attributed to the volume component (approximately 1 L) rather than to the nutrients. Sixty patients scheduled for elective total hip replacement under spinal anesthesia were recruited to a clinical trial, and randomly allocated to preoperative fasting, to oral ingestion of tap water, or to oral ingestion of a carbohydrate drink. An intravenous glucose tolerance test calculated glucose clearance and insulin sensitivity on the day before surgery, in the postoperative ward, and on the day after surgery. Other parameters were stress (cortisol in plasma and urine), muscle catabolism (urinary 3-methylhistidine), and wellbeing. Fifty-seven patients completed the study. In the postoperative ward, the glucose clearance and the insulin response had decreased from the previous day by 23% and 36%, respectively. Insulin sensitivity did not decrease until the next morning (-48%) and was due to an increased insulin response (+51%). Cortisol excretion was highest on the day of surgery, while 3-methylhistidine increased 1 day later. Follow-up on the third postoperative day showed an average of 1.5 complications per patient. Wellbeing was better 2 weeks after than before the surgery. None of the measured parameters differed significantly between the study groups. Preoperative ingestion of tap water or a nutritional drink had no statistically significant effect on glucose clearance, insulin sensitivity, postoperative complications, or wellbeing in patients undergoing elective hip surgery.

Prediction of 30-day morbidity after primary cytoreductive surgery for advanced stage ovarian cancer.

PubMed

Gerestein, C G; Nieuwenhuyzen-de Boer, G M; Eijkemans, M J; Kooi, G S; Burger, C W

2010-01-01

Treatment in advanced stage epithelial ovarian cancer (EOC) is based on primary cytoreductive surgery followed by platinum-based chemotherapy. Successful cytoreduction to minimal residual tumour burden is the most important determinant of prognosis. However, extensive surgical procedures to achieve maximal debulking are inevitably associated with postoperative morbidity and mortality. The objective of this study is to determine predictors of 30-day morbidity after primary cytoreductive surgery for advanced stage EOC. All patients in the South Western part of the Netherlands who underwent primary cytoreductive surgery for advanced stage EOC between January 2004 and December 2007 were identified from the Rotterdam Cancer Registry database. All peri- and postoperative complications within 30 days after surgery were registered and classified according to the definitions of the National Surgical Quality Improvement Programme (NSQIP). To investigate independent predictors of 30-day morbidity, a Cox proportional hazards model with backward stepwise elimination was utilised. The identified predictors were entered into a nomogram. Two hundred and ninety-three patients entered the study protocol. Optimal cytoreduction was achieved in 136 (46%) patients. 30-day morbidity was seen in 99 (34%) patients. Postoperative morbidity could be predicted by age (P=0.007; odds ratio [OR] 1.034), WHO performance status (P=0.046; OR 1.757), extent of surgery (P=0.1308; OR=2.101), and operative time (P=0.017; OR 1.007) with an optimism corrected c-statistic of 0.68. 30-day morbidity could be predicted by age, WHO performance status, operative time and extent of surgery. The generated nomogram could be valuable for predicting operative risk in the individual patient.

Parecoxib Provides Analgesic and Opioid-Sparing Effects Following Major Orthopedic Surgery: A Subset Analysis of a Randomized, Placebo-Controlled Clinical Trial.

PubMed

Diaz-Borjon, Efrain; Torres-Gomez, Armando; Essex, Margaret Noyes; Salomon, Patricia; Li, Chunming; Cheung, Raymond; Parsons, Bruce

2017-06-01

Orthopedic surgeries are among the most common and most painful surgeries performed. A multimodal analgesic approach is recommended to reduce opioid consumption, provide effective pain relief, and improve outcomes following surgery. This study examined the efficacy and opioid-sparing effects of parecoxib following major orthopedic surgery. This subset analysis of a large, multicenter, randomized, double-blind, placebo-controlled study of parecoxib examined treatment effects on postoperative pain severity, pain interference with function, opioid consumption, occurrence of opioid-related symptoms, safety, and patient satisfaction following major orthopedic surgery. Pain scores were significantly lower in the parecoxib group (n = 142) compared with placebo (n = 139) on day 2 (-22%; p < 0.001) and day 3 (-17%; p = 0.004). Pain interference with function scores were also significantly lower in the parecoxib group on day 2 (-32%; p < 0.001) and day 3 (-27%; p = 0.003) relative to placebo. Additionally, significantly less supplemental morphine was required in the parecoxib group relative to placebo through 24 h (-28%; p = 0.008) and 48 h (-33%; p < 0.001). Patients in the parecoxib group had a reduced risk of experiencing opioid-related symptoms including fatigue, drowsiness, inability to concentrate, confusion, nausea, constipation, and confusion on day 2 and/or day 3. Finally, more patients receiving parecoxib (42%) rated treatment as "excellent" compared to those receiving placebo (21%). These findings support the use of parecoxib for the management of pain following major orthopedic surgery.

Initial Treatment for Newly Diagnosed Elderly Colorectal Cancer Patients: Patterns of Care in Italy and the United States

PubMed Central

2013-01-01

Cancer is a major component of health-care expenditures in most developed countries. The costs of cancer care are expected to increase due to rising incidence (as the population ages) and increasing use of targeted anticancer therapies. However, epidemiological analysis of patterns of care may be required prior to empirically well-grounded cost analyses. Additionally, comparisons of care between health-care delivery systems and countries can identify opportunities to improve practice. They can also increase understanding of patient outcomes and economic consequences of differences in policies related to cancer screening, treatment, and programs of care. In this study, we compared patterns of colorectal cancer treatment during the first year following diagnosis in two cohorts of elderly patients from some areas of Italy and the United States using cancer registry linked to administrative data. We evaluated hospital use, initial treatments (surgery, chemotherapy, and radiation), and timeliness of surgery and adjuvant therapy, taking into account patient characteristics and clinical features, such as stage at diagnosis and the cancer subsite. We observed greater use of adjuvant chemotherapy in stage III and IV colon cancer patients and adjuvant therapy in all stages of rectal cancer patients in the US cohort. We found a higher rate of open surgeries in the Italian cohort, a similar rate of hospitalization, but a higher number of hospital days in the Italian cohort. However, in spite of structural differences between the United States and Italy in health-care organization and delivery as well as in data collection, patterns of care and the timing of care in the year after diagnosis are generally similar among patients within stage of disease at diagnosis. Comparative studies of the costs associated with patterns of cancer care will be important for future research. PMID:23962512

Minimally invasive direct coronary artery bypass versus off-pump coronary surgery through sternotomy

PubMed Central

Birla, R; Patel, P; Aresu, G

2013-01-01

Introduction Although it is not a new technique, minimally invasive direct coronary artery bypass (MIDCAB) is employed only by a few surgeons in the UK. We compared our experience with MIDCAB with that of single vessel off-pump coronary artery bypass (OPCAB) graft surgery through a standard median sternotomy. Methods Patients who underwent either MIDCAB or OPCAB between April 2008 and July 2011 were reviewed. Exclusion criteria included patients with an ejection fraction of <0.5 or previous cardiac surgery. Data were obtained retrospectively from our prospective database, medical records and through general practitioners. Results Overall, 74 patients were analysed in the MIDCAB group and 78 in the OPCAB group. Their demographics and EuroSCORE (European System for Cardiac Operative Risk Evaluation) values were comparable (p>0.05). There was no statistically significant difference in the two groups in terms of mortality, recurrent myocardial infarction, postoperative stroke, wound infection, atrial fibrillation or need for reintervention. The MIDCAB group had six conversions to a sternotomy. Eight patients in each group required blood transfusion, with the average transfusion being 1.8 units in the MIDCAB group and 3.2 units in the OPCAB group. The mean duration of ventilation and intensive care unit stay was 5.0 hours and 38.4 hours in the MIDCAB group and 5.4 and 47.8 hours in the OPCAB group. The mean hospital stay was significantly reduced in the MIDCAB population (6.1 vs 8.5 days, p<0.05). Conclusions MIDCAB can be performed safely in appropriately selected patients with outcomes comparable with OPCAB. The potential benefits include shorter hospital stay, reduced need for blood transfusion and faster recovery. PMID:24112493

[Analysis of economic viability of a mobile eye clinic of a referral Ophthalmology Service].

PubMed

Lima, Luiz Henrique Soares Gonçalves de; Sousa, Luciene Barbosa de

2005-01-01

To analyse the economic viability of a mobile eye clinic of a tertiary referral Ophthalmology Service. The amount of money spent with the purchase and construction of the unit in 2000, and the expenses with its maintenance and operation in 2001 were considered, comparing these expenses with the income obtained from appointments, supplementary tests and eye surgeries through the "Sistema Unico de Saúde" (a health care service provided by the government), in 2001. In order to make an economic analysis, an interest rate of 10% per year and a period of depreciation of 10 years were stipulated. The total amount spent to buy and set up a mobile unit of "Hospital Oftamológico de Sorocaba" was R$ 184,140,00. The amount spent with its maintenance and operation during 2001 was R$ 28,000.00. The unit was used on average during 2 days each week in 2001 and 6492 appointments were made in this period, generating an income of R$ 32,460.00. The appointments generated complementary tests and eye surgeries making up R$ 51,540.00. Therefore, the total amount received directly with the appointments, complementary tests and eye surgeries during 2001 was R$ 84,000.00 paid by the "Sistema Unico de Saúde", according to values established beforehand. Using these values it is possible to make an economic analysis of this enterprise and this was done with and without money savings for depreciation, taking into account the income and the expenses. Besides attending poor communities that are located in distant neighborhoods, a mobile eye clinic can be a source of income for ophthalmologic services.

Predictors of stroke associated with coronary artery bypass grafting in patients with diabetes mellitus and multivessel coronary artery disease.

PubMed

Domanski, Michael J; Farkouh, Michael E; Zak, Victor; Feske, Steven; Easton, Donald; Weinberger, Jesse; Hamon, Martial; Escobedo, Jorge; Shrader, Peter; Siami, Flora S; Fuster, Valentin

2015-05-15

This study assesses demographic and clinical variables associated with perioperative and late stroke in diabetes mellitus patients after multivessel coronary artery bypass grafting (CABG). Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) is the largest randomized trial of diabetic patients undergoing multivessel CABG. FREEDOM patients had improved survival free of death, myocardial infarction, or stroke and increased overall survival after CABG compared to percutaneous intervention. However, the stroke rate was greater following CABG than percutaneous intervention. We studied predictors of stroke in CABG-treated patients analyzing separately overall, perioperative (≤30 days after surgery), and late (>30 days after surgery) stroke. For long-term outcomes (overall stroke and late stroke), Cox proportional hazards regression was used, accounting for time to event, and logistic regression was used for perioperative stroke. Independent perioperative stroke predictors were previous stroke (odds ratio [OR] 6.96, 95% confidence interval [CI] 1.43 to 33.96; p = 0.02), warfarin use (OR 10.26, 95% CI 1.10 to 96.03; p = 0.02), and surgery outside the United States or Canada (OR 9.81, 95% CI 1.28 to 75.40; p = 0.03). Independent late stroke predictors: renal insufficiency (hazard ratio [HR] 3.57, 95% CI 1.01 to 12.64; p = 0.048), baseline low-density lipoprotein ≥105 mg/dl (HR 3.28, 95% CI 1.19 to 9.02; p = 0.02), and baseline diastolic blood pressure (each 1 mm Hg increase reduces stroke hazard by 5%; HR 0.95, 95% CI 0.91 to 0.99; p = 0.03). There was no overlap between predictors of perioperative versus late stroke. In conclusion, late post-CABG strokes were associated with well-described risk factors. Nearly half of the strokes were perioperative. Independent risk factors for perioperative stroke: previous stroke, previous warfarin use, and CABG performed outside the United States or Canada. Copyright © 2015 Elsevier Inc. All rights reserved.

Peri-operative management of high-risk paediatric adenotonsillectomy patients: A survey of 35 UK tertiary referral centres.

PubMed

Cheong, Ryan Chin Taw; Bowles, Philippe; Moore, Andrew; Watts, Simon

2017-05-01

Peri-operative management of high-risk paediatric patients undergoing adenotonsillectomy for treatment of obstructive sleep apnoea varies between tertiary referral hospitals. 'Day of surgery cancellation' (DoSC) rates of up to 11% have been reported due to pre-booked critical care being unavailable on the day of surgery as a result of competing needs from other hospital departments. We report the results of a survey of peri-operative management in UK tertiary care centres of high-risk paediatric patients undergoing adenotonsillectomy for obstructive sleep apnoea (OSA). An 8-point questionnaire was developed using a cloud-based software platform (www.surveymonkey.com). A web-link to the survey was embedded in a customised e-mail which was sent via secure server to the Clinical Leads for Paediatric Otolaryngology at 35 United Kingdom (UK) Tertiary referral centres. The survey response rate was 60% (n = 21). Almost all (94.1%) of centres considered paediatric critical care facilities to be limited, with 70.6% (n = 12) stating that DoSC often occurred due to unavailable paediatric critical care capacity. There was variation between tertiary referral units in the practice applied for pre-booking critical care beds (our survey identifies 6 variations) (Table 1). The most frequent selection method reported (47.1%) was at the discretion of the booking clinician at the time of listing the patient for surgery. In the context of limited critical care resources, variation in practice and difficulty in accurately predicting which patients will require post-operative critical care beds, a review and consensus on best practice in the peri-operative management of high risk paediatric adenotonsillectomy patients may offer a safe means of reducing cancellations and improving patient care, resource allocation and hospital efficiency. Copyright © 2017 Elsevier B.V. All rights reserved.

Efficacy and safety of tranexamic acid versus ϵ-aminocaproic acid in cardiovascular surgery.

PubMed

Falana, Olabisi; Patel, Gourang

2014-12-01

Blood conservation is a major concern in the management of surgical patients because of transfusion-related complications, limited supply, and health care costs. Tranexamic acid (TXA) and ϵ-aminocaproic acid (ϵACA) are lysine analogue antifibrinolytics used to reduce surgical bleeding and transfusions. To evaluate the efficacy and safety of TXA compared with ϵACA in the management of cardiovascular surgical bleeding at an academic medical center. This single-center, retrospective, observational cohort study included 120 patients undergoing cardiovascular surgery with or without cardiopulmonary bypass, who received at least 1 dose of perioperative TXA or ϵACA. The efficacy outcome-massive perioperative bleeding-was a composite end point of chest tube drainage >1500 mL in any 8-hour period after surgery, perioperative transfusion of 10 or more units of packed red blood cells, reoperation for bleeding, or death from hemorrhage within 30 days. The safety outcomes were incidence of thromboembolic events, postoperative renal dysfunction, seizure, and 30-day all-cause mortality. The primary end point-massive perioperative bleeding-occurred in 10 patients (16.7%) in the TXA group compared with 5 patients (8.3%) in the ϵACA group (P = 0.17). There were no significant differences in the secondary end points of 30-day all-cause mortality, thromboembolic events, renal dysfunction, and seizure. There were no differences in the efficacy and safety outcomes between TXA and ϵACA in the management of cardiovascular surgical bleeding at our institution. Considering the substantial cost difference and comparable efficacy and safety, ϵACA may have better value over TXA for reducing cardiovascular surgical bleeding. © The Author(s) 2014.

Antibiotics in third molar extraction; are they really necessary: A non-inferiority randomized controlled trial

PubMed Central

Arora, Ankit; Roychoudhury, Ajoy; Bhutia, Ongkila; Pandey, Sandeep; Singh, Surender; Das, Bimal K.

2014-01-01

Introduction: Antibiotic resistance is now a serious problem, although it was not so only a few years ago. The need of the hour is to give clear evidence of the efficacy of antibiotic use, or lack thereof, to the surgeon for a procedure as common as mandibular third molar surgery. Aim: This study aimed to evaluate whether postoperative combined amoxicillin and clavulanic acid in mandibular third molar extraction is effective in preventing inflammatory complications. Study and Design: The study was structured as a prospective randomized double-blind placebo-controlled clinical trial. Materials and Methods: A study was designed wherein the 96 units (two bilaterally similar impacted mandibular third molars per head in 48 patients) were randomly assigned to two treatment groups (Group I and Group II). Each patient served as his/her own control. Each patient received 625 mg of combined amoxicillin and clavulanic acid 1 h before surgery. In the case of third molars belonging to Group I, 625 mg of combined amoxicillin and clavulanic acid TDS was continued for 3 days; in Group II, placebo in similar-looking packs was continued for 3 days. The patients were evaluated on the third and seventh postoperative days for signs of clinical infection and for microbial load evaluation. Statistical Analysis: The data between the two groups were statistically analyzed by the two-tailed Fisher's exact test, with a 95% confidence interval. Results: The difference was not statistically significant between the test group and the control group with regard to erythema, dehiscence, swelling, pain, trismus, and infection based on microbial load. The data were statistically significant for alveolar osteitis, with the occurrence of alveolar osteitis (14.58%) in the placebo group. Conclusion: Postoperative antibiotics are recommended only for patients undergoing contaminated, long-duration surgery. PMID:25937728

Resource use and costs associated with opioid-induced constipation following total hip or total knee replacement surgery.

PubMed

Wittbrodt, Eric T; Gan, Tong J; Datto, Catherine; McLeskey, Charles; Sinha, Meenal

2018-01-01

Constipation is a well-known complication of surgery that can be exacerbated by opioid analgesics. This study evaluated resource utilization and costs associated with opioid-induced constipation (OIC). This retrospective, observational, and propensity-matched cohort study utilized the Premier Healthcare Database. The study included adults ≥18 years of age undergoing total hip or total knee replacement as inpatients who received an opioid analgesic and were discharged between January 1, 2012, and June 30, 2015. Diagnosis codes identified patients with OIC who were then matched 1:1 to patients without OIC. Generalized linear and logistic regression models were used to compare inpatient resource utilization, total hospital costs, inpatient mortality, and 30-day all-cause readmissions and emergency department visits. Of 788,448 eligible patients, 40,891 (5.2%) had OIC. Covariates were well balanced between matched patients with and without OIC (n=40,890 each). In adjusted analyses, patients with OIC had longer hospital lengths of stay (3.6 versus 3.3 days; p <0.001), higher total hospital costs (US$17,479 versus US$16,265; p <0.001), greater risk of intensive care unit admission (odds ratio [OR]=1.12, 95% CI: 1.01-1.24), and increased likelihood of 30-day hospital read-missions (OR=1.16, 95% CI: 1.11-1.22) and emergency department visits (OR=1.38, 95% CI: 1.07-1.79) than patients without OIC. No statistically significant difference was found with inpatient mortality (OR=0.89, 95% CI: 0.59-1.35). OIC was associated with greater resource utilization and hospital costs for patients undergoing primarily elective total hip or total knee replacement surgery. These results support OIC screening and management strategies as part of perioperative care management.

Application of the Single Use Negative Pressure Wound Therapy Device (PICO) on a Heterogeneous Group of Surgical and Traumatic Wounds

PubMed Central

Payne, Caroline; Edwards, Daren

2014-01-01

Objectives: Traumatic wounds and surgery inherently have their complications. Localized infections, wound dehiscence, and excessive wound leakage can be devastating to the patient with a prolonged recovery, but it is also costly to the hospital with an increased length of stay, extra workload, and dressing changes. The single use PICO (Smith and Nephew Healthcare, Hull, United Kingdom) negative pressure wound therapy (NPWT) dressing has revolutionized our management of various acute, chronic, and high output wounds. It requires fewer dressing changes than conventional practice, is used in the outpatient setting, and is a necessary adjuvant therapy to hasten wound healing. Aims: To observe the efficacy of the PICO vacuum-assisted healing within a cost improvement programme. Settings: Plastic surgery department, Royal London Hospital. Materials and Methods: Twenty-one patients with a diversity of postoperative or posttraumatic wounds were considered suitable for PICO application and treated totally on an outpatient basis once the PICO dressing was applied. All wounds were then subjected to continued PICO dressings until healed. Results: All patients tolerated the PICO well with no dressing failure or failure to comply. The number of dressings per patient ranged from 1 to 7. The cost per patient of treatment ranged from £120 to £1578. Estimated cost of all PICO dressing for 21 patients including plastic surgery dressing clinic appointments = £13,345. Median length of treatment to healing (days) = 16; standard deviation = 9.5. Eight patients would have had an inpatient bed stay with conventional therapy, total 24 bed days saved at Bartshealth @£325 per day. Conclusions: The outpatient application of a disposable NPWT can benefit a wide range of clinical wounds that optimizes patient care, promotes rapid wound healing, and importantly helps manage costs. PMID:24917894

Is laparoscopic sleeve gastrectomy safer than laparoscopic gastric bypass? a comparison of 30-day complications using the MBSAQIP data registry.

PubMed

Kumar, Sandhya B; Hamilton, Barbara C; Wood, Stephanie G; Rogers, Stanley J; Carter, Jonathan T; Lin, Matthew Y

2018-03-01

Laparoscopic sleeve gastrectomy (LSG) has become popular due to its technical ease and excellent short-term results. Understanding the risk profile of LSG compared with the gold standard laparoscopic Roux-en-Y gastric bypass (LRYGB) is critical for patient selection. To use traditional regression techniques and random forest classification algorithms to compare LSG with LRYGB using the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Data Registry. United States. Outcomes were leak, morbidity, and mortality within 30 days. Variable importance was assessed using random forest algorithms. Multivariate models were created in a training set and evaluated on the testing set with receiver operating characteristic curves. The adjusted odds of each outcome were compared. Of 134,142 patients, 93,062 (69%) underwent LSG and 41,080 (31%) underwent LRYGB. One hundred seventy-eight deaths occurred in 96 (.1%) of LSG patients compared with 82 (.2%) of LRYGB patients (P<.001). Morbidity occurred in 8% (5.8% in LSG versus 11.7% in LRYGB, P<.001). Leaks occurred in 1% (.8% in LSG versus 1.6% in LRYGB, P<.001). The most important predictors of all outcomes were body mass index, albumin, and age. In the adjusted multivariate models, LRYGB had higher odds of all complications (leak: odds ratio 2.10, P<.001; morbidity: odds ratio 2.02, P<.001; death: odds ratio 1.64, P<.01). In the Metabolic and Bariatric Surgery Accreditation and Quality Improvements data registry for 2015, LSG had half the risk-adjusted odds of death, serious morbidity, and leak in the first 30 days compared with LRYGB. Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.

Current practice of thoracic outlet decompression surgery in the United States.

PubMed

Rinehardt, Elena K; Scarborough, John E; Bennett, Kyla M

2017-09-01

Thoracic outlet syndrome (TOS) and its management are relatively controversial topics. Most of the literature reporting the outcomes of surgical decompression for TOS derives from single-center experiences. The objective of our study was to describe the current state of TOS surgery among hospitals that participate in the American College of Surgeons National Surgical Quality Improvement Program database. Our study sample consisted of patients from the 2005 to 2014 American College of Surgeons National Surgical Quality Improvement Program database who underwent first or cervical rib resection as their index procedure and whose constellation of diagnosis and procedure codes identified them as having neurogenic, arterial, or venous TOS. Patient and procedure characteristics were determined, as were the 30-day incidence of specific complications including nerve injury. Multimodel inference was used for multivariable analysis of the composite outcome of readmission or reoperation ≤30 days. We identified 1431 patients undergoing operation for TOS: 83% for neurogenic TOS, 3% for arterial TOS, and 12% for venous TOS. Vascular surgeons performed 90% of procedures. Only four patients (0.3%) demonstrated evidence of nerve injury. The rate of bleeding complication requiring transfusion was also quite low, at 1.4%. The 30-day incidence of readmission or reoperation, or both, in our study cohort was 8.6%. The risk of this outcome was increased in patients with a higher American Society of Anesthesiologists Physical Status Classification, those whose procedure was for non-neurogenic symptoms, and those whose procedure took longer to complete. The findings of our study will provide surgeons who advocate for the surgical management of TOS with reassurance that such intervention is associated with an extremely low risk of disability resulting from iatrogenic nerve injury and major bleeding events. Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Hydrogel sealant versus sutures to prevent fluid egress after cataract surgery.

PubMed

Masket, Samuel; Hovanesian, John A; Levenson, Jeffrey; Tyson, Farrell; Flynn, William; Endl, Michael; Majmudar, Parag A; Modi, Satish; Chu, Ralph; Raizman, Michael B; Lane, Stephen S; Kim, Terry

2014-12-01

To evaluate the effectiveness of a hydrogel sealant versus a suture in preventing fluid egress after wound leakage in cataract surgery. Twenty-four ophthalmic clinical practices in the United States. Prospective randomized parallel-arm controlled multicenter subject-masked study. Healthy patients having uneventful clear corneal incision (CCI) cataract surgery were eligible for the study. Spontaneous and provoked fluid egress from wounds was evaluated at the time of surgery using a calibrated force gauge. Eyes with leakage were randomized to receive a hydrogel sealant (Resure) or a nylon suture at the main incision site. Incision leakage was reevaluated 1, 3, 7, and 28 days postoperatively. Of 500 eyes, 488 had leakage at the time of cataract surgery. The leak was spontaneous in 244 cases (48.8%), and 488 (97.6%) of all incisions leaked with 1.0 ounce or less of applied force. After randomization, 12 (4.1%) of 295 eyes in the sealant group and 60 (34.1%) of 176 eyes in the suture group had wound leakage with provocation (P<.0001). The overall incidence of adverse ocular events was statistically significantly lower in the sealant group than in the suture group (P<.05). In this study, 97.6% of CCIs leaked after cataract surgery. The hydrogel sealant was safe and effective and better than a suture for the intraoperative management of CCIs with leakage as seen on Seidel testing and for the prevention of postoperative fluid egress. Copyright © 2014 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.

Early biomarkers of acute kidney failure after heart angiography or heart surgery in patients with acute coronary syndrome or acute heart failure.

PubMed

Torregrosa, Isidro; Montoliu, Carmina; Urios, Amparo; Elmlili, Nisrin; Puchades, María Jesús; Solís, Miguel Angel; Sanjuán, Rafael; Blasco, Maria Luisa; Ramos, Carmen; Tomás, Patricia; Ribes, José; Carratalá, Arturo; Juan, Isabel; Miguel, Alfonso

2012-01-01

Acute kidney injury (AKI) is a common complication in cardiac surgery and coronary angiography, which worsens patients' prognosis. The diagnosis is based on the increase in serum creatinine, which is delayed. It is necessary to identify and validate new biomarkers that allow for early and effective interventions. To assess the sensitivity and specificity of neutrophil gelatinase-associated lipocalin in urine (uNGAL), interleukin-18 (IL-18) in urine and cystatin C in serum for the early detection of AKI in patients with acute coronary syndrome or heart failure, and who underwent cardiac surgery or catheterization. The study included 135 patients admitted to the intensive care unit for acute coronary syndrome or heart failure due to coronary or valvular pathology and who underwent coronary angiography or cardiac bypass surgery or valvular replacement. The biomarkers were determined 12 hours after surgery and serum creatinine was monitored during the next six days for the diagnosis of AKI. The area under the ROC curve (AUC) for NGAL was 0.983, and for cystatin C and IL-18 the AUCs were 0.869 and 0.727, respectively. At a cut-off of 31.9 ng/ml for uNGAL the sensitivity was 100% and the specificity was 91%. uNGAL is an early marker of AKI in patients with acute coronary syndrome or heart failure and undergoing cardiac surgery and coronary angiography, with a higher predictive value than cystatin C or IL-18.

Day surgery and recovery in women with a suspicious breast lesion: evaluation of a psychoeducational nursing intervention.

PubMed

Allard, Nicole

2006-01-01

The study assessed whether a nursing intervention based on self-regulation theory, the Attentional Focus and Symptom Management Intervention (AFSMI), could help women who underwent day surgery for breast cancer to achieve better pain management and decreased emotional distress. The sample consisted of 117 patients with breast cancer who were outpatients and undergoing surgery as part of the initial treatment for their cancer. All subjects were interviewed at three different occasions. The subjects were randomized into the experimental group (n = 61) or the usual care group (control, n = 56). The subjects in the experimental group received the intervention in two sessions, 3-4 days and 10-11 days after surgery. The outcomes were the subjects' pain and emotional distress. Results showed significant differences between the experimental and control group at post-test on home management, total mood disturbance, confusion and tension scores implying that the intervention was effective in achieving these outcomes. Clinical significance has illustrated that a nursing intervention applied during immediate recovery of breast cancer surgery is quite clinically relevant to reduce emotional distress. Self-regulation theory could effectively be used as a guide in developing nursing intervention programs in practice for patients with cancer undergoing day surgery as a primary treatment.

Analgesic Effects of Tramadol, Tramadol–Gabapentin, and Buprenorphine in an Incisional Model of Pain in Rats (Rattus norvegicus)

PubMed Central

McKeon, Gabriel P; Pacharinsak, Cholawat; Long, Charles T; Howard, Antwain M; Jampachaisri, Katechan; Yeomans, David C; Felt, Stephen A

2011-01-01

Postoperative pain management in laboratory animals relies heavily on a limited number of drug classes, such as opioids and nonsteroidal antiinflammatory drugs. Here we evaluated the effects of saline, tramadol, tramadol with gabapentin, and buprenorphine (n = 6 per group) in a rat model of incisional pain by examining thermal hyperalgesia and weight-bearing daily for 6 d after surgery. All drugs were administered preemptively and continued for 2 consecutive days after surgery. Rats treated with saline or with tramadol only showed thermal hyperalgesia on days 1 through 4 and 1 through 3 after surgery, respectively. In contrast, buprenorphine-treated rats showed no thermal hyperalgesia on days 1 and 2 after surgery, and rats given tramadol with gabapentin showed reduced thermal hyperalgesia on days 2 and 4. For tests of weight-bearing, rats treated with saline or with tramadol only showed significantly less ipsilateral weight-bearing on day 1 after surgery, whereas rats given either buprenorphine or tramadol with gabapentin showed no significant change in ipsilateral weight-bearing after surgery. These data suggest that tramadol alone provides insufficient analgesia in this model of incisional pain; buprenorphine and, to a lesser extent, tramadol with gabapentin provide relief of thermal hyperalgesia and normalize weight-bearing. PMID:21439212

"Does the Organization of Plastic Surgery Units into Independent Departments Affect Academic Productivity?"

PubMed

Loewenstein, Scott N; Duquette, Stephen; Valsangkar, Nakul; Avula, Umakanth; Lad, Neha; Socas, Juan; Flores, Roberto L; Sood, Rajiv; Koniaris, Leonidas G

2017-07-12

There is an increased push for plastic surgery units in the United States to become independent departments administered autonomously rather than as divisions of a multispecialty surgery department. The purpose of this research was to determine if there are any quantifiable differences in the academic performance of departments versus divisions. Using a list of the plastic surgery units affiliated with The American Council of Academic Plastic Surgeons (ACAPS), unit websites were queried for departmental status and to obtain a list of affiliated faculty. Academic productivity was then quantified using the SCOPUS database. National Institute of Health (NIH) funding was determined through the Research Portfolio Online Reporting Tools database. Plastic surgery departments were comparable to divisions in academic productivity, evidenced by a similar number of publications per faculty (38.9 versus 38.7; p=0.94), number of citations per faculty (692 versus 761; p=0.64), H-indices (9.9 versus 9.9; p=0.99), and NIH grants (3.25 versus 2.84; p=0.80), including RO1 grants (1.33 versus 0.84; p=0.53). There was a trend for departments to have a more equitable male to female ratio (2.8 versus 4.1; p=0.06), and departments trained a greater number of integrated plastic surgery residents (9.0 versus 5.28; p=0.03). This study demonstrates that the academic performance of independent plastic surgery departments is generally similar to divisions, but with nuanced distinctions.

Effect of vasoconstriction on pain after mandibular third molar surgery: A single-blind, randomized controlled trial.

PubMed

Martin, Wilhelmus J J M; Skorpil, Nynke E; Ashton-James, Claire E; Tuinzing, D Bram; Forouzanfar, Tymour

2016-01-01

Previous research has demonstrated the efficacy of using local compression to reduce postoperative pain after third molar surgery. It has been theorized that compression reduces pain intensity through vasoconstriction. The current research tests the veracity of this vasoconstriction hypothesis by testing the impact of local epinephrine (a local vasoconstrictor) versus a control on patients' pain ratings over 7 days following surgery. Fifty patients scheduled for mandibular third molar surgery were randomly assigned to receive one cartridge of Ultracaine DS Forte (the treatment group) or one cartridge of Ultracaine DS (the control group) after surgical removal of the third molar. Participants used the visual analog scale (VAS) to provide daily ratings of pain intensity for 7 days following surgery. In addition, on day 7, the perceived effectiveness of the pain treatment was measured with the global perceived effect (GPE) scale. A quality- of-life questionnaire was also completed. A repeated-measures ANOVA indicated that the treatment group perceived significantly less pain than the control group on days 2 to 7 following surgery. In addition, 77.8% of the treatment group perceived their pain treatment to be successful, while only 69.6% of the control group reported that their pain was reduced successfully by day 7. The results of this study provide an initial proof of concept that epinephrine may have an analgesic effect on the period following third molar surgery. Further research with larger sample sizes is needed to strengthen evidence for the clinical utility of offering localized epinephrine to patients following third molar surgery.

Effects of bariatric surgery on disability pension in Swedish obese subjects.

PubMed

Gripeteg, L; Lindroos, A K; Peltonen, M; Sjöström, L; Narbro, K

2012-03-01

Prospective controlled data on the long-term effects of bariatric surgery on disability pension are not available. This study prospectively compare disability pension in surgically and conventionally treated obese men and women. The Swedish obese subjects study started in 1987 and involved 2010 obese patients who had bariatric surgery and 2037 contemporaneously matched obese controls, who received conventional treatment. Outcomes of this report were: (i) incidence of disability pension from study inclusion to 31 December 2006 in all subjects, and, (ii) number of disability pension days over 10 years in a subgroup of individuals (N=2901) followed for at least 10 years where partial pensions were recalculated to full number of days per year. Objective information on granted disability pension was obtained from the Swedish Social Insurance Agency and disability pension follow-up rate was 99.9%. In men, the unadjusted incidence of disability pension did not differ between the surgery and control groups (N=156 in both groups). When adjusting for baseline confounders in men, a reduced risk of disability pension was suggested in the surgery group (hazard ratio 0.79, 95% confidence interval 0.62-1.00; P=0.05). Furthermore, the adjusted average number of disability pension days was lower in the surgery group, 609 versus 734 days (P=0.01). In women, bariatric surgery was not associated with significant effects on incidence or number of days of disability pension. Bariatric surgery may be associated with favourable effects on disability pension for up to 19 years in men whereas neither favourable nor unfavourable effects could be detected in women.

Surgical and Functional Outcomes Following Buried Penis Repair With Limited Panniculectomy and Split-thickness Skin Graft.

PubMed

Hampson, Lindsay A; Muncey, Wade; Chung, Paul H; Ma, C C; Friedrich, Jeffrey; Wessells, Hunter; Voelzke, Bryan B

2017-12-01

To report surgical and functional outcomes of buried penis surgery. Outcomes following buried penis surgery at the University of Washington were assessed from June 1, 2005 to June 1, 2016. Patient demographic and surgical data were abstracted from a retrospective chart review. All patients were attempted to be contacted by phone for long-term follow-up. Uni- and multivariate analysis was performed to evaluate for association with any complication. A total of 42 men underwent buried penis repair surgery (mean short-term follow-up 8.1 months). There was an overall 33% 90-day complication rate (21 events). In univariate analysis, body mass index (BMI; P = .02) and no history of gastric bypass (P = .03) were significant predictors of any complication. In multivariate analysis, only BMI remained significant (odds ratio 1.1 for each increase in unit of BMI, 95% confidence interval 1.01-1.27). Twenty-seven patients were reached for long-term follow-up (mean 39 months). Patients reported improvements in every functional domain that was assessed. Of the patients, 85% reported they would undergo buried penis surgery again, 74% that surgery led to a positive change in their lives, and 85% that the surgery had remained a long-term success. Surgical correction of buried penis with penile split-thickness skin graft and limited panniculectomy is well tolerated and results in functional, long-term improvements. BMI is associated with an increased likelihood of a complication following surgery. Copyright © 2017 Elsevier Inc. All rights reserved.

Same-Day Versus Next-Day Repair of Fovea-Threatening Primary Rhegmatogenous Retinal Detachments.

PubMed

Gorovoy, Ian R; Porco, Travis C; Bhisitkul, Robert B; de Juan, Eugene; Schwartz, Daniel M; Stewart, Jay M

2016-01-01

To evaluate the outcomes of same-day versus next-day repair of fovea-threatening rhegmatogenous retinal detachments (FT RRD). Retrospective, multi-surgeon observational case series. Operative reports and medical records were reviewed to evaluate a number of visual and anatomic outcomes, including presenting features, intraoperative complications, and postoperative results in the repair of primary FT RRD undergoing same-day versus next-day repair with scleral buckling, pars plana vitrectomy, or both procedures. A total of 96 consecutive patients (43 same-day, 45 next-day, and eight two days later) were compared. There was no statistically significant difference in visual outcomes between same-day and next-day repair at postoperative months 3 and 6 and at last follow-up (month 3 mean BCVA 20/30 same day; 20/32 next day; p = 0.82). Preoperative vision was strongly correlated with postoperative acuity. Effect of differences in length or type of visual symptoms, location of RRD, gender, or lens status on postoperative month 3 best-corrected visual acuity (BCVA) was not statistically significant. Overall, 85% of patients had a BCVA of 20/40 or better at postoperative month 3. Reoperation rate and intraoperative complications were not statistically different between the two groups. Re-attachment was achieved in all but one patient in both groups. Time in the operating room was longer for same-day surgery (2.98 ± 0.46 hours) compared to next-day surgery (2.54 ± 0.38 hours) (p < 0.001), which was statistically significant even when factoring in the type of surgery performed. However, one case did progress to a macula-off detachment in a superior RRD with breaks found in lattice degeneration. Next-day surgery provided equivalent visual outcomes. Emergent, same-day surgery has logistical and resource implications as it may be more expensive, may necessitate rescheduling of previously booked cases, and may limit preoperative examination by the surgeon and perioperative team.

Pain after pediatric otorhinolaryngologic surgery: a prospective multi-center trial.

PubMed

Guntinas-Lichius, Orlando; Volk, Gerd Fabian; Geissler, Katharina; Komann, Marcus; Meissner, Winfried

2014-07-01

The purpose of this study was to describe postoperative pain within the first day after pediatric otorhinolaryngologic surgery and to identify factors influencing postoperative pain. Using a prospective evaluation and a Web-based multi-center registry, children ≥4 years of age (n = 365) rated their pain using questionnaires of the project Quality Improvement in Postoperative Pain Treatment for Children including faces numeric rating scales (FNRS, 0-10) for the determination of patient's pain on ambulation and his/her maximal and minimal pain within 8 h after day case surgery or at the first postoperative day for inpatient cases. Additionally, functional interference and therapy-related side effects were assessed. Half of the children were 4 or 5 years of age. The predominant types of surgery were adenoidectomy and tonsillectomy ± ear ventilation tubes. Although analgesics were applied preoperatively, intraoperatively, in the recovery room and on ward, maximal pain within the first day after surgery reached 4.4 ± 3.3 (FNRS). Pain was highest after oral surgery, especially after tonsillectomy and nose surgery. 39% of the children reported pain interference with breathing (39%). The most frequent side effect was drowsiness (55%). Multivariate analysis revealed that maximal pain was independently associated with the non-standardized use of opioids in the recovery room, or use of non-opioid or opioids on ward. Analgesia and perioperative pain management in pediatric otorhinolaryngologic surgery seems to be highly variable. Tonsillectomy and nose surgery are very painful. After otorhinolaryngologic surgery many children seem to receive less analgesia than needed or ineffective analgesic drug regimes.

RAPP, a systematic e-assessment of postoperative recovery in patients undergoing day surgery: study protocol for a mixed-methods study design including a multicentre, two-group, parallel, single-blind randomised controlled trial and qualitative interview studies

PubMed Central

Dahlberg, K; Odencrants, S; Hagberg, L

2016-01-01

Introduction Day surgery is a well-established practice in many European countries, but only limited information is available regarding postoperative recovery at home though there is a current lack of a standard procedure regarding postoperative follow-up. Furthermore, there is also a need for improvement of modern technology in assessing patient-related outcomes such as mobile applications. This article describes the Recovery Assessment by Phone Points (RAPP) study protocol, a mixed-methods study to evaluate if a systematic e-assessment follow-up in patients undergoing day surgery is cost-effective and improves postoperative recovery, health and quality of life. Methods and analysis This study has a mixed-methods study design that includes a multicentre, two-group, parallel, single-blind randomised controlled trial and qualitative interview studies. 1000 patients >17 years of age who are undergoing day surgery will be randomly assigned to either e-assessed postoperative recovery follow-up daily in 14 days measured via smartphone app including the Swedish web-version of Quality of Recovery (SwQoR) or to standard care (ie, no follow-up). The primary aim is cost-effectiveness. Secondary aims are (A) to explore whether a systematic e-assessment follow-up after day surgery has a positive effect on postoperative recovery, health-related quality of life (QoL) and overall health; (B) to determine whether differences in postoperative recovery have an association with patient characteristic, type of surgery and anaesthesia; (C) to determine whether differences in health literacy have a substantial and distinct effect on postoperative recovery, health and QoL; and (D) to describe day surgery patient and staff experiences with a systematic e-assessment follow-up after day surgery. The primary aim will be measured at 2 weeks postoperatively and secondary outcomes (A–C) at 1 and 2 weeks and (D) at 1 and 4 months. Trial registration number NCT02492191; Pre-results. PMID:26769788

RAPP, a systematic e-assessment of postoperative recovery in patients undergoing day surgery: study protocol for a mixed-methods study design including a multicentre, two-group, parallel, single-blind randomised controlled trial and qualitative interview studies.

PubMed

Nilsson, U; Jaensson, M; Dahlberg, K; Odencrants, S; Grönlund, Å; Hagberg, L; Eriksson, M

2016-01-13

Day surgery is a well-established practice in many European countries, but only limited information is available regarding postoperative recovery at home though there is a current lack of a standard procedure regarding postoperative follow-up. Furthermore, there is also a need for improvement of modern technology in assessing patient-related outcomes such as mobile applications. This article describes the Recovery Assessment by Phone Points (RAPP) study protocol, a mixed-methods study to evaluate if a systematic e-assessment follow-up in patients undergoing day surgery is cost-effective and improves postoperative recovery, health and quality of life. This study has a mixed-methods study design that includes a multicentre, two-group, parallel, single-blind randomised controlled trial and qualitative interview studies. 1000 patients >17 years of age who are undergoing day surgery will be randomly assigned to either e-assessed postoperative recovery follow-up daily in 14 days measured via smartphone app including the Swedish web-version of Quality of Recovery (SwQoR) or to standard care (ie, no follow-up). The primary aim is cost-effectiveness. Secondary aims are (A) to explore whether a systematic e-assessment follow-up after day surgery has a positive effect on postoperative recovery, health-related quality of life (QoL) and overall health; (B) to determine whether differences in postoperative recovery have an association with patient characteristic, type of surgery and anaesthesia; (C) to determine whether differences in health literacy have a substantial and distinct effect on postoperative recovery, health and QoL; and (D) to describe day surgery patient and staff experiences with a systematic e-assessment follow-up after day surgery.The primary aim will be measured at 2 weeks postoperatively and secondary outcomes (A-C) at 1 and 2 weeks and (D) at 1 and 4 months. NCT02492191; Pre-results. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Robenacoxib versus meloxicam for the control of peri-operative pain and inflammation associated with orthopaedic surgery in cats: a randomised clinical trial.

PubMed

Speranza, Cindy; Schmid, Vincent; Giraudel, Jerome M; Seewald, Wolfgang; King, Jonathan N

2015-03-26

Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used in veterinary medicine. Robenacoxib is a NSAID with high selectivity for the cyclo-oxygenase-2 enzyme. In this study, the efficacy and safety of robenacoxib were evaluated in a prospective, randomised, active- and placebo-controlled masked clinical trial in 147 cats undergoing orthopaedic surgery. Cats were randomised into two treatment groups: Group 1, robenacoxib (2 mg/kg) administered via subcutaneous (s.c.) injection before surgery, followed by robenacoxib tablets (1-2.4 mg/kg) administered post-operatively for approximately 9 days (n = 101) and Group 2, meloxicam (0.3 mg/kg) administered s.c. before surgery, followed by placebo tablets administered post-operatively for approximately 9 days (n = 46). Cats were assessed using numerical rating scales (NRSs) by clinicians before surgery and at 3, 8, 22 and 28 hours after surgery and at the final visit (VF on approximately Day 10), and daily by their owners from Day 1 to the VF. The primary end point was the global investigator score which was the sum of clinician NRSs for posture, behaviour and pain on palpation/manipulation. The efficacy of the single robenacoxib injection, assessed during 3 to 22 hours, was statistically non-inferior to meloxicam, with a relative efficacy of 1.029 (95% confidence interval, 0.847-1.231). No significant differences were detected during the follow-up treatment with robenacoxib tablets for approximately 9 days compared with placebo via clinician assessments at 28 hours and the VF, or in owner assessments on Days 1-VF. There were no significant differences in frequencies of reported adverse events, clinical observations and haematology or clinical chemistry variables between the groups. Single s.c. injection of robenacoxib before surgery had non-inferior efficacy compared with meloxicam in controlling post-operative pain and inflammation in cats undergoing orthopaedic surgery. Follow-up treatment with oral robenacoxib tablets for approximately 9 days was well tolerated, but there were no differences in the efficacy scores after Day 1 compared with the group receiving meloxicam s.c. followed by placebo control.

The effect of autogenic training on salivary immunoglobulin A in surgical patients with breast cancer: a randomized pilot trial.

PubMed

Minowa, Chika; Koitabashi, Kikuyo

2014-11-01

Psychological stress among breast cancer patients can inhibit immune function and contribute to disease progression. We investigated the effects of autogenic training (AT), a relaxation method for reducing stress, on salivary immunoglobulin A (sIgA) in breast cancer surgery patients. Thirty patients scheduled to undergo breast cancer surgery were randomly assigned to an AT or control group (usual care). Patients in the AT group underwent training for 7 days after surgery. Salivary IgA and heart rate variability were assessed on the day before surgery, and on the third and seventh postoperative days. Levels of sIgA were significantly higher on the seventh postoperative day in the AT group (n = 7) compared to the control group (n = 7) (p = 0.049). These findings suggest that AT may improve immune function in breast surgery patients. Copyright © 2014 Elsevier Ltd. All rights reserved.

National Patterns of Care and Outcomes after Combined Modality Therapy for Stage IIIA Non-small Cell Lung Cancer

PubMed Central

Patel, Aalok P.; Crabtree, Traves D.; Bell, Jennifer M.; Guthrie, Tracey J.; Robinson, Clifford G.; Morgensztern, Daniel; Colditz, Graham A.; Kreisel, Daniel; Krupnick, A. Sasha; Bradley, Jeffrey D.; Patterson, G. Alexander; Meyers, Bryan F.; Puri, Varun

2014-01-01

Introduction The role of surgery in addition to chemotherapy and radiation for stage IIIA non-small cell lung cancer (NSCLC) remains controversial. Since there is limited data on the benefit from surgery in this setting, we evaluated the use of combined modality therapy nationally, and explored the outcomes with and without the addition of surgery. Methods Patient variables and treatment-related outcomes were abstracted for patients with clinical stage IIIA NSCLC from the National Cancer Database. Patients receiving chemotherapy and radiation (CR) were compared to those undergoing chemotherapy, radiation, and surgery in any sequence (CRS). Results Between 1998 and 2010, 61339 patients underwent combined modality treatment for clinical stage IIIA NSCLC. Of these, 51979 (84.7%) received CR while 9360 (15.3%) underwent CRS. Patients in the CRS group were younger, more likely females and Caucasians, had smaller tumors and lower Charlson comorbidity scores. The 30-day surgical mortality was 200/8993 (2.2%). The median overall survival favored the CRS group in both unmatched (32.4 months vs. 15.7 months, p<.001) and matched analysis based on patient characteristics (34.3 months vs. 18.4months, p<.001). Conclusion There is significant heterogeneity in the treatment of stage IIIA NSCLC in the United States. Patients selected for surgery in addition to chemoradiation therapy appear to have better long-term survival. PMID:24722151

Topical and low-dose intravenous tranexamic acid in cyanotic cardiac surgery.

PubMed

Patel, Jigar; Prajapati, Mrugesh; Patel, Hardik; Gandhi, Hemang; Deodhar, Shilpa; Pandya, Himani

2017-02-01

Background Coagulopathy is a major problem in surgery for cyanotic congenital heart disease. Tranexamic acid has been used both topically and systemically and plays a vital role in pediatric cardiac surgery by reducing blood loss and blood product requirement. We aimed to determine the anti-fibrinolytic effectiveness of low-dose systemic or topical tranexamic acid or a combination of both. Methods Seventy-five patients were divided in 3 groups of 25. Group A patients were given tranexamic acid 20 mg kg -1 intravenously after sternotomy and 20 mg kg -1 after heparin reversal. Group B patients were given tranexamic acid 50 mg kg -1 in 20 mL of saline intrapericardially before sternal closure, with the drain clamped for 20 min. Group C patients were given tranexamic acid 20 mg kg -1 intravenously after sternotomy and 50 mg kg -1 intrapericardially before sternal closure. A number of clinical variables were recorded in the first 3 postoperative days. Ventilator time, intensive care unit stay, and outcome were also recorded. Results Chest tube drainage and blood product requirements were lowest in group C. Blood urea and serum creatinine levels were higher in groups A and C ( p < 0.05). Intensive care unit stay and ventilator time were similar in all 3 groups. No patient died and none had a seizure or other neurological event or thromboembolic complication postoperatively. Conclusion The combination of low-dose intravenous and topical tranexamic acid reduces postoperative blood loss and blood product requirement without incurring neurological, renal or thromboembolic complications. We recommend the routine use of topical and low-dose systemic tranexamic acid in cyanotic pediatric cardiac surgery.

Aspirin responsiveness changes in obese patients following bariatric surgery.

PubMed

Norgard, Nicholas B; Monte, Scott V; Fernandez, Stanley F; Ma, Qing

2017-08-01

Bariatric surgery has emerged as a promising treatment option for weight loss and to counter the metabolic consequences of obesity. Obesity has been linked to a hyperaggregable state, as well as a blunted response to aspirin. This pilot study assessed the hypothesis that bariatric surgery would lead to an improvement in aspirin-induced platelet inhibition and a reduction in platelet aggregability. Fifteen patients scheduled to undergo bariatric surgery were administered two 7-day courses of aspirin 81 mg: the first course administered before surgery and the second was 3 months following surgery. Platelet aggregation was measured before and after each aspirin course using VerifyNow-Aspirin. The primary endpoint was the change in on-treatment aspirin reactive units (ARU) pre- and postsurgery. Data from bariatric surgery study patients were compared to data of normal weighted subjects gathered in a previous study. Roux-en-Y gastric bypass was performed in 80%, and 20% underwent sleeve gastrectomy. The mean starting body mass index (BMI) was 46.9 kg/m 2 . Patients lost on average 24.5 kg, resulting in a postsurgical BMI of 38.5 kg/m 2 . Postbariatric surgery, off-treatment ARU was significantly reduced from presurgery levels (602±59 vs 531±78; P=.035). On-aspirin platelet reactivity was also significantly reduced following surgery (469±60 vs 432±143, P=.03). There was a significant correlation between the extent of weight loss and the degree of improvement in on-aspirin platelet reactivity (r 2 =.49, P=.024). Presurgery on-aspirin platelet reactivity was significantly higher in obese patients compared to normal weighted subjects (469±60 vs 419±52; P=.016) and reduced to the baseline after the surgery (432±63 vs 419±52; P=.54). Aspirin-induced platelet inhibition may be more potent following bariatric surgery. The mechanisms behind this improvement require further investigation. © 2017 John Wiley & Sons Ltd.

Positioning In Macular hole Surgery (PIMS): statistical analysis plan for a randomised controlled trial.

PubMed

Bell, Lauren; Hooper, Richard; Bunce, Catey; Pasu, Saruban; Bainbridge, James

2017-06-13

The treatment of idiopathic full-thickness macular holes involves surgery to close the hole. Some surgeons advise patients to adopt a face-down position to increase the likelihood of successful macular hole closure. However, patients often find the face-down positioning arduous. There is a lack of conclusive evidence that face-down positioning improves the outcome. The 'Positioning In Macular hole Surgery' (PIMS) trial will assess whether advice to position face-down after surgery improves the surgical success rate for the closure of large (≥400 μm) macular holes. The PIMS trial is a multicentre, parallel-group, superiority clinical trial with 1:1 randomisation. Patients (n = 192) with macular holes (≥400 μm) will be randomised after surgery to either face-down positioning or face-forward positioning for at least 8 h (which can be either consecutive or nonconsecutive) a day, for 5 days following surgery. Inclusion criteria are: presence of an idiopathic full-thickness macular hole ≥400 μm in diameter, as measured by optical coherence tomography (OCT) scans, on either or both eyes; patients electing to have surgery for a macular hole, with or without simultaneous phacoemulsification and intraocular lens implant; ability and willingness to position face-down or in an inactive face-forward position; a history of visual loss suggesting a macular hole of 12 months' or less duration. The primary outcome is successful macular hole closure at 3 months post surgery. The treatment effect will be reported as an odds ratio with 95% confidence interval, adjusted for size of macular hole and phakic lens status at baseline. Secondary outcome measures at 3 months are: further surgery for macular holes performed or planned (of those with unsuccessful closure); patient-reported experience of positioning; whether patients report they would still have elected to have the operation given what they know at follow-up; best-corrected visual acuity (BCVA) measured using Snellen charts at a standard distance of 6 m; patient-reported health and quality of life assessed using the National Eye Institute Visual Function Questionnaire (VFQ-25). The PIMS trial is the first multicentre randomised control trial to investigate the value of face-down positioning following macular hole standardised surgery. International Standard Randomised Controlled Trials Number registry, ID: ISRCTN12410596. Registered on 11 February 2015. United Kingdom Clinical Research Network, ID: UKCRN17966 . Registered on 26 November 2014.

Impact of medical tourism on cosmetic surgery in the United States.

PubMed

Franzblau, Lauren E; Chung, Kevin C

2013-10-01

Developing countries have been attracting more international patients by building state-of-the-art facilities and offering sought-after healthcare services at a fraction of the cost of the US healthcare system. These price differentials matter most for elective procedures, including cosmetic surgeries, which are paid for out of pocket. It is unclear how this rise in medical tourism will affect the practice of plastic surgery, which encompasses a uniquely large number of elective procedures. By examining trends in the globalization of the cosmetic surgery market, we can better understand the current situation and what plastic surgeons in the United States can expect. In this article, we explore both domestic and foreign factors that affect surgical tourism and the current state of this industry. We also discuss how it may affect the practice of cosmetic surgery within the United States.

Symptomatic pneumocephalus: A rare complication of discal herniation's surgery.

PubMed

Gader, Ghassen; Karmeni, Nadhir; Ben Saïd, Imed; Jemel, Hafedh

2018-05-23

Context We report the case of a 40-year-old woman with no pathological history, operated from an L4-L5 disc herniation by a left unilateral approach. The dura mater enveloping the left L5 root was accidentally injured at its lateral face causing a breach with CSF leakage. This breach could not be sutured. A few hours after waking, the patient presented an agitation followed by three generalized tonico-clonic seizures. Cerebral imaging revealed pneumocephalus. The patient was hospitalized in an intensive care unit. The symptoms gradually faded and the patient was discharged 3 days after surgery. Findings Pneumocephalus is defined by the presence of air inside the skull. The symptoms of pneumocephalus are generally non-specific and varied, and this complication should also be kept in mind to prevent potentially severe course. The prevention of postoperative pneumocephalus depends on a well-defined strategy in the case of iatrogenic dural tear. Conclusions Symptomatic pneumocephalus is a very rare complication in the course of lumbar surgery. Conservative therapy may be appropriate even in severe symptomatic manifestations.

Alexis Carrel (1873-1944): visionary vascular surgeon and pioneer in organ transplantation.

PubMed

Aida, Lai

2014-08-01

Alexis Carrel was a French surgeon in the 20th century. He made significant contributions to many advances in the fields of vascular surgery, cardiothoracic surgery and organ transplantation. He demonstrated that blood vessels can be united end-to-end and pioneered the triangulation suturing technique in vascular anastomosis. The methods he developed are still in use to this day. He insisted on the importance of absolute asepsis in vascular surgery when such practices were almost unheard of. He was also considered the father of solid organ transplantation. He was awarded the Nobel Prize in recognition of his work. Together with Charles Lindbergh, he developed the extracorporeal perfusion pump to keep organs alive outside the human body. His contribution to medicine also extended to tissue culture and wound management. He was one of the most controversial figures of his generation, believing in the idea of genetic superiority and eugenics and he was associated with fascism in the 1930s. © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

Loxoprofen sodium and celecoxib for postoperative pain in patients after spinal surgery: a randomized comparative study.

PubMed

Sekiguchi, Hiroyuki; Inoue, Gen; Nakazawa, Toshiyuki; Imura, Takayuki; Saito, Wataru; Uchida, Kentaro; Miyagi, Masayuki; Takahira, Naonobu; Takaso, Masashi

2015-07-01

Nonsteroidal anti-inflammatory drugs (NSAIDs) are often used to treat inflammation, pain, and fever, but no criterion standard exists for the management of postoperative pain following spinal surgery. In the present study, we compared the analgesic efficacy of loxoprofen sodium (loxoprofen) and celecoxib for the management of postoperative pain following spinal surgery. One-hundred forty-one patients (mean age 62.2 years) were randomly assigned to two groups before spinal surgery: a loxoprofen group (n = 73, 180 mg/day) and a celecoxib group (n = 68, 200 mg/day). The drugs were administered from 1 day until 7 days after surgery. A numeric rating scale (NRS) was used to evaluate pain at nine predefined times every day and the findings were compared between the two groups. Laboratory data and adverse events were also recorded. There was no significant difference in the maximum and mean NRS scores on each day between loxoprofen and celecoxib, suggesting a comparable analgesic effect for these two NSAIDs. Greater improvement in the NRS score between preadministration (baseline) and 30 min or 2 h after administration was obtained for loxoprofen. This tendency was shown for both slight (NRS score <5 at baseline) and severe pain (NRS score ≥ 5 at baseline). Loxoprofen was discontinued in one patient on day 4 because of renal dysfunction. Celecoxib was discontinued in one patient on day 2 at the patient's request. Both loxoprofen sodium and celecoxib were well tolerated for the relief of acute postoperative pain after spinal surgery. A single administration of loxoprofen showed superior and rapid effectiveness compared with celecoxib for both slight and severe postoperative pain.

Postoperative outcomes in patients with a do-not-resuscitate (DNR) order undergoing elective procedures.

PubMed

Brovman, Ethan Y; Walsh, Elisa C; Burton, Brittany N; Kuo, Christine E; Lindvall, Charlotta; Gabriel, Rodney A; Urman, Richard D

2018-05-18

Do-not-resuscitate (DNR) status has been shown to be an independent risk factor for mortality in the post-operative period. Patients with DNR orders often undergo elective surgeries to alleviate symptoms and improve quality of life, but there are limited data on outcomes for informed decision making. Retrospective cohort study. A multi-institutional setting including operating room, postoperative recovery area, inpatient wards, and the intensive care unit. A total of 566 patients with a DNR status and 316,431 patients without a DNR status undergoing elective procedures using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) from 2012. Patients undergoing elective surgical procedures. We analyzed the risk-adjusted 30-day morbidity and mortality outcomes for the matched DNR and non-DNR cohorts undergoing elective surgeries. DNR patients had significantly increased odds of 30-day mortality (OR 2.51 [1.55-4.05], p < 0.001) compared with non-DNR patients. In the DNR versus non-DNR cohort there was no significant difference in the occurrence of a number of 30-day complications, the rate of resuscitative measures undertaken, including cardiac arrest requiring CPR, reintubation, or return to the OR. The most common complications in both DNR and non-DNR patients undergoing elective procedures were transfusion, urinary tract infection, reoperation, and sepsis. Finally, the DNR patients had a significantly increased total length of hospital stay (7.65 ± 9.55 vs. 6.87 ± 9.21 days, p = 0.002). DNR patients, as compared with non-DNR patients, have increased post-operative mortality but not morbidity, which may arise from unmeasured severity of illness or transition to comfort care in accordance with a patient's wishes. The informed consent process for elective surgeries in this patient population should include a discussion of acceptable operative risk. Copyright © 2018 Elsevier Inc. All rights reserved.

Systematic review of preoperative physical activity and its impact on postcardiac surgical outcomes.

PubMed

Kehler, D Scott; Stammers, Andrew N; Tangri, Navdeep; Hiebert, Brett; Fransoo, Randy; Schultz, Annette S H; Macdonald, Kerry; Giacomontonio, Nicholas; Hassan, Ansar; Légaré, Jean-Francois; Arora, Rakesh C; Duhamel, Todd A

2017-08-11

The objective of this systematic review was to study the impact of preoperative physical activity levels on adult cardiac surgical patients' postoperative: (1) major adverse cardiac and cerebrovascular events (MACCEs), (2) adverse events within 30 days, (3) hospital length of stay (HLOS), (4) intensive care unit length of stay (ICU LOS), (5) activities of daily living (ADLs), (6) quality of life, (7) cardiac rehabilitation attendance and (8) physical activity behaviour. A systematic search of MEDLINE, Embase, AgeLine and Cochrane library for cohort studies was conducted. Eleven studies (n=5733 patients) met the inclusion criteria. Only self-reported physical activity tools were used. Few studies used multivariate analyses to compare active versus inactive patients prior to surgery. When comparing patients who were active versus inactive preoperatively, there were mixed findings for MACCE, 30 day adverse events, HLOS and ICU LOS. Of the studies that adjusted for confounding variables, five studies found a protective, independent association between physical activity and MACCE (n=1), 30-day postoperative events (n=2), HLOS (n=1) and ICU LOS (n=1), but two studies found no protective association for 30-day postoperative events (n=1) and postoperative ADLs (n=1). No studies investigated if activity status before surgery impacted quality of life or cardiac rehabilitation attendance postoperatively. Three studies found that active patients prior to surgery were more likely to be inactive postoperatively. Due to the mixed findings, the literature does not presently support that self-reported preoperative physical activity behaviour is associated with postoperative cardiac surgical outcomes. Future studies should objectively measure physical activity, clearly define outcomes and adjust for clinically relevant variables. Trial registration number NCT02219815. PROSPERO number CRD42015023606. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

National review of use of extracorporeal membrane oxygenation as respiratory support in thoracic surgery excluding lung transplantation.

PubMed

Rinieri, Philippe; Peillon, Christophe; Bessou, Jean-Paul; Veber, Benoît; Falcoz, Pierre-Emmanuel; Melki, Jean; Baste, Jean-Marc

2015-01-01

Extracorporeal membrane oxygenation (ECMO) for respiratory support is increasingly used in intensive care units (ICU), but rarely during thoracic surgical procedures outside the transplantation setting. ECMO can be an alternative to cardiopulmonary bypass for major trachea-bronchial surgery and single-lung procedures without in-field ventilation. Our aim was to evaluate the intraoperative use of ECMO as respiratory support in thoracic surgery: benefits, indications and complications. This was a multicentre retrospective study (questionnaire) of use of ECMO as respiratory support during the thoracic surgical procedure. Lung transplantation and lung resection for tumour invading the great vessels and/or the left atrium were excluded, because they concern respiratory and circulatory support. From March 2009 to September 2012, 17 of the 34 centres in France applied ECMO within veno-venous (VV) (n=20) or veno-arterial (VA) (n=16) indications in 36 patients. Ten VA ECMO were performed with peripheral cannulation and 6 with central cannulation; all VV ECMO were achieved through peripheral cannulation. Group 1 (total respiratory support) was composed of 28 patients without mechanical ventilation, involving 23 tracheo-bronchial and 5 single-lung procedures. Group 2 (partial respiratory support) was made up of 5 patients with respiratory insufficiency. Group 3 was made up of 3 patients who underwent thoracic surgery in a setting of acute respiratory distress syndrome (ARDS) with preoperative ECMO. Mortality at 30 days in Groups 1, 2 and 3 was 7, 40 and 67%, respectively (P<0.05). In Group 1, ECMO was weaned intraoperatively or within 24 h in 75% of patients. In Group 2, ECMO was weaned in ICU over several days. In Group 1, 2 patients with VA support were converted to VV support for chronic respiratory indications. Bleeding was the major complication with 17% of patients requiring return to theatre for haemostasis. There were two cannulation-related complications (6%). VV or VA ECMO is a satisfactory alternative to in-field ventilation in complex tracheo-bronchial surgery or in single-lung surgery. ECMO should be considered and used in precarious postoperative respiratory conditions. Full respiratory support can be achieved with VV ECMO. Indications for and results of ECMO during surgery in patients with ARDS warrant further careful investigation. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Management of Peritonitis After Minimally Invasive Colorectal Surgery: Can We Stick to Laparoscopy?

PubMed

Marano, Alessandra; Giuffrida, Maria Carmela; Giraudo, Giorgio; Pellegrino, Luca; Borghi, Felice

2017-04-01

Although laparoscopy is becoming the standard of care for the treatment of colorectal disease, its application in case of postoperative peritonitis is still not widespread. The objective of this article is to evaluate the role of laparoscopy in the management of postoperative peritonitis after elective minimally invasive colorectal resection for malignant and benign diseases. Between April 2010 and May 2016, 536 patients received primary minimally invasive colorectal surgery at our Department. Among this series, we carried out a retrospective study of those patients who, having developed signs of peritonitis, were treated with a laparoscopic reintervention. Patient demographics, type of complication and of the main relaparoscopic treatment, and main outcomes of reoperation were recorded. A total of 20 patients (3.7%) underwent relaparoscopy for the management of postoperative peritonitis, of which exact causes were detected by laparoscopy in 75% as follows: anastomotic leakage (n = 8, 40%), colonic ischemia (n = 2, 10%), iatrogenic bowel tear (n = 4, 20%), and other (n = 1, 5%). The median time between operations was 3.5 days (range, 2-8). The laparoscopic reintervention was tailored case by case and ranged from lavage and drainage to redo anastomosis with ostomy fashioning. Conversion rate was 10% and overall morbidity was 50%. No cases required additional surgery and 30-day mortality was nil. Three patients (15%) were admitted to intensive care unit for 24-hour surveillance. Our experience suggests that in experienced hands and in hemodynamically stable patients, a prompt laparoscopic reoperation appears as an accurate diagnostic tool and an effective and safe option for the treatment of postoperative peritonitis after primary colorectal minimally invasive surgery.

Assessment of tear osmolarity and other dry eye parameters in post-LASIK eyes.

PubMed

Hassan, Ziad; Szalai, Eszter; Berta, Andras; Modis, Laszlo; Nemeth, Gabor

2013-07-01

To assess the tear osmolarity using the TearLab device after laser in situ keratomileusis (LASIK) and to compare the values with those obtained by traditional tear film tests before and after the procedure. Thirty eyes of 15 refractive surgery candidates (5 men and 10 women of mean age: 30.55 ± 11.79 years) were examined. Using a special questionnaire (Ocular Surface Disease Index), subjective dry eye complaints were evaluated, and then, the tear osmolarity was measured with the TearLab system (TearLab Corporation) and conventional dry eye tests were carried out. Examinations were performed preoperatively and at 1, 30, and 60 days after the surgery. The mean value of tear osmolarity was 303.62 ± 12.29 mOsm/L before the surgery and 303.58 ± 20.14 mOsm/L at 60 days after the treatment (P = 0.69). Mean lid parallel conjunctival folds value was 0.68 ± 0.68 before the procedure and 0.58 ± 0.65 subsequent to surgery (P = 0.25). Meibomian gland dysfunction was not detected. No significant deviation was observed in the values of Schirmer test, corneal staining, tear break-up time, and lid parallel conjunctival folds when compared with postoperatively obtained values during the follow-up period (P > 0.05). During LASIK flap creation, intact corneal innervation is damaged, and the ocular surface lacrimal functional unit can be impaired. In our study, no abnormal dry eye test results were observed before or after the procedure. Based on our results, LASIK treatment is safe for dry eye involving the administration of adequate artificial tears for a minimum of 3 months.

Association Between State Medical Malpractice Environment and Surgical Quality and Cost in the United States.

PubMed

Bilimoria, Karl Y; Sohn, Min-Woong; Chung, Jeanette W; Minami, Christina A; Oh, Elissa H; Pavey, Emily S; Holl, Jane L; Black, Bernard S; Mello, Michelle M; Bentrem, David J

2016-06-01

The US medical malpractice system is designed to deter negligence and encourage quality of care through threat of liability. To examine whether state-level malpractice environment is associated with outcomes and costs of colorectal surgery. Observational study of 116,977 Medicare fee-for-service beneficiaries who underwent colorectal surgery using administrative claims data. State-level malpractice risk was measured using mean general surgery malpractice insurance premiums; paid claims per surgeon; state tort reforms; and a composite measure. Associations between malpractice environment and postoperative outcomes and price-standardized Medicare payments were estimated using hierarchical logistic regression and generalized linear models. thirty-day postoperative mortality; complications (pneumonia, myocardial infarction, venous thromboembolism, acute renal failure, surgical site infection, postoperative sepsis, any complication); readmission; total price-standardized Medicare payments for index hospitalization and 30-day postdischarge episode-of-care. Few associations between measures of state malpractice risk environment and outcomes were identified. However, analyses using the composite measure showed that patients treated in states with greatest malpractice risk were more likely than those in lowest risk states to experience any complication (OR: 1.31; 95% CI: 1.22-1.41), pneumonia (OR: 1.36; 95%: CI, 1.16-1.60), myocardial infarction (OR: 1.44; 95% CI: 1.22-1.70), venous thromboembolism (OR:2.11; 95% CI: 1.70-2.61), acute renal failure (OR: 1.34; 95% CI; 1.22-1.47), and sepsis (OR: 1.38; 95% CI: 1.24-1.53; all P < 0.001). There were no consistent associations between malpractice environment and Medicare payments. There were no consistent associations between state-level malpractice risk and higher quality of care or Medicare payments for colorectal surgery.

Paediatric mild head injury: is routine admission to a tertiary trauma hospital necessary?

PubMed

Tallapragada, Krishna; Peddada, Ratna Soundarya; Dexter, Mark

2018-03-01

Previous studies have shown that children with isolated linear skull fractures have excellent clinical outcomes and low risk of surgery. We wish to identify other injury patterns within the spectrum of paediatric mild head injury, which need only conservative management. Children with low risk of evolving neurosurgical lesions could be safely managed in primary hospitals. We retrospectively analysed all children with mild head injury (i.e. admission Glasgow coma score 13-15) and skull fracture or haematoma on a head computed tomography scan admitted to Westmead Children's Hospital, Sydney over the years 2009-2014. Data were collected regarding demographics, clinical findings, mechanism of injury, head computed tomography scan findings, neurosurgical intervention, outcome and length of admission. Wilcoxon paired test was used with P value <0.05 considered significant. Four hundred and ten children were analysed. Three hundred and eighty-one (93%) children were managed conservatively, 18 (4%) underwent evacuation of extradural haematoma (TBI surgery) and 11 (3%) needed fracture repair surgery. Two children evolved a surgical lesion 24 h post-admission. Only 17 of 214 children transferred from peripheral hospitals needed neurosurgery. Overall outcomes: zero deaths, one needed brain injury rehabilitation and 63 needed child protection unit intervention. Seventy-five percentage of children with non-surgical lesions were discharged within 2 days. Eighty-three percentage of road transfers were discharged within 3 days. Children with small intracranial haematomas and/or skull fractures who need no surgery only require brief inpatient symptomatic treatment and could be safely managed in primary hospitals. Improved tertiary hospital transfer guidelines with protocols to manage clinical deterioration could have cost benefit without risking patient safety. © 2017 Royal Australasian College of Surgeons.

Physiological exercise loading suppresses post-traumatic osteoarthritis progression via an increase in bone morphogenetic proteins expression in an experimental rat knee model.

PubMed

Iijima, H; Ito, A; Nagai, M; Tajino, J; Yamaguchi, S; Kiyan, W; Nakahata, A; Zhang, J; Wang, T; Aoyama, T; Nishitani, K; Kuroki, H

2017-06-01

To evaluate the dose-response relationship of exercise loading in the cartilage-subchondral bone (SB) unit in surgically-induced post-traumatic osteoarthritis (PTOA) of the knee. Destabilized medial meniscus (DMM) surgery was performed on the right knee of 12-week-old male Wistar rats, and sham surgery was performed on the contralateral knee. Four weeks after the surgery, the animals were subjected to moderate (12 m/min) or intense (21 m/min) treadmill exercises for 30 min/day, 5 days/week for 4 weeks. PTOA development in articular cartilage and SB was examined using histological and immunohistochemical analyses, micro-computed tomography (micro-CT) analysis, and biomechanical testing at 8 weeks after surgery. Gremlin-1 was injected to determine the role of bone morphogenetic protein (BMP) signaling on PTOA development following moderate exercise. Moderate exercise increased BMP-2, BMP-4, BMP-6, BMP receptor 2, pSmad-5, and inhibitor of DNA binding protein-1 expression in the superficial zone chondrocytes and suppressed cartilage degeneration, osteophyte growth, SB damage, and osteoclast-mediated SB resorption. However, intense exercise had little effect on BMP expression and even caused progression of these osteoarthritis (OA) changes. Gremlin-1 injection following moderate exercise caused progression of the PTOA development down to the level of the non-exercise DMM-operated knee. Exercise regulated cartilage-SB PTOA development in DMM-operated knees in a dose-dependent manner. Our findings shed light on the important role of BMP expression in superficial zone chondrocytes in attenuation of PTOA development following physiological exercise loading. Further studies to support a mechanism by which BMPs would be beneficial in preventing PTOA progression are warranted. Copyright © 2016 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.

Evaluation of the Effectiveness of a Surgical Checklist in Medicare Patients.

PubMed

Reames, Bradley N; Scally, Christopher P; Thumma, Jyothi R; Dimick, Justin B

2015-01-01

Surgical checklists are increasingly used to improve compliance with evidence-based processes in the perioperative period. Although enthusiasm exists for using checklists to improve outcomes, recent studies have questioned their effectiveness in large populations. We sought to examine the association of Keystone Surgery, a statewide implementation of an evidence-based checklist and Comprehensive Unit-based Safety Program, on surgical outcomes and health care costs. We performed a study using national Medicare claims data for patients undergoing general and vascular surgery (n=1,002,241) from 2006 to 2011. A difference-in-differences approach was used to evaluate whether implementation was associated with improved surgical outcomes and decreased costs when compared with a national cohort of nonparticipating hospitals. Propensity score matching was used to select 10 control hospitals for each participating hospital. Costs were assessed using price-standardized 30-day Medicare payments for acute hospitalizations, readmissions, and high-cost outliers. Keystone Surgery implementation in participating centers (N=95 hospitals) was not associated with improved outcomes. Difference-in-differences analysis accounting for trends in nonparticipating hospitals (N=950 hospitals) revealed no differences in adjusted rates of 30-day mortality [relative risk (RR)=1.03; 95% confidence intervals (CI), 0.97-1.10], any complication (RR=1.03; 95% CI, 0.99-1.07), reoperations (RR=0.89; 95% CI, 0.56-1.22), or readmissions (RR=1.01; 95% CI, 0.97-1.05). Medicare payments for the index admission increased following implementation ($516 average increase in payments; 95% CI, $210-$823 increase), as did readmission payments ($564 increase; 95% CI, $89-$1040 increase). High-outlier payments ($965 increase; 95% CI, $974decrease to $2904 increase) did not change. Implementation of Keystone Surgery in Michigan was not associated with improved outcomes or decreased costs in Medicare patients.

Patients' views of the consent process for adult cardiac surgery: questionnaire survey.

PubMed

Howlader, Mohammad H; Dhanji, Al-Rehan; Uppal, Rakesh; Magee, Patrick; Wood, Alan J; Anyanwu, Ani C

2004-12-01

Consent for surgical procedures has assumed increasing importance in surgical practice in recent days especially following the public inquiry into paediatric cardiac surgery deaths at Bristol in the UK. This study examines patient perceptions and recollections following surgical consent as currently practised in a UK cardiac unit. One hundred consecutive patients who underwent cardiac surgery in a London teaching hospital from January to February 2003 were studied. Patients completed questionnaires a day before their discharge from the hospital. The majority of patients (89/100) responded that the information given at consent had been adequate or more than adequate. The time spent on the consent process was thought to be adequate by 91 patients. Eleven patients felt the consent had been insensitive. Several patients (38/100) felt use of booklets in preference to verbal explanations would be less intimidating. For most patients (94/100) the operation and postoperative course met their expectations; although 12 patients experienced untold complications, only five felt that they should have been informed of the possibility of the complication. Although most patients were informed of the risk of death during consent, at time of discharge 43 had forgotten the figure that had been quoted. Regarding the influence of media and publicity, 19 patients said that media had influenced their expectations of the consent process, 59 would have liked to see hospital league tables while 26 would have liked to know the mortality figures for their surgeon prior to giving consent. Our study shows that patients undergoing cardiac surgery are largely satisfied with our improved consent procedures in the post-Bristol era. Use of booklets may be a useful adjunct to verbal consent as currently practised.

Successful linking of the Society of Thoracic Surgeons Database to Social Security data to examine the accuracy of Society of Thoracic Surgeons mortality data.

PubMed

Jacobs, Jeffrey P; O'Brien, Sean M; Shahian, David M; Edwards, Fred H; Badhwar, Vinay; Dokholyan, Rachel S; Sanchez, Juan A; Morales, David L; Prager, Richard L; Wright, Cameron D; Puskas, John D; Gammie, James S; Haan, Constance K; George, Kristopher M; Sheng, Shubin; Peterson, Eric D; Shewan, Cynthia M; Han, Jane M; Bongiorno, Phillip A; Yohe, Courtney; Williams, William G; Mayer, John E; Grover, Frederick L

2013-04-01

The Society of Thoracic Surgeons Adult Cardiac Surgery Database has been linked to the Social Security Death Master File to verify "life status" and evaluate long-term surgical outcomes. The objective of this study is explore practical applications of the linkage of the Society of Thoracic Surgeons Adult Cardiac Surgery Database to Social Securtiy Death Master File, including the use of the Social Securtiy Death Master File to examine the accuracy of the Society of Thoracic Surgeons 30-day mortality data. On January 1, 2008, the Society of Thoracic Surgeons Adult Cardiac Surgery Database began collecting Social Security numbers in its new version 2.61. This study includes all Society of Thoracic Surgeons Adult Cardiac Surgery Database records for operations with nonmissing Social Security numbers between January 1, 2008, and December 31, 2010, inclusive. To match records between the Society of Thoracic Surgeons Adult Cardiac Surgery Database and the Social Security Death Master File, we used a combined probabilistic and deterministic matching rule with reported high sensitivity and nearly perfect specificity. Between January 1, 2008, and December 31, 2010, the Society of Thoracic Surgeons Adult Cardiac Surgery Database collected data for 870,406 operations. Social Security numbers were available for 541,953 operations and unavailable for 328,453 operations. According to the Society of Thoracic Surgeons Adult Cardiac Surgery Database, the 30-day mortality rate was 17,757/541,953 = 3.3%. Linkage to the Social Security Death Master File identified 16,565 cases of suspected 30-day deaths (3.1%). Of these, 14,983 were recorded as 30-day deaths in the Society of Thoracic Surgeons database (relative sensitivity = 90.4%). Relative sensitivity was 98.8% (12,863/13,014) for suspected 30-day deaths occurring before discharge and 59.7% (2120/3551) for suspected 30-day deaths occurring after discharge. Linkage to the Social Security Death Master File confirms the accuracy of data describing "mortality within 30 days of surgery" in the Society of Thoracic Surgeons Adult Cardiac Surgery Database. The Society of Thoracic Surgeons and Social Security Death Master File link reveals that capture of 30-day deaths occurring before discharge is highly accurate, and that these in-hospital deaths represent the majority (79% [13,014/16,565]) of all 30-day deaths. Capture of the remaining 30-day deaths occurring after discharge is less complete and needs improvement. Efforts continue to encourage Society of Thoracic Surgeons Database participants to submit Social Security numbers to the Database, thereby enhancing accurate determination of 30-day life status. The Society of Thoracic Surgeons and Social Security Death Master File linkage can facilitate ongoing refinement of mortality reporting. Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Effect of a single acupuncture treatment on surgical wound healing in dogs: a randomized, single blinded, controlled pilot study

PubMed Central

2010-01-01

Background The aim of the study was to investigate the effect of acupuncture on wound healing after soft tissue or orthopaedic surgery in dogs. Methods 29 dogs were submitted to soft tissue and/or orthopaedic surgeries. Five dogs had two surgical wounds each, so there were totally 34 wounds in the study. All owners received instructions for post operative care as well as antibiotic and pain treatment. The dogs were randomly assigned to treatment or control groups. Treated dogs received one dry needle acupuncture treatment right after surgery and the control group received no such treatment. A veterinary surgeon that was blinded to the treatment, evaluated the wounds at three and seven days after surgery in regard to oedema (scale 0-3), scabs (yes/no), exudate (yes/no), hematoma (yes/no), dermatitis (yes/no), and aspect of the wound (dry/humid). Results There was no significant difference between the treatment and control groups in the variables evaluated three and seven days after surgery. However, oedema reduced significantly in the group treated with acupuncture at seven days compared to three days after surgery, possibly due the fact that there was more oedema in the treatment group at day three (although this difference was nor significant between groups). Conclusions The use of a single acupuncture treatment right after surgery in dogs did not appear to have any beneficial effects in surgical wound healing. PMID:20950467

Mobile gastrointestinal and endoscopic surgery in rural Ecuador: 20 years' experience of Cinterandes.

PubMed

Shalabi, H T; Price, M D; Shalabi, S T; Rodas, E B; Vicuña, A L; Guzhñay, B; Price, R R; Rodas, E

2017-12-01

Five billion people worldwide do not have timely access to surgical care. Cinterandes is one of the only mobile surgical units in low- and middle-income countries. This paper examines the methodology that Cinterandes uses to deliver mobile surgery. Founding and core staff were interviewed, four missions were participated in, and internal documents and records were analysed between 1 May and 1 July 2014. Cinterandes performed 7641 operations over the last 20 years (60% gastrointestinal/laparoscopic), travelling 300,000 km to remote areas of Ecuador. The mobile surgery programme was initiated by a local Ecuadorian surgeon in 1980. Funding was acquired from businesses, private hospitals, and individuals, to fund a low-cost surgical truck, simple equipment, and running costs. The mobile surgical unit is a 24-foot modified Isuzu truck containing a preparation room with general equipment storage and running water, together with an operating room including the operating table, anaesthetic and surgical equipment. Mission structure includes: patient identification by a network of local medical personnel in remote regions; pre-operative assessment at 1 week by core team via teleconsultations; four-day surgical missions; post-operative recovery in tents or a local clinic; post-operative follow-up care by local personnel and remote teleconsultations. The permanent core team includes seven members; lead surgeon, lead anaesthetist, operating-room technician, medical coordinator, driver, general coordinator, and receptionist. Additional support members include seven regular surgeons, residents, medical students, and volunteers. Surgery is a very effective way to gain the trust of the community, due to immediate results. Trust opens doors to other programmes (e.g. family medicine). Surgery can be incorporated with all other aspects of health care, which can in turn be incorporated with all other aspects of human development, education, food production and nutrition, housing, work and productivity, communication, and recreation.

Off-pump versus On-pump Coronary Artery Bypass Grafting in Frail Patients: Study Protocol for the FRAGILE Multicenter Randomized Controlled Trial.

PubMed

Mejía, Omar Asdrúbal Vilca; Sá, Michel Pompeu Barros Oliveira; Deininger, Maurilio Onofre; Dallan, Luís Roberto Palma; Segalote, Rodrigo Coelho; Oliveira, Marco Antonio Praça de; Atik, Fernando Antibas; Santos, Magaly Arrais Dos; Silva, Pedro Gabriel Melo de Barros E; Milani, Rodrigo Mussi; Hueb, Alexandre Ciappina; Monteiro, Rosangela; Lima, Ricardo Carvalho; Lisboa, Luiz Augusto Ferreira; Dallan, Luís Alberto Oliveira; Puskas, John; Jatene, Fabio Biscegli

2017-01-01

Advances in modern medicine have led to people living longer and healthier lives. Frailty is an emerging concept in medicine yet to be explored as a risk factor in cardiac surgery. When it comes to CABG surgery, randomized controlled clinical trials have primarily focused on low-risk (ROOBY, CORONARY), elevated-risk (GOPCABE) or high-risk patients (BBS), but not on frail patients. Therefore, we believe that off-pump CABG could be an important technique in patients with limited functional capacity to respond to surgical stress. In this study, the authors introduce the new national, multicenter, randomized, controlled trial "FRAGILE", to be developed in the main cardiac surgery centers of Brazil, to clarify the potential benefit of off-pump CABG in frail patients. FRAGILE is a two-arm, parallel-group, multicentre, individually randomized (1:1) controlled trial which will enroll 630 patients with blinded outcome assessment (at 30 days, 6 months, 1 year, 2 years and 3 years), which aims to compare adverse cardiac and cerebrovascular events after off-pump versus on-pump CABG in pre-frail and frail patients. Primary outcomes will be all-cause mortality, acute myocardial infarction, cardiac arrest with successful resuscitation, low cardiac output syndrome/cardiogenic shock, stroke, and coronary reintervention. Secondary outcomes will be major adverse cardiac and cerebrovascular events, operative time, mechanical ventilation time, hyperdynamic shock, new onset of atrial fibrillation, renal replacement therapy, reoperation for bleeding, pneumonia, length of stay in intensive care unit, length of stay in hospital, number of units of blood transfused, graft patency, rate of complete revascularization, neurobehavioral outcomes after cardiac surgery, quality of life after cardiac surgery and costs. FRAGILE trial will determine whether off-pump CABG is superior to conventional on-pump CABG in the surgical treatment of pre-frail and frail patients. ClinicalTrials.gov, ID: NCT02338947. Registered on August 29th 2014; last updated on March 21st 2016.

American Society of Anesthesiologists classification in cataract surgery: Results from the Ophthalmic Surgery Outcomes Data Project.

PubMed

Payal, Abhishek R; Sola-Del Valle, David; Gonzalez-Gonzalez, Luis A; Cakiner-Egilmez, Tulay; Chomsky, Amy S; Vollman, David E; Baze, Elizabeth F; Lawrence, Mary; Daly, Mary K

2016-07-01

To explore the association of American Society of Anesthesiologists (ASA) classification with cataract surgery outcomes. Five Veterans Affairs Medical Centers, United States. Retrospective observational cohort study. The study analyzed the outcomes of cataract surgery cases. Corrected distance visual acuity (CDVA), unanticipated events, and vision-related quality of life (VRQL) were assessed using the National Eye Institute Visual Function Questionnaire (NEI-VFQ), comparing ASA classes I through IV. For some analyses, ASA classes I and II were designated as Group A and ASA classes III and IV were designated Group B. Of the 4923 cases, 875 (17.8%) were in Group A, 4032 (81.9%) were in Group B, and 16 (0.3%) had missing data. The mean CDVA and mean composite NEI-VFQ score improved after cataract surgery in both groups (P < .0001); however, Group A had a better mean postoperative CDVA and postoperative VFQ composite scores than Group B (P < .0001, both outcomes). A higher ASA class was associated with an increased risk for 2 unanticipated events; that is, clinically significant macular edema (CSME) (Group A: 4 [0.47%] versus Group B: 50 [1.28%]; adjusted odds ratio [OR], 3.02; 95% confidence interval [CI], 1.02-13.05; P = 0.04) and readmission to the hospital within 30 days (2 [0.23%] versus 56 [1.41%]; OR, 8.26; 95% CI, 1.71-148.62; P = .004) CONCLUSIONS: Among United States veterans, the ASA classification could be an important predictor of VRQL and visual outcomes. In this cohort, it was associated with an increased risk for 2 serious unanticipated events-CSME and readmission to the hospital-both costly, unwanted outcomes. Dr. Vollman is a consultant to Forsight Vision5. None of the authors has a financial or proprietary interest in any material or method mentioned. Copyright © 2016 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.

Postoperative paediatric pain prevalence: A retrospective analysis in a university teaching hospital.

PubMed

Avian, Alexander; Messerer, Brigitte; Wünsch, Gerit; Weinberg, Annelie; Kiesling, Andreas Sandner; Berghold, Andrea

2016-10-01

Overall pain prevalence in paediatric patients is well documented, but relatively little attention has been paid to pain prevalence and intensity on specific postoperative days within the first week following an operation. To evaluate reported pain prevalence on the day of surgery and each day during the following week and to analyse pain trajectories. Retrospective study. Single centre university hospital. 815 postoperative children and adolescents (age≤18 years) were included (female: 36%, age 9.8±5.8). Children with ear, nose, throat (e.g. tonsillectomy), eye (e.g. strabismus repair) or dental surgery (e.g. dental extraction) were treated at other departments and therefore were not included in this study. Retrospective analysis of the overall and clinically relevant (pain score ≥4/10) postoperative pain prevalence in children and adolescents during the first week after surgery. Possible influencing factors (age, sex, body mass index, type of anaesthesia, type of surgery and duration of surgery) on pain trajectories are analysed using mixed model techniques. Overall, 36% of 815 analysed children and adolescents suffered from pain ≥4 during their entire hospital stay. Compared to the day of surgery, the number of patients with pain ≥4 was slightly higher on day 1 after surgery (21% vs. 25%, respectively). In self-reported pain intensity rating (done for patients age≥4 years) the type of surgery (p<.001) was the only significant variable influencing pain intensity. In observational pain assessment (age<4 years) pain scores increased with patient's age (p=.004). In this patient group, pain intensity ratings did not differ between types of surgery (p=.278). Type of surgery is an important predictor for self-reported pain intensity ratings in children but not for observational pain assessment in younger children. In younger children observational pain assessment ratings increase with age. Copyright © 2016 Elsevier Ltd. All rights reserved.

Patient Body Mass Index is an Independent Predictor of 30-Day Hospital Readmission After Elective Spine Surgery.

PubMed

Elsamadicy, Aladine A; Adogwa, Owoicho; Vuong, Victoria D; Mehta, Ankit I; Vasquez, Raul A; Cheng, Joseph; Karikari, Isaac O; Bagley, Carlos A

2016-12-01

Hospital readmission within 30 days of index surgery is receiving increased scrutiny as an indicator of poor quality of care. Reducing readmissions achieves the dual benefit of improving quality and reducing costs. With the growing prevalence of obesity, understanding its impact on 30-day unplanned readmissions and patients' perception of health status is important for appropriate risk stratification of patients. The aim of this study was to determine if obesity is an independent risk factor for unplanned 30-day readmissions after elective spine surgery. The medical records of 500 patients (nonobese, n = 281; obese, n = 219) undergoing elective spine surgery at a major academic medical center were reviewed. Preoperative body mass index (BMI) was measured on all patients. BMI that was ≥30 kg/m 2 was classified as obese. Patient demographics, comorbidities, and postoperative complication rates were collected. The primary outcome investigated was unplanned all-cause 30-day hospital readmission. The association between preoperative obesity and 30-day readmission rate was assessed via multivariate logistic regression analysis. Baseline characteristics and operative variables and complication profiles were similar between both cohorts. Overall, 8.6% of patients were readmitted within 30 days of discharge; obese patients experienced a 2-fold increase in 30-day readmission rates (obese 12.33% vs. nonobese 5.69%, P = 0.01). In a multivariate logistic regression analysis, preoperative obesity (BMI ≥30 kg/m 2 ) was found to be an independent predictor of 30-day readmission after elective spine surgery (P = 0.001). Preoperative obesity is an independent risk factor for readmission within 30 days of discharge after elective spine surgery. In a cost-conscious health care climate, preoperative BMI can identify patients at risk for early unplanned hospital readmission. Copyright © 2016 Elsevier Inc. All rights reserved.

Analysis of Macular and Retinal Nerve Fiber Layer Thickness in Children with Refractory Amblyopia after Femtosecond Laser-assisted Laser In situ Keratomileusis: A Retrospective Study.

PubMed

Zhao, Peng-Fei; Zhou, Yue-Hua; Zhang, Jing; Wei, Wen-Bin

2017-09-20

Localized macular edema and retinal nerve fiber layer (RNFL) thinning have been reported shortly after laser in situ keratomileusis (LASIK) in adults. However, it is still unclear how LASIK affects the retina of children. This study aimed to investigate the macular retina and RNFL thickness in children with refractive amblyopia who underwent femtosecond laser-assisted LASIK (FS-LASIK). In this study, we included 56 eyes of 32 patients with refractive amblyopia who underwent FS-LASIK in our hospital from January 2012 to December 2016. Foveal (foveal center retinal, parafoveal retinal, and perifoveal), macular inner retinal (superior and inferior), and peripapillary RNFL thicknesses (superior, inferior, temporal, and nasal) were measured using Fourier-domain optical coherence tomography before surgery and 1 day, 3 days, and 1 week after surgery. We divided these patients into three groups based on their refractive error: High myopic group with 22 eyes (equivalent sphere, >6.00 D), mild myopic group with 19 eyes (equivalent sphere, 0-6.00 D), and hyperopic group with 15 eyes (equivalent sphere, >+0.50 D). We compared the macular retina and RNFL thickness before and after LASIK. A paired simple t-test was used for data analysis. One week after surgery, the visual acuity for all 56 eyes of the 32 patients reached their preoperative best-corrected vision. Visual acuity improved two lines or better for 31% of the patients. The residual refractive errors in 89% of the patients were within ±0.5 D. In the high myopic group, the foveal center retinal and parafoveal retinal thicknesses were thicker 1 day and 3 days after surgery than before surgery (t = 2.689, P = 0.012; t = 2.383, P = 0.018, respectively); no significant difference was found 1 week after surgery (P > 0.05). The foveal center retinal and parafoveal retinal thicknesses were greater 1 day after surgery than they were before surgery (P = 0.000 and P = 0.005, respectively) in the mild myopic and hyperopic groups. No significant difference was found 3 days or 1 week after surgery (P > 0.05). In all three groups, no significant difference was found in the macular inner retinal or peripapillary RNFL thickness 1 day, 3 days, or 1 week after surgery (P > 0.05). The foveal center retinal edema after FS-LASIK is mild and reversible in children, that mostly occurred in the high myopic group with no effect on the visual acuity, and is always relieved within 1 week.

Craniosynostosis repair

MedlinePlus

... days before the surgery. Ask the doctor which medicines your child should still take on the day of the ... for pain. Your doctor can prescribe other pain medicines if your child needs them. Most children who have endoscopic surgery ...

Outpatient Management and Surgeon Specialty for Thyroglossal Duct Cyst Excision: A Retrospective Analysis of 377 Patients and 30-Day Outcomes in the American College of Surgeons NSQIP-P Database.

PubMed

Farquhar, Douglas R; Rawal, Rounak B; Masood, Maheer M; McClain, Wade G; Kilpatrick, Lauren A; Rose, Austin S; Zdanski, Carlton J

2018-06-14

Thyroglossal duct cysts (TGDC) excisions was traditionally an inpatient procedure, but there has been a recent trend towards outpatient surgery. Our aim is to use the NSQIP-P to examine overall thirty-day outcomes for TGDC excision, and to determine whether they are affected by admission status and surgeon specialty. We assessed the demographics, preoperative risk factors, and negative outcomes of admitted and same-day surgery TGDC patients, and TGDC patients of surgeons with different training. Outcomes were thirty-day rates for readmissions, reoperations, unplanned reintubations, major complications, and minor complications. Of 377 TGDC patients, 81% had outpatient surgery and 19% had inpatient surgery. Pediatric otolaryngologists performed 64% of the operations, followed by pediatric surgeons, general otolaryngologists, and general and plastic surgeons (23%, 12%, and 2% respectively). There was a 3% reoperation rate, no major complications, and a 3% wound infection rate. In multivariate analysis, neither admission status nor surgeon specialty were associated with negative 30-day outcomes. Premature birth (OR 6.5, p = 0.008) and male sex (OR 16, p = 0.008) were the only significant predictors. Outpatient pediatric TGDC surgery appears to have similar readmission, complication, and reoperation rates as inpatient surgery. Thirty-day outcomes do not vary by the surgeon's training, although recurrence rates could not be evaluated with this database. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Safe and sustainable increases in day case emergency surgery.

PubMed

Hotchen, Andrew J; Coleman, Grant; O'Callaghan, John M; McWhinnie, Doug

2016-03-01

Selected patients referred to emergency general surgery departments are suitable for day case emergency surgery with no overnight hospital stay. There are no well-described sustainable pathways for these expedited operations and in many hospitals patients undergo unnecessary admissions and experience long waiting times. The authors proposed a new, sustainable, day case emergency surgery pathway which was implemented to streamline the assessment, treatment and discharge of acute surgical referrals. It requires rapid assessment of the patient by a senior clinician, and ready availability of diagnostic services and operating facilities. To assess this pathway, the authors conducted a prospective audit of general surgical referrals to a district general hospital in the UK. During the inclusion period 746 emergency referrals were assessed, 281 (37%) of these underwent an operation. Over a 5-month investigation period, the audit found that approximately 27% of all emergency general surgery patients requiring an operation could be managed with day case emergency surgery. This figure was maintained throughout the duration of the study. Operations included incision and drainage of abscesses, incarcerated hernia repairs and appendicectomies. The average length of stay of all surgical admissions decreased from 5 days to less than 3 days and the median time to senior review was 30 minutes. The authors have developed a pathway involving permanent members of the surgical assessment team that is sustainable over a 5-month period. The pathway has allowed rapid assessment of patients and reduced unnecessary inpatient stay in a sustainable and reproducible manner.

Low-Dose Strontium-90 Irradiation Is Effective in Preventing the Recurrence of Pterygia: A Ten-Year Study

PubMed Central

Guo, Liang; Guo, Yong-yuan

2012-01-01

Background To study the long-term effects of low-dosage strontium-90 (Sr90) irradiation on the recurrence of pterygium. Methodology/Principal Findings One hundred twenty eyes from 104 patients with primary or recurrent pterygia were treated with surgery followed by Sr90 irradiation. In brief, starting on the sixth day after surgery, patients were treated with irradiation three times every other day at a total combined dosage of 2000 cGy to 3000 cGy. Corneal topography was used to evaluate ocular surface regularity before and after treatment. Patient follow-up was performed 2 days, 5 days, 2 weeks, 1 month, 3 months, 1 year, 5 years, and 10 years after surgery. Recurrence of pterygium was not observed in any of the patients in this study. Obvious cataract progression was observed in 6 eyes, which may be due to aging. During follow-up studies, only one eye was reported with dryness and foreign-body sensation. Significant pterygium-induced astigmatism was observed in corneal topography, which decreased after surgery. Conclusions/Significance Sr90 irradiation is effective in preventing the recurrence of primary and recurrent pterygia. We recommend delivering a total combined dosage of 2000 cGy to 3000 cGy of Sr90 irradiation administered in three batches every other day starting from the sixth day after surgery. Surgery is important in the rapid recovery of the cornea from pterygium-induced astigmatism. PMID:22952695

The effect of preoperative nutritional status on postoperative outcomes in children undergoing surgery for congenital heart defects in San Francisco (UCSF) and Guatemala City (UNICAR).

PubMed

Radman, Monique; Mack, Ricardo; Barnoya, Joaquin; Castañeda, Aldo; Rosales, Monica; Azakie, Anthony; Mehta, Nilesh; Keller, Roberta; Datar, Sanjeev; Oishi, Peter; Fineman, Jeffrey

2014-01-01

The objective of this study was to determine the association between preoperative nutritional status and postoperative outcomes in children undergoing surgery for congenital heart defects (CHD). Seventy-one patients with CHD were enrolled in a prospective, 2-center cohort study. We adjusted for baseline risk differences using a standardized risk adjustment score for surgery for CHD. We assigned a World Health Organization z score for each subject's preoperative triceps skin-fold measurement, an assessment of total body fat mass. We obtained preoperative plasma concentrations of markers of nutritional status (prealbumin, albumin) and myocardial stress (B-type natriuretic peptide [BNP]). Associations between indices of preoperative nutritional status and clinical outcomes were sought. Subjects had a median (interquartile range [IQR]) age of 10.2 (33) months. In the University of California at San Francisco (UCSF) cohort, duration of mechanical ventilation (median, 19 hours; IQR, 29 hours), length of intensive care unit stay (median, 5 days; IQR 5 days), duration of any continuous inotropic infusion (median, 66 hours; IQR 72 hours), and preoperative BNP levels (median, 30 pg/mL; IQR, 75 pg/mL) were associated with a lower preoperative triceps skin-fold z score (P < .05). Longer duration of any continuous inotropic infusion and higher preoperative BNP levels were also associated with lower preoperative prealbumin (12.1 ± 0.5 mg/dL) and albumin (3.2 ± 0.1; P < .05) levels. Lower total body fat mass and acute and chronic malnourishment are associated with worse clinical outcomes in children undergoing surgery for CHD at UCSF, a resource-abundant institution. There is an inverse correlation between total body fat mass and BNP levels. Duration of inotropic support and BNP increase concomitantly as measures of nutritional status decrease, supporting the hypothesis that malnourishment is associated with decreased myocardial function. Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Small-bowel obstruction secondary to bezoar impaction: a diagnostic dilemma.

PubMed

Ho, Thomas W; Koh, Dean C

2007-05-01

Gastrointestinal bezoar (GIB) is uncommon and is reported to occur in 4% of all admissions for small-bowel obstruction (SBO). Because of a lack of diagnostic features, it is often associated with a delay in treatment, with increased morbidity. In this article, we report our experience with managing bezoar-induced SBO and the role of early computed tomography (CT) imaging in establishing the diagnosis. We retrospectively reviewed all cases of bezoar-induced SBO treated in our unit between 1999 and 2005. There were 43 patients, of whom 2 had a recurrence, giving a total of 45 episodes. The frequency of bezoar in our patients presenting with SBO was 4.3%. All patients were of Asian origin: 41 Chinese, 1 Indian, and 1 Malay. Twenty-eight (65%) patients had previous abdominal surgery of which 26 were gastric surgery. Thirty-eight (88%) patients were edentulous. Forty-one (91%) underwent serial abdominal radiography, whereas only 4 patients (9%) had either CT imaging or contrast study alone. Only 11 (24%) cases had a correct diagnosis of bezoar impaction made preoperatively by CT imaging. The diagnostic accuracy of CT imaging in our series was 65%, with six cases of misdiagnosis. Overall, CT led to a change in management of 76% (13 in 17). The median time to surgery from admission was 2 (0-10) days. There were 2 cases of ischemic bowel that necessitated bowel resection. The median length of hospital stay was 11 (5-100) days. Ten patients (22%) had postoperative complications, and there was one death. Bezoar-induced SBO is uncommon and remains a diagnostic and management challenge. It should be suspected in patients with an increased risk of formation of GIB, such as previous gastric surgery, poor dentition, and a suggestive history of increased fibre intake. We advocate that CT imaging be performed early in these at-risk patients and in patients presenting with SBO with or without a history of abdominal surgery in order to reduce unnecessary delays before appropriate surgical intervention.

A comparison of two surgical approaches in functional neurosurgery: individualized versus conventional stereotactic frames.

PubMed

Matzke, Cornelia; Lindner, Dirk; Schwarz, Johannes; Classen, Joseph; Hammer, Niels; Weise, David; Rumpf, Jost-Julian; Fritzsch, Dominik; Meixensberger, Jürgen; Winkler, Dirk

2015-01-01

The individualized Starfix® miniframe belongs to a new generation of stereotactic systems enabling high-precision electrode placement with considerably better time-efficiency in deep brain stimulation (DBS). We evaluated the usability and reliability of this novel technique in patients with idiopathic Parkinson's disease (IPD) and compared surgical and clinical results with those obtained in a historical group in which a conventional stereotactic frame was employed. Sixty patients underwent surgery for implantation of DBS electrodes in the subthalamic nucleus. In 31 of them (group I) a conventional Zamorano-Dujovny frame was used and in 29 of them (group II) a Starfix® miniframe was used. Image fusion of preoperatively acquired 3D T1w and T2w 1.5 T MR-image series was used for the targeting procedure. Placement of the test electrodes and permanent electrodes corresponded to standard functional neurosurgery and included microelectrode recording and macrostimulation. Clinical (L-Dopa equivalent dose, United Parkinson's disease rating scale part III) and time for surgical electrode implantation were evaluated postoperatively in a 3-, 6- and 12-month follow-up. Twelve months postoperatively, L-Dopa dose was significantly reduced from 685.19 to 205.88 mg/day and from 757.92 to 314.42 mg/day in groups I and II, respectively. A comparable reduction of the LED could be observed 1 year after surgery. Motor function has improved in a significant and identical manner with 59% (group I) and 61% (group II). Besides clinical effects by stimulation therapy there was a significantly reduced surgery time required for electrode implantation using the Starfix® miniframe (group I: 234.1 min, group II: 173.6 min; p < 0.001). Individualized miniframes such as the Starfix® miniframe allow implantation of DBS electrodes in IPD that is equally effective as conventional systems. The time efficiency achieved in surgery using of the Starfix® system helps to minimize patients' discomfort during DBS surgery.

Development of Electronic Medical Record-Based "Rounds Report" Results in Improved Resident Efficiency, More Time for Direct Patient Care and Education, and Less Resident Duty Hour Violations.

PubMed

Ham, Phillip B; Anderton, Toby; Gallaher, Ryan; Hyrman, Mike; Simmerman, Erika; Ramanathan, Annamalai; Fallaw, David; Holsten, Steven; Howell, Charles Gordon

2016-09-01

Surgeons frequently report frustration and loss of efficiency with electronic medical record (EMR) systems. Together, surgery residents and a programmer at Augusta University created a rounds report (RR) summarizing 24 hours of vitals, intake/output, labs, and other values for each inpatient that were previously transcribed by hand. The objective of this study was to evaluate the RR's effect on surgery residents. Surgery residents were queried to assess the RR's impact. Outcome measures were time spent preparing for rounds, direct patient care time, educational activity time, rates of incorrect/incomplete data on rounds, and rate of duty hour violations. Hospital wide, 17,200 RRs were generated in the 1-month study. Twenty-three surgery residents participated. Time spent preparing for rounds decreased per floor patient (15.6 ± 3.0 vs 6.0 ± 1.2, P < 0.0001) and per intensive care unit patient (19.9 ± 2.9 vs 7.5 ± 1.2 P < 0.0001). The work day spent in direct patient care increased from 45.1 ± 5.6 to 54.0 ± 5.7 per cent (P = 0.0044). Educational activity time increased from 35.2 ± 5.4 to 54.7 ± 7.1 minutes per resident per day (P = 0.0004). Reported duty hour violations decreased 58 per cent (P < 0.0001). American Board of Surgery in Training exam scores trended up, and estimates of departmental annual financial savings range from $66,598 to $273,141 per year. Significant improvements occur with surgeon designed EMR tools like the RR. Hospitals and EMR companies should pair interested surgeons with health information technology developers to facilitate EMR enhancements. Improvements like RRs can have broad ranging, multidisciplinary impact and should be standard in all EMRs used for inpatient care at academic medical centers.

Patient access in plastic surgery: an operational and financial analysis of service-based interventions to improve ambulatory throughput in an academic surgery practice.

PubMed

Hultman, Charles Scott; Gilland, Wendell G; Weir, Samuel

2015-06-01

Inefficient patient throughput in a surgery practice can result in extended new patient backlogs, excessively long cycle times in the outpatient clinics, poor patient satisfaction, decreased physician productivity, and loss of potential revenue. This project assesses the efficacy of multiple throughput interventions in an academic, plastic surgery practice at a public university. We implemented a Patient Access and Efficiency (PAcE) initiative, funded and sponsored by our health care system, to improve patient throughput in the outpatient surgery clinic. Interventions included: (1) creation of a multidisciplinary team, led by a project redesign manager, that met weekly; (2) definition of goals, metrics, and target outcomes; 3) revision of clinic templates to reflect actual demand; 4) working down patient backlog through group visits; 5) booking new patients across entire practice; 6) assigning a physician's assistant to the preoperative clinic; and 7) designating a central scheduler to coordinate flow of information. Main outcome measures included: patient satisfaction using Press-Ganey surveys; complaints reported to patient relations; time to third available appointment; size of patient backlog; monthly clinic volumes with utilization rates and supply/demand curves; "chaos" rate (cancellations plus reschedules, divided by supply, within 48 hours of booked clinic date); patient cycle times with bottleneck analysis; physician productivity measured by work Relative Value Units (wRVUs); and downstream financial effects on billing, collection, accounts receivable (A/R), and payer mix. We collected, managed, and analyzed the data prospectively, comparing the pre-PAcE period (6 months) with the PAcE period (6 months). The PAcE initiative resulted in multiple improvements across the entire plastic surgery practice. Patient satisfaction increased only slightly from 88.5% to 90.0%, but the quarterly number of complaints notably declined from 17 to 9. Time to third available new patient appointment dropped from 52 to 38 days, whereas the same metric for a preoperative appointment plunged from 46 to 16 days. The size of the new patient backlog fell from 169 to 110 patients, and total monthly clinic volume climbed from 574 to 766 patients. Our "chaos" rate dropped from 12.3% to 1.8%. Mean patient cycle time in the clinic decreased dramatically from 127 to 44 minutes. Mean monthly productivity for the practice increased from 2479 to 2702 RVUs. Although our collection rate did not change, days in A/R dropped from 66 to 57 days. Mean monthly charges increased from U.S. $535,213 to U.S. $583,193, and mean monthly collections improved from U.S. $181,967 to U.S. $210,987. Payer mix remained unchanged. Implementation of a PAcE initiative, focusing on outpatient clinic throughput, yields significant improvements in access to care, patient satisfaction as measured by complaints, physician productivity, and financial performance. An academic, university-based, plastic surgery practice can use throughput interventions to deliver timely care and to enhance financial viability.

Modelling physiological deterioration in post-operative patient vital-sign data.

PubMed

Pimentel, Marco A F; Clifton, David A; Clifton, Lei; Watkinson, Peter J; Tarassenko, Lionel

2013-08-01

Patients who undergo upper-gastrointestinal surgery have a high incidence of post-operative complications, often requiring admission to the intensive care unit several days after surgery. A dataset comprising observational vital-sign data from 171 post-operative patients taking part in a two-phase clinical trial at the Oxford Cancer Centre, was used to explore the trajectory of patients' vital-sign changes during their stay in the post-operative ward using both univariate and multivariate analyses. A model of normality based vital-sign data from patients who had a "normal" recovery was constructed using a kernel density estimate, and tested with "abnormal" data from patients who deteriorated sufficiently to be re-admitted to the intensive care unit. The vital-sign distributions from "normal" patients were found to vary over time from admission to the post-operative ward to their discharge home, but no significant changes in their distributions were observed from halfway through their stay on the ward to the time of discharge. The model of normality identified patient deterioration when tested with unseen "abnormal" data, suggesting that such techniques may be used to provide early warning of adverse physiological events.

Day surgery nurses' selection of patient preoperative information.

PubMed

Mitchell, Mark

2017-01-01

To determine selection and delivery of preoperative verbal information deemed important by nurses to relay to patients immediately prior to day surgery. Elective day-case surgery is expanding, patient turnover is high and nurse-patient contact limited. In the brief time-frame available, nurses must select and precisely deliver information to patients, provide answers to questions and gain compliance to ensure a sustained, co-ordinated patient throughput. Concise information selection is therefore necessary especially given continued day surgery expansion. Electronic questionnaire. A survey investigating nurses' choice of patient information prior to surgery was distributed throughout the UK via email addresses listed on the British Association of Day Surgery member's website (January 2015-April 2015). Participants were requested to undertake the survey within 2-3 weeks, with 137 participants completing the survey giving a 44% response rate. Verbal information deemed most important by nurses preoperatively was checking fasting time, information about procedure/operation, checking medication, ensuring presence of medical records/test results and concluding medical investigations checks. To a lesser extent was theatre environment information, procedure/operation start time and possible time to discharge. Significant differences were established between perceived importance of information and information delivery concerning the procedure/operation and anaesthesia details. Nurses working with competing demands and frequent interruptions, prioritised patient safety information. Although providing technical details during time-limited encounters, efforts were made to individualise provision. A more formal plan of verbal information provision could help ease nurses' cognitive workload and enhance patient satisfaction. This study provides evidence that verbal information provided immediately prior to day surgery may vary with experience. Nurse educators and managers may need to provide greater guidance for such complex care settings as delivery of increasingly technical details during brief encounters is gaining increasing priority. © 2016 John Wiley & Sons Ltd.

Prognostic model for psychological outcomes in ambulatory surgery patients: A prospective study using a structural equation modeling framework.

PubMed

Mijderwijk, Hendrik-Jan; Stolker, Robert Jan; Duivenvoorden, Hugo J; Klimek, Markus; Steyerberg, Ewout W

2018-01-01

Surgical procedures are increasingly carried out in a day-case setting. Along with this increase, psychological outcomes have become prominent. The objective was to evaluate prospectively the prognostic effects of sociodemographic, medical, and psychological variables assessed before day-case surgery on psychological outcomes after surgery. The study was carried out between October 2010 and September 2011. We analyzed 398 mixed patients, from a randomized controlled trial, undergoing day-case surgery at a university medical center. Structural equation modeling was used to jointly study presurgical prognostic variables relating to sociodemographics (age, sex, nationality, marital status, having children, religion, educational level, employment), medical status (BMI, heart rate), and psychological status associated with anxiety (State-Trait Anxiety Inventory (STAI), Hospital Anxiety and Depression Scale (HADS-A)), fatigue (Multidimensional Fatigue Inventory (MFI)), aggression (State-Trait Anger Scale (STAS)), depressive moods (HADS-D), self-esteem, and self-efficacy. We studied psychological outcomes on day 7 after surgery, including anxiety, fatigue, depressive moods, and aggression regulation. The final prognostic model comprised the following variables: anxiety (STAI, HADS-A), fatigue (MFI), depression (HADS-D), aggression (STAS), self-efficacy, sex, and having children. The corresponding psychological variables as assessed at baseline were prominent (i.e. standardized regression coefficients ≥ 0.20), with STAI-Trait score being the strongest predictor overall. STAI-State (adjusted R2 = 0.44), STAI-Trait (0.66), HADS-A (0.45) and STAS-Trait (0.54) were best predicted. We provide a prognostic model that adequately predicts multiple postoperative outcomes in day-case surgery. Consequently, this enables timely identification of vulnerable patients who may require additional medical or psychological preventive treatment or-in a worst-case scenario-could be unselected for day-case surgery.

Flat inferior vena cava: indicator of poor prognosis in trauma and acute care surgery patients.

PubMed

Ferrada, Paula; Vanguri, Poornima; Anand, Rahul J; Whelan, James; Duane, Therese; Wolfe, Luke; Ivatury, Rao

2012-12-01

Flat inferior vena cava (IVC) on ultrasound examination has been shown to correlate with hypovolemic status. We hypothesize that a flat IVC on limited echocardiogram (LTTE) performed in the emergency room (ER) correlates with poor prognosis in acutely ill surgical patients. We conducted a retrospective review of all patients undergoing LTTE in the ER from September 2010 until June 2011. IVC diameter was estimated by subxiphoid window. Flat IVC was defined as diameter less than 2 cm. Fat IVC was defined as diameter greater than 2 cm. Need for intensive care unit admission, blood transfusion requirement, mortality, and need for emergent operation between patients with flat versus Fat IVC were compared. One hundred one hypotensive patients had LTTE performed in the ER. Average age was 38 years. Admission diagnosis was blunt trauma (n = 80), penetrating trauma (n = 13), acute care surgery pathology (n = 7), and burn (n = 1). Seventy-four patients had flat IVC on initial LTTE. Compared with those with fat IVC, flat patients were found have higher rates of intensive care unit admission (51.3 vs 14.8%; P = 0.001), blood transfusion requirement (12.2 vs 3.7%), and mortality (13.5 vs 3.7%). This population also underwent emergent surgery on hospital Day 1 more often (16.2 vs 0%; P = 0.033). Initial flat IVC on LTTE is an indicator of hypovolemia and a predictor of poor outcome.

Postoperative infections after major heart surgery and prevention of ventilator-associated pneumonia: a one-day European prevalence study (ESGNI-008).

PubMed

Bouza, E; Hortal, J; Muñoz, P; Pascau, J; Pérez, M J; Hiesmayr, M

2006-11-01

Few data have been published on the prevalence of postoperative infection in patients undergoing major heart surgery (MHS). The degree of compliance with standard measures used to prevent them is unknown. This study assessed the prevalence of infections, particularly ventilator-associated pneumonia (VAP), in patients undergoing MHS in 42 institutions from 13 European countries. On the study day, there were 321 postoperative MHS patients, of whom 164 (51%) were mechanically ventilated. The overall prevalence of infection was 26.8%. Lower respiratory tract infections represented 57% of all the infections present on the study day. Other infections included intravenous-catheter-related bloodstream infections (2.8%), surgical site infections (2.2%), urinary tract infections (0.9%) and postoperative mediastinitis (0.9%). Of the mechanically ventilated patients, 55 (33.5%) were not being nursed in a semi-recumbent position, 36 (22%) had heat-moisture exchangers with no antibacterial filters, and intracuff pressure was not monitored in 78 patients (47.6%). Only 13 patients (8%) were given continuous subglottic suctioning, 64 patients (39%) did not receive postural oscillation, and gastric overdistension was not actively prevented in 23 patients (14%). In conclusion, these data from intensive care units across Europe provide information on postoperative infections in an important subset of the patient population, and stress the need for active interventions to prevent VAP in patients undergoing MHS.

Retroperitoneal ectopic pregnancy: a case report and review of the literature.

PubMed

Yang, Man; Cidan, Lamu; Zhang, Dan

2017-10-16

Retroperitoneal ectopic pregnancy (REP) is an extremely rare type of ectopic pregnancy, with a total of less than 20 cases reported in the English literature. However, failure to recognize REP may result in severe consequences. We report a case of 32-year-old woman with REP. She had amenorrhea, left lower abdominal pain, but no vaginal bleeding. Her urine human chorionic gonadotropin (HCG) test was positive and blood HCG level was 1880 m-international units per milliliter (mIU/mL). Transvaginal ultrasound sonography showed a left adnexal mass. Laparoscopy found an enlarged uterus, normal right uterine tube and ovary, and normal left uterine tube. The left ovary was partly covered by a blood clot, but appeared normal after removing the clot. There was a 10-mm circular peritoneal defect located lateral to the left sacrocervical ligament, anterior to the left ovarian fossa, and next to the lower edge of the left broad ligament. The patient was diagnosed of having REP with the gestational tissues covered by the peritoneum. The REP was removed by laparoscopic surgery. Bleeding was stopped by bipolar coagulation and absorbable hemostatic cellulose. The patient recovered smoothly and was discharged on the next day after surgery. Her blood HCG returned to normal range 29 days after surgery. REP is very rare, but in any suspected case of ectopic pregnancy, caution must be paid to find signs of REP when the common sites of ectopic pregnancy do not have any positive findings.

Radical prostatectomy innovation and outcomes at military and civilian institutions.

PubMed

Leow, Jeffrey J; Weissman, Joel S; Kimsey, Linda; Hoburg, Andrew; Helmchen, Lorens A; Jiang, Wei; Hevelone, Nathanael; Lipsitz, Stuart R; Nguyen, Louis L; Chang, Steven L

2017-06-01

Limited data are available regarding the impact of the type of healthcare delivery system on technology diffusion and associated clinical outcomes. We assessed the adoption of minimally invasive radical prostatectomy (MIRP), a recent clinical innovation, and whether this adoption altered surgical morbidity for prostate cancer surgery. Retrospective review of administrative data from TRICARE, the healthcare program of the United States Military Health System. Surgery occurred at military hospitals, supported by federal appropriations, or civilian hospitals, supported by hospital revenue. We evaluated TRICARE beneficiaries with prostate cancer (International Classification of Disease, 9th Revision, Clinical Modification [ICD-9-CM] code: 185) who received a radical prostatectomy (60.5) between 2005 and 2009. MIRP was identified based on minimally invasive surgery codes (54.21, 17.42). We assessed yearly MIRP utilization, 30-day postoperative complications (Clavien classification system), length of stay, blood transfusion, and long-term urinary incontinence and erectile dysfunction. A total of 3366 men underwent radical prostatectomy at military hospitals compared with 1716 at civilian hospitals, with minimal clinic-demographic differences. MIRP adoption was 30% greater at civilian hospitals. There were fewer blood transfusions (odds ratio, 0.44; P <.0001) and shorter lengths of stay (incidence risk ratio, 0.85; P <.0001) among civilian hospitals, while 30-day postoperative complications, as well as long-term urinary incontinence and erectile dysfunction rates, were comparable. Compared with military hospitals, civilian hospitals had a greater MIRP adoption during this timeframe, but had comparable surgical morbidity.

Incorporating Comorbidity Within Risk Adjustment for UK Pediatric Cardiac Surgery.

PubMed

Brown, Katherine L; Rogers, Libby; Barron, David J; Tsang, Victor; Anderson, David; Tibby, Shane; Witter, Thomas; Stickley, John; Crowe, Sonya; English, Kate; Franklin, Rodney C; Pagel, Christina

2017-07-01

When considering early survival rates after pediatric cardiac surgery it is essential to adjust for risk linked to case complexity. An important but previously less well understood component of case mix complexity is comorbidity. The National Congenital Heart Disease Audit data representing all pediatric cardiac surgery procedures undertaken in the United Kingdom and Ireland between 2009 and 2014 was used to develop and test groupings for comorbidity and additional non-procedure-based risk factors within a risk adjustment model for 30-day mortality. A mixture of expert consensus based opinion and empiric statistical analyses were used to define and test the new comorbidity groups. The study dataset consisted of 21,838 pediatric cardiac surgical procedure episodes in 18,834 patients with 539 deaths (raw 30-day mortality rate, 2.5%). In addition to surgical procedure type, primary cardiac diagnosis, univentricular status, age, weight, procedure type (bypass, nonbypass, or hybrid), and era, the new risk factor groups of non-Down congenital anomalies, acquired comorbidities, increased severity of illness indicators (eg, preoperative mechanical ventilation or circulatory support) and additional cardiac risk factors (eg, heart muscle conditions and raised pulmonary arterial pressure) all independently increased the risk of operative mortality. In an era of low mortality rates across a wide range of operations, non-procedure-based risk factors form a vital element of risk adjustment and their presence leads to wide variations in the predicted risk of a given operation. Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

Adverse Outcomes after Major Surgery in Patients with Pressure Ulcer: A Nationwide Population-Based Retrospective Cohort Study

PubMed Central

Chou, Chia-Lun; Lee, Woan-Ruoh; Yeh, Chun-Chieh; Shih, Chun-Chuan

2015-01-01

Background Postoperative adverse outcomes in patients with pressure ulcer are not completely understood. This study evaluated the association between preoperative pressure ulcer and adverse events after major surgeries. Methods Using reimbursement claims from Taiwan’s National Health Insurance Research Database, we conducted a nationwide retrospective cohort study of 17391 patients with preoperative pressure ulcer receiving major surgery in 2008-2010. With a propensity score matching procedure, 17391 surgical patients without pressure ulcer were selected for comparison. Eight major surgical postoperative complications and 30-day postoperative mortality were evaluated among patients with pressure ulcer of varying severity. Results Patients with preoperative pressure ulcer had significantly higher risk than controls for postoperative adverse outcomes, including septicemia, pneumonia, stroke, urinary tract infection, and acute renal failure. Surgical patients with pressure ulcer had approximately 1.83-fold risk (95% confidence interval 1.54-2.18) of 30-day postoperative mortality compared with control group. The most significant postoperative mortality was found in those with serious pressure ulcer, such as pressure ulcer with local infection, cellulitis, wound or treatment by change dressing, hospitalized care, debridement or antibiotics. Prolonged hospital or intensive care unit stay and increased medical expenditures were also associated with preoperative pressure ulcer. Conclusion This nationwide propensity score-matched retrospective cohort study showed increased postoperative complications and mortality in patients with preoperative pressure ulcer. Our findings suggest the urgency of preventing and managing preoperative pressure ulcer by a multidisciplinary medical team for this specific population. PMID:26000606

A case study of infant physiologic response to skin-to-skin contact following surgery for complex congenital heart disease

PubMed Central

Harrison, Tondi M.; Ludington-Hoe, Susan

2014-01-01

Background Infants with complex congenital heart disease requiring surgical intervention within the first days or weeks of life may be the most seriously ill infants needing intensive nursing and medical care immediately after birth. Skin to skin contact (SSC) is well-accepted and practiced as a positive therapeutic intervention in premature infants, but is not routinely offered to infants in cardiac intensive care units. Physiologic effects of SSC in the congenital heart disease population must be examined before recommending incorporation of SSC into standard care routines. Objective The purpose of this case study was to describe the physiologic response to a single session of SSC in an 18-day-old infant with hypoplastic left heart syndrome. Methods Repeated measures of heart rate, respiratory rate, oxygen saturation, blood pressure, and temperature were recorded 30 minutes prior to SSC, during SSC (including interruptions for bottle and breast feedings), and 10 minutes after SSC was completed. Results All physiologic parameters were clinically acceptable throughout the 135-minute observation. Conclusion This case study provides beginning evidence that SSC is safe in full-term infants following surgery for complex congenital heart disease. Further research with a larger sample is needed to examine effects of SSC on infant physiology before surgery and earlier in the postoperative time period as well as on additional outcomes such as length of stay, maternal-infant interaction, and neurodevelopment. PMID:25325374

[The treatment of cicatricial alopecia after burn with the technique of synchronously perforating and transplanting hair follicular-units].

PubMed

Wang, Ji-ping; Fan, Jin-cai; Chai, Jia-ke

2009-12-01

To study the effect of the technique of synchronously perforating and transplanting hair follicular-units in the treatment of cicatricial alopecia after burn. One hundred and sixty-six patients with 217 bald scar areas after burn were treated with above-mentioned technique from January 2002 to April 2008. Scalp strips, with conforming the necessity for grafting, were harvested from the occipital or temporal region. A series of follicular-units, each composing 1 - 3 hairs, were dissected from the strips under microscope or magnifying glass. Size-matching micro-slots were made in the scarred recipient area with 16 - 20 G needles to accept the grafts. The prepared follicular-unit was synchronously implanted into the bottom of the micro-slot as the needle being withdrawn. Patients who were not satisfactory with the density of hairs after I stage surgery underwent II stage surgery a half year later. Ten recipient areas with clear boundary in 10 patients were optionally chosen to observe the density of follicular-units and hair amount with naked eyes after I stage surgery. Survived transplanted hairs in above-mentioned 10 areas were counted to calculate hair survival rate at follow-up. Patients' postoperative satisfaction ratings were surveyed with questionnaire. In one half of the patients, treatment was finished after I stage surgery, the other one half received 2 stages of surgery. The follicular-unit density reached 15 - 25 grafts/cm(2) with 40 - 70 hairs/cm(2) after I stage surgery. All patients were followed up for over 8 months. Grafted hairs grew well in a natural way. 96.5% mean hair survival rate was observed in the 10 recipient areas. From patients who received only I stage surgery, 61 patients (73.5%) were very satisfactory and 22 patients (26.5%) satisfactory with the results. From the other half of patients, 76 patients (91.6%) were very satisfactory and 7 patients (8.4%) satisfactory with the results. The technique of perforating and transplanting follicular-unit hair synchronously is safe and effective with less surgery-induced injury and less bleeding. Hairs transplanted on cicatricial alopecia area with this technique grow well with high survival rate.

[Oral and maxillofacial surgery residency training in the United States: what can we learn].

PubMed

Ren, Y F

2017-04-09

China is currently in the process of establishing formal residency training programs in oral and maxillofacial surgery and other medical and dental specialties. Regulatory agencies, and educational and academic institutions in China are exploring mechanisms, goals and standards of residency training that meet the needs of the Chinese healthcare system. This article provides an introduction of residency training in oral and maxillofacial surgery in the United States, with emphasis on the accreditation standard by the Commission on Dental Accreditation. As there are fundamental differences in the medical and dental education systems between China and United States, the training standards in the United States may not be entirely applicable in China. A competency-based training model that focus on overall competencies in medical knowledge, clinical skills and values at the time of graduation should be taken into consideration in a Chinese residency training program in oral and maxillofacial surgery.

The medicalization of obesity, bariatric surgery, and population health.

PubMed

Ortiz, Selena E; Kawachi, Ichiro; Boyce, Angie M

2017-09-01

This article examines how the medicalization of obesity validates the use of bariatric surgery to treat obesity in the United States and how expansions in access to bariatric surgery normalize surgical procedures as disease treatment and prevention tools. Building on this discussion, the article poses two questions for population health regarding health technology: (1) to what extent does bariatric surgery treat obesity in the United States while diverting attention away from the ultimate drivers of the epidemic and (2) to what extent does bariatric surgery improve outcomes for some groups in the US population while simultaneously generating disparities? We conduct a brief, historical analysis of the American Medical Association's decision to reclassify obesity as a disease through internal documents, peer-reviewed expert reports, and major media coverage. We use medicalization theory to show how this decision by the American Medical Association channels increased focus on obesity into the realm of medical intervention, particularly bariatric surgery, and use this evidence to review research trends on bariatric surgery. We propose research questions that investigate the population health dimensions of bariatric surgery in the United States and note key areas of future research. Our objective is to generate a discourse that considers bariatric surgery beyond the medical realm to better understand how technological interventions might work collectively with population-level obesity prevention efforts and how, in turn, population health approaches may improve bariatric surgery outcomes.

Incidence of potential drug interactions in a transplant centre setting and relevance of electronic alerts for clinical practice support.

PubMed

Polidori, Piera; Di Giorgio, Concetta; Provenzani, Alessio

2012-01-01

Adverse drug events may occur as a result of drug-drug interactions (DDIs). Information technology (IT) systems can be an important decision-making tool for healthcare workers to identify DDIs. The aim of the study is to analyse drug prescriptions in our main hospital units, in order to measure the incidence and severity of potential DDIs. The utility of clinical decision-support systems (CDSSs) and computerised physician order entry (CPOE) in term of alerts adherence was also assessed. DDIs were assessed using a Micromedex® healthcare series database. The system, adopted by the hospital, generates alerts for prescriptions with negative interactions and thanks to an 'acknowledgement function' it is possible to verify physician adherence to alerts. This function, although used previously, became mandatory from September 2010. Physician adherence to alerts and mean monthly incidence of potential DDIs in analysed units, before and after the mandatory 'acknowledgement function', were calculated. The intensive care unit (ICU) registered the greatest incidence of potential DDIs (49.0%), followed by the abdominal surgery unit and dialysis (43.4 and 42.0%, respectively). The cardiothoracic surgery unit (41.6%), step-down unit (38.3%) and post-anaesthesia care unit (30.0%) were comparable. The operating theatre and endoscopy registered the fewest potential DDIs (28.2 and 22.7%, respectively). Adherence to alerts after the 'acknowledgement function' increased by 25.0% in the ICU, 54.0% in the cardiothoracic surgery unit, 52.5% in the abdominal surgery unit, 58.0% in the stepdown unit, 67.0% in dialysis, 51.0% in endoscopy and 48.0% in the post-anaesthesia care unit. In the operating theatre, adherence to alerts decreased from 34.0 to 30.0%. The incidence of potential DDIs after mandatory use of the 'acknowledgement function' decreased slightly in endoscopy (-2.9%), the abdominal surgery unit (-2.7%), dialysis (-1.9%) and the step-down unit (-1.4%). Improving DDI alerts will improved patient safety by more appropriately alerting clinicians.

Response to treatment and interval to surgery after preoperative short-course radiotherapy in rectal cancer.

PubMed

García-Cabezas, Sonia; Rodríguez-Liñán, Milagrosa; Otero-Romero, Ana M; Bueno-Serrano, Carmen M; Gómez-Barbadillo, José; Palacios-Eito, Amalia

2016-10-01

Preoperative short-course radiotherapy with immediate surgery improves local control in patients with rectal cancer. Tumor responses are smaller than those described with radiochemotherapy. Preliminary data associate this lower response to the short period until surgery. The aim of this study is to analyze the response to preoperative short-course radiotherapy and its correlation with the interval to surgery especially analyzing patients with mesorectal fascia involvement. A total of 155 patients with locally advanced rectal cancer treated with preoperative radiotherapy (5×5Gy) were retrospectively analyzed. Tumor response in terms of rates of complete pathological response, downstaging, tumor regression grading and status of the circumferential resection margin were quantified. The mean interval from radiotherapy to surgery was 23 days. The rate of complete pathological response was 2.2% and 28% experienced downstaging (stage decreased). No differences between these rates and interval to surgery were detected. Eighty-eight patients had magnetic resonance imaging for staging (in 31 patients the mesorectal fascia was involved).The mean time to surgery in patients with involvement of the fascia and R0 surgery was 27 days and 16 days if R1 (P=.016). The cutoff of 20 days reached the highest probability of achieving a free circumferential resection margin between patients with mesorectal fascia involvement, with no statistically significant differences: RR 3.036 95% CI=(0.691-13.328), P=.06. After preoperative short-course radiotherapy, an interval>20 days enhances the likelihood of achieving a free circumferential resection margin in patients with mesorectal fascia involvement. Copyright © 2016 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.

Older Age Confers a Higher Risk of 30-Day Morbidity and Mortality Following Laparoscopic Bariatric Surgery: an Analysis of the Metabolic and Bariatric Surgery Quality Improvement Program.

PubMed

Haskins, Ivy N; Ju, Tammy; Whitlock, Ashlyn E; Rivas, Lisbi; Amdur, Richard L; Lin, Paul P; Vaziri, Khashayar

2018-04-17

There is a paucity of literature describing the association of age with the risk of adverse events following bariatric surgery. The purpose of this study is to investigate the association of age with 30-day morbidity and mortality following laparoscopic bariatric surgery using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. All adult patients undergoing laparoscopic Roux-en-Y gastric bypass (RNGYB) or sleeve gastrectomy (SG) were identified within the MBSAQIP database. Patients were divided into five equal age quintiles. Binary outcomes of interest, including cardiac, pulmonary, wound, septic, clotting, and renal events, in addition to the incidence of related 30-day unplanned reintervention, related 30-day mortality, and a composite morbidity and mortality outcome were compared across the age quintiles and procedures. A total of 266,544 patients met inclusion criteria. Older age was associated with an increased risk of all morbidity outcomes except venous thromboembolism events, 30-day mortality, and the composite morbidity and mortality outcome. Patients who underwent Roux-en-Y gastric bypass had worse outcomes per quintile for almost every outcome of interest when compared to patients who underwent sleeve gastrectomy. Older patients and patients who undergo Roux-en-Y gastric bypass are at an increased risk of perioperative morbidity and mortality following laparoscopic bariatric surgery. Additional studies are needed to determine the association of age with long-term weight loss and cardiometabolic comorbidity resolution following bariatric surgery in order to determine if the increased perioperative risk is offset by improved long-term outcomes in older patients undergoing bariatric surgery.

Can oral vitamin K before elective surgery substitute for preoperative heparin bridging in patients on vitamin K antagonists?

PubMed

Steib, A; Barre, J; Mertes, M; Morel, M H; Nathan, N; Ozier, Y; Treger, M; Samama, C M

2010-03-01

After a vitamin K antagonist (VKA) overdose, 1-2 mg of oral vitamin K can lower the International Normalized Ratio (INR) to the therapeutic range. To establish whether oral vitamin K can substitute for heparin bridging and decrease the INR to < or = 1.5 before elective surgery. Patients on long-term VKAs were randomized either to heparin bridging after the last VKA dose on day -5 before surgery (group H) or to VKA treatment until day -2, followed by 1 mg of oral vitamin K on the day before surgery (group K). Blood clotting variables were assessed on days -5/-2, 1 and 0, and postoperatively. If the target INR was not achieved 2 h before incision, surgery was deferred or performed after injection of prothrombin complex concentrate (PCC). In 30 of 94 included patients, baseline INR was outside the chosen range (18, INR < 2; 12, INR > 3.5), leaving 34 eligible patients in group H and 30 in group K. The groups were balanced in terms of body mass index, VKA treatment duration and indication, scheduled surgery, preoperative and postoperative hemoglobin, and blood loss. The INR was significantly higher in group K on days -1 and 0 than in group H. An INR < or = 1.5 was not achieved in 20 group K patients (66%). Surgery was postponed or performed after PCC injection in 12 of these 20 patients. Oral vitamin K (1 mg) cannot substitute for heparin bridging before surgery. In addition, one-third of patients on VKAs were exposed to a risk of bleeding (overdose) or thrombosis (underdose), thus highlighting the need for new oral anticoagulants.

Comparing Outcomes of Coronary Artery Bypass Grafting Among Large Teaching and Urban Hospitals in China and the United States.

PubMed

Zheng, Zhe; Zhang, Heng; Yuan, Xin; Rao, Chenfei; Zhao, Yan; Wang, Yun; Normand, Sharon-Lise; Krumholz, Harlan M; Hu, Shengshou

2017-06-01

Coronary artery disease is prevalent in China, with concomitant increases in the volume of coronary artery bypass grafting (CABG). The present study aims to compare CABG-related outcomes between China and the United States among large teaching and urban hospitals. Observational analysis of patients aged ≥18 years, discharged from acute-care, large teaching and urban hospitals in China and the United States after hospitalization for an isolated CABG surgery. Data were obtained from the Chinese Cardiac Surgery Registry in China and the National Inpatient Sample in the United States. Analysis was stratified by 2 periods: 2007, 2008, and 2010; and 2011 to 2013 periods. The primary outcome was in-hospital mortality, and the secondary outcome was length of stay. The sample included 51 408 patients: 32 040 from 77 hospitals in the China-CABG group and 19 368 from 303 hospitals in the US-CABG group. In the 2007 to 2008, 2010 period and for all-age and aged ≥65 years, the China-CABG group had higher mortality than the US-CABG group (1.91% versus 1.58%, P =0.059; and 3.12% versus 2.20%, P =0.004) and significantly higher age-, sex-, and comorbidity-adjusted odds of death (odds ratio, 1.58; 95% confidential interval, 1.22-2.04; and odds ratio, 1.73; 95% confidential interval, 1.24-2.40). There were no significant mortality differences in the 2011 to 2013 period. For preoperative, postoperative, and total hospital stay, respectively, the median (interquartile range) length of stay across the entire study period between China-CABG and US-CABG groups were 9 (8) versus 1 (3), 9 (6) versus 6 (3), and 20 (12) versus 7 (5) days (all P <0.001). This difference did not change significantly over time. In 2011 to 2013, there was no significant difference in in-hospital mortality among patients who underwent an isolated CABG surgery in large teaching and urban hospitals in China and the United States. The longer length of stay in China may represent an opportunity for improvement. © 2017 The Authors.

Impact of Medical Tourism on Cosmetic Surgery in the United States

PubMed Central

Franzblau, Lauren E.

2013-01-01

Summary: Developing countries have been attracting more international patients by building state-of-the-art facilities and offering sought-after healthcare services at a fraction of the cost of the US healthcare system. These price differentials matter most for elective procedures, including cosmetic surgeries, which are paid for out of pocket. It is unclear how this rise in medical tourism will affect the practice of plastic surgery, which encompasses a uniquely large number of elective procedures. By examining trends in the globalization of the cosmetic surgery market, we can better understand the current situation and what plastic surgeons in the United States can expect. In this article, we explore both domestic and foreign factors that affect surgical tourism and the current state of this industry. We also discuss how it may affect the practice of cosmetic surgery within the United States. PMID:25289258

Parecoxib relieves pain and has an opioid-sparing effect following major gastrointestinal surgery

PubMed Central

Essex, Margaret Noyes; Xu, Hao; Parsons, Bruce; Xie, Li; Li, Chunming

2017-01-01

Purpose Parecoxib provides analgesia following a variety of surgeries, including minor gastrointestinal procedures. To our knowledge, there is no data on parecoxib following major gastrointestinal surgery. This study assessed the efficacy and opioid-sparing effects of parecoxib following major gastrointestinal surgeries. Patients and methods Patients in this analysis were a subset from a large, randomized, double-blind, placebo-controlled trial of parecoxib following noncardiac surgeries and consisted of those undergoing a variety of major gastrointestinal surgeries via laparotomy. Pain, pain interference with function, supplemental opioid utilization, opioid-related symptoms, and Patient/Physician Global Evaluation of Study Medication were compared between placebo and parecoxib groups in the 2−3 days following surgery. Results Significantly (p<0.001) lower pain scores were observed in the parecoxib group (n=111), relative to placebo (n=126), on Day 2 (−33%) and Day 3 (−35%). Pain interference with function scores was also significantly (p<0.001) lower among patients receiving parecoxib compared with placebo on Day 2 (−29%) and Day 3 (−36%). At 24, 48, and 72 hours, the cumulative amount of supplemental morphine consumed was 45%, 41%, and 40% less in patients receiving parecoxib compared with placebo (all p<0.001). The risk of experiencing ≥1 opioid-related symptoms was also significantly lower with parecoxib than with placebo on Day 2 (relative risk=0.75; p<0.001). Specifically, the risks of fatigue and drowsiness were significantly (both p<0.05) lower in patients receiving parecoxib compared to those receiving placebo. Patient and Physician Global Evaluation of Study Medication scores were significantly better in the parecoxib group than in the placebo group (p<0.001). Conclusion This study is the first to demonstrate that multiple-dose parecoxib, initiated upon recovery from anesthesia, provides analgesia and opioid-sparing effects following a variety of major gastrointestinal surgeries employing laparotomy. PMID:29026330

Online marketing strategies of plastic surgeons and clinics: a comparative study of the United Kingdom and the United States.

PubMed

Nassab, Reza; Navsaria, Harshad; Myers, Simon; Frame, James

2011-07-01

The cosmetic surgery market is a rapidly growing sector of healthcare, and the use of marketing strategies is now an integral part of any cosmetic surgery practice. In this study, the authors review 50 Web sites from practitioners in London and New York to quantify the utilization of online marketing, comparing results between the United Kingdom and the United States.

Comparison of Patient Outcomes and Cost of Overlapping Versus Nonoverlapping Spine Surgery.

PubMed

Zygourakis, Corinna C; Sizdahkhani, Saman; Keefe, Malla; Lee, Janelle; Chou, Dean; Mummaneni, Praveen V; Ames, Christopher P

2017-04-01

Overlapping surgery recently has gained significant media attention, but there are limited data on its safety and efficacy. To date, there has been no analysis of overlapping surgery in the field of spine. Our goal was to compare overlapping versus nonoverlapping spine surgery patient outcomes and cost. A retrospective review was undertaken of 2319 spine surgeries (n = 848 overlapping; 1471 nonoverlapping) performed by 3 neurosurgery attendings from 2012 to 2015 at the University of California San Francisco. Collected variables included patient age, sex, insurance, American Society of Anesthesiology score, severity of illness, risk of mortality, procedure type, surgeon, day of surgery, source of transfer, admission type, overlapping versus nonoverlapping surgery (≥1 minute of overlapping procedure time), Medicare-Severity Diagnosis-Related Group, osteotomy, and presence of another attending/fellow/resident. Univariate, then multivariate mixed-effect models were used to evaluate the effect of the collected variables on the following outcomes: procedure time, estimated blood loss, length of stay, discharge status, 30-day mortality, 30-day unplanned readmission, unplanned return to OR, and total hospital cost. Urgent spine cases were more likely to be done in an overlapping fashion (all P < 0.01). After we adjusted for patient demographics, clinical indicators, and procedure characteristics, overlapping surgeries had longer procedure times (estimate = 26.17; P < 0.001) and lower rates of discharge to home (odds ratio 0.65; P < 0.001), but equivalent rates of 30-day mortality, readmission, return to the operating room, estimated blood loss, length of stay, and total hospital cost (all P = ns). Overlapping spine surgery may be performed safely at our institution, although continued monitoring of patient outcomes is necessary. Overlapping surgery does not lead to greater hospital costs. Copyright © 2017 Elsevier Inc. All rights reserved.

NIKE: a new clinical tool for establishing levels of indications for cataract surgery.

PubMed

Lundström, Mats; Albrecht, Susanne; Håkansson, Ingemar; Lorefors, Ragnhild; Ohlsson, Sven; Polland, Werner; Schmid, Andrea; Svensson, Göran; Wendel, Eva

2006-08-01

The purpose of this study was to construct a new clinical tool for establishing levels of indications for cataract surgery, and to validate this tool. Teams from nine eye clinics reached an agreement about the need to develop a clinical tool for setting levels of indications for cataract surgery and about the items that should be included in the tool. The tool was to be called 'NIKE' (Nationell Indikationsmodell för Kataraktextraktion). The Canadian Cataract Priority Criteria Tool served as a model for the NIKE tool, which was modified for Swedish conditions. Items included in the tool were visual acuity of both eyes, patients' perceived difficulties in day-to-day life, cataract symptoms, the ability to live independently, and medical/ophthalmic reasons for surgery. The tool was validated and tested in 343 cataract surgery patients. Validity, stability and reliability were tested and the outcome of surgery was studied in relation to the indication setting. Four indication groups (IGs) were suggested. The group with the greatest indications for surgery was named group 1 and that with the lowest, group 4. Validity was proved to be good. Surgery had the greatest impact on the group with the highest indications for surgery. Test-retest reliability test and interexaminer tests of indication settings showed statistically significant intraclass correlations (intraclass correlation coefficients [ICCs] 0.526 and 0.923, respectively). A new clinical tool for indication setting in cataract surgery is presented. This tool, the NIKE, takes into account both visual acuity and the patient's perceived problems in day-to-day life because of cataract. The tool seems to be stable and reliable and neutral towards different examiners.

Predictors of length of stay after urogynecological surgery at a tertiary referral center.

PubMed

Gagnon, Louise-Helene; Tang, Selphee; Brennand, Erin

2017-02-01

The primary objective of this study was to determine significant predictors of length of stay (LOS) beyond the first postoperative day after urogynecological surgery. A single-center retrospective cohort study was conducted in 2015. Our study population included women who underwent inpatient pelvic reconstructive surgery. The primary outcome was LOS beyond the first postoperative day. A logistic regression analysis explored the relationship between 11 selected predictor variables [age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, distance from home to hospital, length of surgery, anesthesia during surgery, route of surgical approach, trial of void recordings, choice of bladder protocol, presence of concomitant sling, surgeon], and LOS. Two hundred and sixty-three patients were included in this study. A logistic regression analysis identified route of surgery and trial of void recordings as the two statistically significant predictors of stay beyond the first postoperative day. The odds of LOS after laparoscopic or open surgery compared with vaginal surgery increased more than fivefold [laparoscopic vs. vaginal approach odds ratio (OR) 5.04, 95 % confidence interval (CI) 1.95-13.03; laparotomy vs. vaginal OR 15.56, 95 % CI 1.77-136.77] and more than threefold for a prolonged pass of the bladder protocol compared with an immediate pass (OR 3.25, 95 % CI 1.54-6.87). Our study identified route of surgery and trial of void recordings as the two predictors with the greatest impact on LOS beyond the first postoperative day. Our results warrant a larger follow-up study.

Remote Ischemic Preconditioning and Outcomes of Cardiac Surgery.

PubMed

Hausenloy, Derek J; Candilio, Luciano; Evans, Richard; Ariti, Cono; Jenkins, David P; Kolvekar, Shyam; Knight, Rosemary; Kunst, Gudrun; Laing, Christopher; Nicholas, Jennifer; Pepper, John; Robertson, Steven; Xenou, Maria; Clayton, Tim; Yellon, Derek M

2015-10-08

Whether remote ischemic preconditioning (transient ischemia and reperfusion of the arm) can improve clinical outcomes in patients undergoing coronary-artery bypass graft (CABG) surgery is not known. We investigated this question in a randomized trial. We conducted a multicenter, sham-controlled trial involving adults at increased surgical risk who were undergoing on-pump CABG (with or without valve surgery) with blood cardioplegia. After anesthesia induction and before surgical incision, patients were randomly assigned to remote ischemic preconditioning (four 5-minute inflations and deflations of a standard blood-pressure cuff on the upper arm) or sham conditioning (control group). Anesthetic management and perioperative care were not standardized. The combined primary end point was death from cardiovascular causes, nonfatal myocardial infarction, coronary revascularization, or stroke, assessed 12 months after randomization. We enrolled a total of 1612 patients (811 in the control group and 801 in the ischemic-preconditioning group) at 30 cardiac surgery centers in the United Kingdom. There was no significant difference in the cumulative incidence of the primary end point at 12 months between the patients in the remote ischemic preconditioning group and those in the control group (212 patients [26.5%] and 225 patients [27.7%], respectively; hazard ratio with ischemic preconditioning, 0.95; 95% confidence interval, 0.79 to 1.15; P=0.58). Furthermore, there were no significant between-group differences in either adverse events or the secondary end points of perioperative myocardial injury (assessed on the basis of the area under the curve for the high-sensitivity assay of serum troponin T at 72 hours), inotrope score (calculated from the maximum dose of the individual inotropic agents administered in the first 3 days after surgery), acute kidney injury, duration of stay in the intensive care unit and hospital, distance on the 6-minute walk test, and quality of life. Remote ischemic preconditioning did not improve clinical outcomes in patients undergoing elective on-pump CABG with or without valve surgery. (Funded by the Efficacy and Mechanism Evaluation Program [a Medical Research Council and National Institute of Health Research partnership] and the British Heart Foundation; ERICCA ClinicalTrials.gov number, NCT01247545.).

Impact of patients nutritional status on major surgery outcome.

PubMed

Mignini, E V; Scarpellini, E; Rinninella, E; Lattanzi, E; Valeri, M V; Clementi, N; Abenavoli, L; Gasbarrini, A; Rasetti, C; Santori, P

2018-06-01

Surgery is a major stress factor that activates several inflammatory and catabolic pathways in man. An appropriate nutritional status allows the body to react properly to this stressor and recover in a faster and more efficient manner. On the other hand, malnutrition is related to a worse surgery outcome and to a higher prevalence of comorbidities and mortality. The aims of this study were to evaluate the nutritional status of patients undergoing major surgery and investigate the potential correlation between malnutrition and surgical outcomes. Mini Nutritional Assessment (MNA) and global clinical examination (including biochemical parameters and comorbidities existence) were undertaken in 50 consecutive patients undergoing major surgery. Patients' clinical conditions were re-evaluated at 3 and 6 days after surgery, recording biochemical parameters and systemic and/or wound-related complications. A compromised nutritional status was present in more than half (54%) of patients (malnutrition in 10% and risk of malnutrition in 44% of patients, respectively). Females were slightly more at risk of malnutrition (48% vs. 41%, p=NS, females vs. males) and clearly malnourished (14% vs. 7%, p<0.05, females vs. males). Age was an independent risk factor for malnutrition and within the elders' group (> 80 years old) 16.70% of patients was diagnosed with malnutrition and 58.3% was at risk of malnutrition. Systemic complications were registered in all patients both at 3 and 6 days after surgery. However, well-nourished and at-risk of malnutrition patients had earlier complications that only partially resolved within six days after the operation. Malnourished patients showed fewer complications at the 3rd post-surgery follow-up day but had a worse outcome six days after surgery. Older age and but not female sex are independent risk factors for malnutrition development in patients undergoing major surgery. More interestingly, more than half of patients with an impaired nutritional status presented a less appropriated stress response to surgery. These data suggest that nutritional status assessment may be important to recognize patients at potential risk of surgical complications and that early nutritional interventions must be promptly arranged.

[Ministernotomy: a preliminary experience in heart valve surgery].

PubMed

Kovarević, Pavle; Mihajlović, Bogoljub; Velicki, Lazar; Redzek, Aleksandar; Ivanović, Vladimir; Komazec, Nikola

2011-05-01

The last decade of the 20th century brought up a significant development in the field of minimally invasive approaches to the valvular heart surgery. Potential benefits of this method are: good esthetic appearance, reduced pain, reduction of postoperative hemorrhage and incidence of surgical site infection, shorter postoperative intensive care units (ICU) period and overall in-hospital period. Partial upper median stemotomy currently presents as a state-of-the art method for minimally invasive surgery of cardiac valves. The aim of this study was to report on initial experience in application of this surgical method in the surgery of mitral and aortic valves. The study was designed and conducted in a prospective manner and included all the patients who underwent minimally invasive cardiac valve surgery through the partial upper median stemotomy during the period November 2008 - August 2009. We analyzed the data on mean age of patients, mean extubation time, mean postoperative drainage, mean duration of hospital stay, as well as on occurance of postoperative complications (postoperative bleeding, surgical site infection and cerebrovascular insult). During the observed period, in the Institute for Cardiovascular Diseases of Vojvodina, Clinic for Cardiovascular Surgery, 17 ministernotomies were performed, with 14 aortic valve replacements (82.35%) and 3 mitral valve replacements (17.65%). Mean age of the patients was 60.78 +/- 12.99 years (64.71% males, 35.29% females). Mean extubation time was 12.53 +/- 8.87 hours with 23.5% of the patients extubated in less than 8 hours. Mean duration of hospital stay was 12.35 +/- 10.17 days (in 29.4% of the patients less than 8 days). Mean postoperative drainage was 547.06 +/- 335.2 mL. Postoperative complications included: bleeding (5.88%) and cerebrovascular insult (5.88%). One patient (5.88%) required conversion to full stemotomy. Partial upper median sternotomy represents the optimal surgical method for the interventions on the whole ascendant aorta (including aortic valve) and mitral valve through the roof of the left atrium, with a few significant advantages compared to the full stemotomy surgical approach.

[Efficacy of topical 0.3% ciprofloxacin application in reducing the conjunctival biota of patients undergoing cataract extraction].

PubMed

Carron, A; Samudio, M; Laspina, F; Fariña, N; Sanabria, R R; Cibils, D; Ramirez, L; Carron, J; Mino de Kaspar, H

2013-09-01

To determine the efficacy of topical 0.3% ciprofloxacin in reducing conjunctival biota in patients undergoing cataract surgery. Experimental, prospective, randomized, controlled and single-blind study. Forty-six eyes of 46 patients were randomized into 2 groups, the study group (n=23) received topical 0.3% ciprofloxacin one day before surgery for six times, and on the day of the surgery one drop every 15minutes starting one hour before surgery until 3 doses were completed. The control group (n=23) did not receive any antibiotics. For both groups for the surgical field 10% povidone-iodine was applied. Samples from the conjunctiva were taken at four different times and then cultured on solid media (chocolate agar, blood agar) and enrichment broth (thioglycolate). The aqueous humor samples were also cultured in thioglycolate. The presence of bacteria was identified quantitatively and qualitatively, and the frequency of contamination was measured by considering the presence of bacteria in liquid and solid culture media. The number of colony forming units (CFU) was counted in the solid culture medium. Positive cultures were obtained in 82.6% and 78.2% of the patients in the study and control groups, respectively, before the administration of 0.3% ciprofloxacin. The administration of 0.3% ciprofloxacin significantly reduced the CFU compared to the control group (P<.05). Immediately after the use of povidone-iodine, the proportion of patients with a positive culture decreased to 21.7% in the study group, and 8.7% in the control group. At the end of the surgery, this percentage was 26% and 30.4%, respectively. The most common isolated pathogen was negative-coagulase Staphylococcus (66.7%). The administration of 0.3% ciprofloxacin reduces conjunctival bacterial load in the preoperative period. However, it was unable to eradicate the bacteria completely. The administration of povidone-iodine reduced conjunctival biota in 50%-70% of patients undergoing cataract surgery. Copyright © 2012 Sociedad Española de Oftalmología. Published by Elsevier Espana. All rights reserved.

Perioperative Management of Antithrombotic Therapy

PubMed Central

Douketis, James D.; Spyropoulos, Alex C.; Spencer, Frederick A.; Mayr, Michael; Jaffer, Amir K.; Eckman, Mark H.; Dunn, Andrew S.

2012-01-01

Background: This guideline addresses the management of patients who are receiving anticoagulant or antiplatelet therapy and require an elective surgery or procedure. Methods: The methods herein follow those discussed in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines article of this supplement. Results: In patients requiring vitamin K antagonist (VKA) interruption before surgery, we recommend stopping VKAs 5 days before surgery instead of a shorter time before surgery (Grade 1B). In patients with a mechanical heart valve, atrial fibrillation, or VTE at high risk for thromboembolism, we suggest bridging anticoagulation instead of no bridging during VKA interruption (Grade 2C); in patients at low risk, we suggest no bridging instead of bridging (Grade 2C). In patients who require a dental procedure, we suggest continuing VKAs with an oral prohemostatic agent or stopping VKAs 2 to 3 days before the procedure instead of alternative strategies (Grade 2C). In moderate- to high-risk patients who are receiving acetylsalicylic acid (ASA) and require noncardiac surgery, we suggest continuing ASA around the time of surgery instead of stopping ASA 7 to 10 days before surgery (Grade 2C). In patients with a coronary stent who require surgery, we recommend deferring surgery > 6 weeks after bare-metal stent placement and > 6 months after drug-eluting stent placement instead of undertaking surgery within these time periods (Grade 1C); in patients requiring surgery within 6 weeks of bare-metal stent placement or within 6 months of drug-eluting stent placement, we suggest continuing antiplatelet therapy perioperatively instead of stopping therapy 7 to 10 days before surgery (Grade 2C). Conclusions: Perioperative antithrombotic management is based on risk assessment for thromboembolism and bleeding, and recommended approaches aim to simplify patient management and minimize adverse clinical outcomes. PMID:22315266

Early Ambulation Decreases Length of Hospital Stay, Perioperative Complications and Improves Functional Outcomes in Elderly Patients Undergoing Surgery for Correction of Adult Degenerative Scoliosis.

PubMed

Adogwa, Owoicho; Elsamadicy, Aladine A; Fialkoff, Jared; Cheng, Joseph; Karikari, Isaac O; Bagley, Carlos

2017-09-15

Ambispective cohort review. To examine the effects of early mobilization on patient outcomes, complications profile, and 30-day readmission rates. Prolonged immobilization after surgery can result in functional decline and an increased risk of hospital-associated complications. We conducted an ambispective study of 125 elderly patients (>65 years) undergoing elective spinal surgery for correction of adult degenerative scoliosis. We identified all unplanned readmissions within 30 days of discharge. Unplanned readmissions were defined to have occurred as a result of either a surgical or a nonsurgical complication. "Days of immobility" was defined as the number of days until a patient moved out of bed beyond a chair. Patients in the top and bottom quartiles were dichotomized into "early ambulators" and "late ambulators", respectively. Early ambulators were ambulatory within 24 hours of surgery, whereas late ambulators were ambulatory at a minimum of 48 hours after surgery. Complication rates, duration of hospital stay, and 30-day readmission rates were compared between early ambulators and late ambulators. Baseline characteristics were similar between both cohorts. Compared with patients with a longer duration of immobility (i.e., late ambulators), the prevalence of at least one perioperative complication was significantly lower in the early ambulators cohort (30% vs. 54%, P = 0.06). The length of inhospital stay was 34% shorter in the early ambulators cohort (5.33 days vs. 8.11 days, P = 0.01). Functional independence was superior in the early ambulators cohort, with the majority of patients discharged directly home after surgery compared with late ambulators (71.2% vs. 22.0%, P = 0.01). Early ambulation after surgery significantly reduces the incidence of perioperative complications, shortens duration of inhospital stay, and contributes to improved perioperative functional status in elderly patients. Even a delay of 24 hours to ambulation is associated with higher complication rates and inferior functional outcomes. 3.

Hair Transplantation Controversies.

PubMed

Avram, Marc R; Finney, Robert; Rogers, Nicole

2017-11-01

Hair transplant surgery creates consistently natural appearing transplanted hair for men. It is increasingly popular procedure to restore natural growing hair for men with hair loss. To review some current controversies in hair transplant surgery. Review of the English PubMed literature and specialty literature in hair transplant surgery. Some of the controversies in hair transplant surgery include appropriate donor harvesting technique including elliptical donor harvesting versus follicular unit extraction whether manual versus robotic, the role of platelet-rich plasma and low-level light surgery in hair transplant surgery. Hair transplant surgery creates consistently natural appearing hair. As with all techniques, there are controversies regarding the optimal method for performing the procedure. Some of the current controversies in hair transplant surgery include optimal donor harvesting techniques, elliptical donor harvesting versus follicular unit extraction, the role of low-level light therapy and the platelet-rich plasma therapy in the procedure. Future studies will further clarify their role in the procedure.

Risk factors associated with postoperative pain after ophthalmic surgery: a prospective study

PubMed Central

Lesin, Mladen; Dzaja Lozo, Mirna; Duplancic-Sundov, Zeljka; Dzaja, Ivana; Davidovic, Nikolina; Banozic, Adriana; Puljak, Livia

2016-01-01

Background Risk factors associated with postoperative pain intensity and duration, as well as consumption of analgesics after ophthalmic surgery are poorly understood. Methods A prospective study was conducted among adults (N=226) who underwent eye surgery at the University Hospital Split, Croatia. A day before the surgery, the patients filled out questionnaires assessing personality, anxiety, pain catastrophizing, sociodemographics and were given details about the procedure, anesthesia, and analgesia for each postoperative day. All scales were previously used for the Croatian population. The intensity of pain was measured using a numerical rating scale from 0 to 10, where 0 was no pain and 10 was the worst imaginable pain. The intensity of pain was measured before the surgery and then 1 hour, 3 hours, 6 hours, and 24 hours after surgery, and then once a day until discharge from the hospital. Univariate and multivariate analyses were performed. Results A multivariate analysis indicated that independent predictors of average pain intensity after the surgery were: absence of premedication before surgery, surgery in general anesthesia, higher pain intensity before surgery and pain catastrophizing level. Independent predictors of postoperative pain duration were intensity of pain before surgery, type of anesthesia, and self-assessment of health. Independent predictors of pain intensity ≥5 during the first 6 hours after the procedure were the type of procedure, self-assessment of health, premedication, and the level of pain catastrophizing. Conclusion Awareness about independent predictors associated with average postoperative pain intensity, postoperative pain duration, and occurrence of intensive pain after surgery may help health workers to improve postoperative pain management in ophthalmic surgery. PMID:26858525

Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes.

PubMed

Botto, Fernando; Alonso-Coello, Pablo; Chan, Matthew T V; Villar, Juan Carlos; Xavier, Denis; Srinathan, Sadeesh; Guyatt, Gordon; Cruz, Patricia; Graham, Michelle; Wang, C Y; Berwanger, Otavio; Pearse, Rupert M; Biccard, Bruce M; Abraham, Valsa; Malaga, German; Hillis, Graham S; Rodseth, Reitze N; Cook, Deborah; Polanczyk, Carisi A; Szczeklik, Wojciech; Sessler, Daniel I; Sheth, Tej; Ackland, Gareth L; Leuwer, Martin; Garg, Amit X; Lemanach, Yannick; Pettit, Shirley; Heels-Ansdell, Diane; Luratibuse, Giovanna; Walsh, Michael; Sapsford, Robert; Schünemann, Holger J; Kurz, Andrea; Thomas, Sabu; Mrkobrada, Marko; Thabane, Lehana; Gerstein, Hertzel; Paniagua, Pilar; Nagele, Peter; Raina, Parminder; Yusuf, Salim; Devereaux, P J; Devereaux, P J; Sessler, Daniel I; Walsh, Michael; Guyatt, Gordon; McQueen, Matthew J; Bhandari, Mohit; Cook, Deborah; Bosch, Jackie; Buckley, Norman; Yusuf, Salim; Chow, Clara K; Hillis, Graham S; Halliwell, Richard; Li, Stephen; Lee, Vincent W; Mooney, John; Polanczyk, Carisi A; Furtado, Mariana V; Berwanger, Otavio; Suzumura, Erica; Santucci, Eliana; Leite, Katia; Santo, Jose Amalth do Espirirto; Jardim, Cesar A P; Cavalcanti, Alexandre Biasi; Guimaraes, Helio Penna; Jacka, Michael J; Graham, Michelle; McAlister, Finlay; McMurtry, Sean; Townsend, Derek; Pannu, Neesh; Bagshaw, Sean; Bessissow, Amal; Bhandari, Mohit; Duceppe, Emmanuelle; Eikelboom, John; Ganame, Javier; Hankinson, James; Hill, Stephen; Jolly, Sanjit; Lamy, Andre; Ling, Elizabeth; Magloire, Patrick; Pare, Guillaume; Reddy, Deven; Szalay, David; Tittley, Jacques; Weitz, Jeff; Whitlock, Richard; Darvish-Kazim, Saeed; Debeer, Justin; Kavsak, Peter; Kearon, Clive; Mizera, Richard; O'Donnell, Martin; McQueen, Matthew; Pinthus, Jehonathan; Ribas, Sebastian; Simunovic, Marko; Tandon, Vikas; Vanhelder, Tomas; Winemaker, Mitchell; Gerstein, Hertzel; McDonald, Sarah; O'Bryne, Paul; Patel, Ameen; Paul, James; Punthakee, Zubin; Raymer, Karen; Salehian, Omid; Spencer, Fred; Walter, Stephen; Worster, Andrew; Adili, Anthony; Clase, Catherine; Cook, Deborah; Crowther, Mark; Douketis, James; Gangji, Azim; Jackson, Paul; Lim, Wendy; Lovrics, Peter; Mazzadi, Sergio; Orovan, William; Rudkowski, Jill; Soth, Mark; Tiboni, Maria; Acedillo, Rey; Garg, Amit; Hildebrand, Ainslie; Lam, Ngan; Macneil, Danielle; Mrkobrada, Marko; Roshanov, Pavel S; Srinathan, Sadeesh K; Ramsey, Clare; John, Philip St; Thorlacius, Laurel; Siddiqui, Faisal S; Grocott, Hilary P; McKay, Andrew; Lee, Trevor W R; Amadeo, Ryan; Funk, Duane; McDonald, Heather; Zacharias, James; Villar, Juan Carlos; Cortés, Olga Lucía; Chaparro, Maria Stella; Vásquez, Skarlett; Castañeda, Alvaro; Ferreira, Silvia; Coriat, Pierre; Monneret, Denis; Goarin, Jean Pierre; Esteve, Cristina Ibanez; Royer, Catherine; Daas, Georges; Chan, Matthew T V; Choi, Gordon Y S; Gin, Tony; Lit, Lydia C W; Xavier, Denis; Sigamani, Alben; Faruqui, Atiya; Dhanpal, Radhika; Almeida, Smitha; Cherian, Joseph; Furruqh, Sultana; Abraham, Valsa; Afzal, Lalita; George, Preetha; Mala, Shaveta; Schünemann, Holger; Muti, Paola; Vizza, Enrico; Wang, C Y; Ong, G S Y; Mansor, Marzida; Tan, Alvin S B; Shariffuddin, Ina I; Vasanthan, V; Hashim, N H M; Undok, A Wahab; Ki, Ushananthini; Lai, Hou Yee; Ahmad, Wan Azman; Razack, Azad H A; Malaga, German; Valderrama-Victoria, Vanessa; Loza-Herrera, Javier D; De Los Angeles Lazo, Maria; Rotta-Rotta, Aida; Szczeklik, Wojciech; Sokolowska, Barbara; Musial, Jacek; Gorka, Jacek; Iwaszczuk, Pawel; Kozka, Mateusz; Chwala, Maciej; Raczek, Marcin; Mrowiecki, Tomasz; Kaczmarek, Bogusz; Biccard, Bruce; Cassimjee, Hussein; Gopalan, Dean; Kisten, Theroshnie; Mugabi, Aine; Naidoo, Prebashini; Naidoo, Rubeshan; Rodseth, Reitze; Skinner, David; Torborg, Alex; Paniagua, Pilar; Urrutia, Gerard; Maestre, Mari Luz; Santaló, Miquel; Gonzalez, Raúl; Font, Adrià; Martínez, Cecilia; Pelaez, Xavier; De Antonio, Marta; Villamor, Jose Marcial; García, Jesús Alvarez; Ferré, Maria José; Popova, Ekaterina; Alonso-Coello, Pablo; Garutti, Ignacio; Cruz, Patricia; Fernández, Carmen; Palencia, Maria; Díaz, Susana; Del Castillo, Teresa; Varela, Alberto; de Miguel, Angeles; Muñoz, Manuel; Piñeiro, Patricia; Cusati, Gabriel; Del Barrio, Maria; Membrillo, Maria José; Orozco, David; Reyes, Fidel; Sapsford, Robert J; Barth, Julian; Scott, Julian; Hall, Alistair; Howell, Simon; Lobley, Michaela; Woods, Janet; Howard, Susannah; Fletcher, Joanne; Dewhirst, Nikki; Williams, C; Rushton, A; Welters, I; Leuwer, M; Pearse, Rupert; Ackland, Gareth; Khan, Ahsun; Niebrzegowska, Edyta; Benton, Sally; Wragg, Andrew; Archbold, Andrew; Smith, Amanda; McAlees, Eleanor; Ramballi, Cheryl; Macdonald, Neil; Januszewska, Marta; Stephens, Robert; Reyes, Anna; Paredes, Laura Gallego; Sultan, Pervez; Cain, David; Whittle, John; Del Arroyo, Ana Gutierrez; Sessler, Daniel I; Kurz, Andrea; Sun, Zhuo; Finnegan, Patrick S; Egan, Cameron; Honar, Hooman; Shahinyan, Aram; Panjasawatwong, Krit; Fu, Alexander Y; Wang, Sihe; Reineks, Edmunds; Nagele, Peter; Blood, Jane; Kalin, Megan; Gibson, David; Wildes, Troy

2014-03-01

Myocardial injury after noncardiac surgery (MINS) was defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. The study's four objectives were to determine the diagnostic criteria, characteristics, predictors, and 30-day outcomes of MINS. In this international, prospective cohort study of 15,065 patients aged 45 yr or older who underwent in-patient noncardiac surgery, troponin T was measured during the first 3 postoperative days. Patients with a troponin T level of 0.04 ng/ml or greater (elevated "abnormal" laboratory threshold) were assessed for ischemic features (i.e., ischemic symptoms and electrocardiography findings). Patients adjudicated as having a nonischemic troponin elevation (e.g., sepsis) were excluded. To establish diagnostic criteria for MINS, the authors used Cox regression analyses in which the dependent variable was 30-day mortality (260 deaths) and independent variables included preoperative variables, perioperative complications, and potential MINS diagnostic criteria. An elevated troponin after noncardiac surgery, irrespective of the presence of an ischemic feature, independently predicted 30-day mortality. Therefore, the authors' diagnostic criterion for MINS was a peak troponin T level of 0.03 ng/ml or greater judged due to myocardial ischemia. MINS was an independent predictor of 30-day mortality (adjusted hazard ratio, 3.87; 95% CI, 2.96-5.08) and had the highest population-attributable risk (34.0%, 95% CI, 26.6-41.5) of the perioperative complications. Twelve hundred patients (8.0%) suffered MINS, and 58.2% of these patients would not have fulfilled the universal definition of myocardial infarction. Only 15.8% of patients with MINS experienced an ischemic symptom. Among adults undergoing noncardiac surgery, MINS is common and associated with substantial mortality.