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1.
Tarik D. Madni Evan Barrios Jonathan B. Imran Luis Taveras Audra T. Clark Holly B. Cunningham Alana Christie Stephen Luk Herb A. Phelan Michael W. Cripps 《American journal of surgery》2019,217(4):787-793
Background
Surgical training is under scrutiny for the effect increased resident autonomy may have on patient outcomes. We hypothesize that as laparoscopic cholecystectomy (LC) difficulty increases, there will be increased involvement by senior residents and attending physicians with no differences in complications.Methods
Ten acute care surgeons were asked to fill out a postoperative questionnaire regarding surgical difficulty after every LC between 11/9/2016 and 3/30/2017. Either the Jonckheere-Terpstra test, Mantel-Haenzel chi square test, or ANOVA was used to test for the association between perioperative data and surgical difficulty.Results
A total of 190?LCs were analyzed. PGY level, percent of surgery time with attending surgeon involvement, partial cholecystectomy rate, and length of operation all significantly rose with increasing level of difficulty (p?<?0.001) with no significant differences in 60-day emergency room bounce-backs, readmission, or complication rates.Conclusions
We found that as LC difficulty increases, so does attending surgeon and/or senior resident involvement, without increased morbidity. 相似文献2.
Francesco Colombo Gianluca Pellino Francesco Selvaggi Fabio Corsi Guido Sciaudone Gianluca M. Sampietro Diego Foschi 《American journal of surgery》2019,217(4):682-688
Background
Although the creation of a stoma reduces the risk of septic pouch complications following ileal pouch-anal anastomosis (IPAA), the stoma itself and its reversal can give rise to substantial morbidity during the two- or three-stage concept. Aim of study is to compare stoma-related complications in Ulcerative Colitis patients undergoing laparoscopic versus open IPAA.Methods
We collected data on 250 IPAA patients from two Italian Centres between 2005 and 2015. We compared perioperative and postoperative events in 150 open vs 100 laparoscopic IPAA. We performed a case-matched analysis based on baseline differences among groups to compare the rate of mechanical complications.Results
There were no significant differences between open and laparoscopic IPAA in overall stoma complications (complications during ileostomy: 11.3% vs 12%,p?=?0.8; early complications: 10% vs 8%,p?=?0.5; late complications: 12.6% vs 6%,p?=?0.08). The case-matched analysis found a slightly reduced incidence of obstructive complications at any stage with laparoscopy.Conclusions
Overall stoma related complications do not seem to be reduced by minimally-invasive approach itself, but patients might experience less mechanical problems with laparoscopy without conversion. 相似文献3.
Byron D. Hughes Eric Sieloff Hemalkumar B. Mehta Anthony J. Senagore 《American journal of surgery》2019,217(3):534-538
Background
In 2008, 2005–2006 National Surgical Quality Improvement Program (NSQIP) data were used to identify surgical operations contributing disproportionately to morbidity and mortality. Since then, numerous enhanced recovery programs have been utilized to augment quality improvement efforts. This study reassesses procedural complication incidence after a decade of quality improvement efforts.Methods
Data from the 2015 NSQIP were used. The same original 36 general surgery procedure groups were created using Current Procedural Terminology codes. Ninety percent of our 409,230 patients matched into a procedure group and adverse event rates were analyzed for each.Results
Ten procedure groups accounted for 80% of adverse events. Colectomy ranked the highest for adverse events (34%), readmissions (27%) and mortality rates (45.8%). For outpatient cholecystectomy, the relative percent point difference for adverse events has increased by 224% since 2005.Conclusion
Refocusing on colectomy and outpatient cholecystectomy represent current priorities in general surgery. 相似文献4.
Karlin Sevensma Thomas Schleichert Caroline Schwickerath Alan Shoemaker Clayton Miller 《American journal of surgery》2019,217(3):479-482
Background
Improving postoperative pain control may lead to improved outcomes including decreased opioid use, shorter hospital stays, and improved patient satisfaction. This study examined the effects of instilling intraperitoneal bupivacaine following laparoscopic appendectomy.Methods
In this prospective, randomized, double-blinded, placebo-controlled study, patients with appendicitis were randomized to receive either the bupivacaine or normal saline instilled at the appendectomy site prior to close. Postoperative pain scores, opioid doses and length of stay were recorded.Results
Pain scores were lower (mean 2.48 versus 3.8; p?=?0.014), and postoperative opioid use was lower (mean 7.394?mg versus 16.921?mg; p?=?0.007) in the bupivacaine group.Conclusions
Instilling bupivacaine at the base of the cecum at the conclusion of laparoscopic appendectomy was associated with reducing postoperative pain scores and in hospital opioid use.Statement
This prospective, randomized, double-blinded, placebo-controlled study enrolled subjects with acute appendicitis undergoing laparoscopic appendectomy. Subjects were randomized to receive either bupivacaine or normal saline intraperitoneally at the close of surgery. In the bupivacaine group, pain scores at 1?h were improved and inpatient postoperative opioid use was less. 相似文献5.
Tamar B. Nobel Shruti Zaveri Prerna Khetan Celia M. Divino 《American journal of surgery》2019,217(4):613-617
Background
Recent data has demonstrated that postoperative patients are at risk of chronic opioid abuse. It is unknown whether surgeon postoperative opioid prescribing changed as the opioid crisis entered its peak.Methods
The Institutional Data Warehouse was queried to identify patients who underwent three common elective ambulatory procedures between 2014 and 2018 (n?=?3495), including: laparoscopic cholecystectomy, laparoscopic inguinal hernia repair (IHR), and open IHR. The main outcome of interest was opioid pills prescribed, converted to an equianalgesic pill number (1 pill?=?5?mg oxycodone).Results
Postoperative opioid prescribing was stable from 2014 to 2016 then decreased significantly in 2017 and 2018 (p?<?0.0001). While the median number of pills prescribed remained stable at 30 between 2014 and 2018, the frequency of patients receiving 30 pills decreased significantly. Multivariate analysis demonstrated significantly fewer pills prescribed postoperatively after 2016.Conclusions
Reductions in postoperative pills prescribed over time as the opioid crisis worsened suggests that surgeons may be considering the potential for opioid abuse and diversion. Persistently high median number of pills prescribed and continued variation in number of pills prescribed suggests room for further improvement. 相似文献6.
Tomoko Mizota Nicholas E. Anton Dimitrios Stefanidis 《American journal of surgery》2019,217(2):222-227
Background
This study aimed to identify differences in pattern recognition skill among individuals with varying surgical experience.Methods
Participants reviewed laparoscopic cholecystectomy videos of various difficulty, and paused them when the cystic duct or artery was identified to outline each structure on the monitor. Time taken to identify each structure, accuracy and work load, which was assessed using the NASA-Task Load Index (TLX), were compared among the three groups.Results
Ten students, ten residents and eight attendings participated in the study. Attendings identified the cystic duct and artery significantly faster and more accurately than students, and identified the cystic artery faster than residents. The NASA-TLX score of attendings was significantly lower than that of students and residents.Conclusions
Attendings identified anatomical structures faster, more accurately, and with less effort than students or residents. This platform may be valuable for the assessment and teaching of pattern recognition skill to novice surgeons.Short summary
Accurate anatomical recognition is paramount to proceeding safely in surgery. The assessment platform used in this study differentiated recognition skill among individuals with varing surgical experience. 相似文献7.
8.
Background
Few studies have evaluated surgical outcomes in long-term follow-up for patients undergoing Laparoscopic Ventral Hernia Repair (LVHR).Methods
A retrospective review of long-term follow-up of LVHR patients (2002–2005) at a single institution.Results
Sixty-three patients (37 males; mean age?=?63, mean BMI?=?33, 41% for recurrence) underwent LVHR. Mean operative time was 164?min. Mean hospital stay was 3.7 days. Short- and long-term complications occurred in 19% and 44% of patients, respectively.Mean follow-up was 12.4 years. Recurrent hernias were noted in 15 patients. Seroma formation occurred in 14 patients; small bowel obstruction occurred in 10 patients. Five patients developed mesh infection. Use of PTFE mesh, longer operative time, and a larger hernia defect were risk factors for mesh infection (p?<?0.05).Conclusions
Long-term outcomes for patients undergoing LVHR are fraught with complications (44%) and a considerable risk of hernia recurrence (23%). 相似文献9.
Daniel A. Hashimoto C. Gustaf Axelsson Cara B. Jones Roy Phitayakorn Emil Petrusa Sophia K. McKinley Denise Gee Carla Pugh 《American journal of surgery》2019,217(2):356-361
Introduction
The objective of this study was to determine whether decision-based procedural mapping demonstrates differences in attendings versus residents.Methods
Attendings and residents were interviewed about operative decision-making in laparoscopic cholecystectomy (LC) using a cognitive task analysis framework. Interviews were converted into procedural maps. Operative steps, patient factors, and surgeon factors noted by attendings and residents were compared. Two scoring methods were used to compare map structures of attendings versus residents.Results
Six attendings and six residents were interviewed. There were no significant differences in the number of patient or surgeon factors identified. Attendings had significantly more operative steps (29.67?±?1.9 vs. 23.3?±?1.9, p?=?0.04) and crosslinks (3.2?±?0.5 vs. 1?±?0.4, p?=?0.005) in their maps and a higher total score (90.2?±?8.4 vs. 63.2?±?3.8, p?=?0.015) than residents.Conclusion
LC procedural map scoring for attendings and residents demonstrated significant differences in structural complexity and may provide a useful framework for assessing decision making. 相似文献10.
A. Hawasli L. Camero T. Williams G. Ambrosi M. Sahly D. Demos S. Harrington 《American journal of surgery》2019,217(3):454-457
Background
Esophagectomy has high cardiac and pulmonary complication rates that can reach 43% and 58% respectively. The original Ivor Lewis esophagectomy was a two-stage procedure. We revisited this procedure using a hybrid minimally-invasive approach.Methods
Thirty-five consecutive patients with esophageal cancer were operated on over an eight-year period. The first stage used laparoscopic mobilization of the stomach, while the second stage used open thoracotomy. Six patients were aborted due to unresectable disease.Results
Twenty-nine patients were studied. The mean operative times for stage-one and stage-two were 108?±?18 and 226?±?63?min respectively. All patients were extubated in the operating room. One (3.4%) patients had cardiac complication and one (3.4%) patient had pulmonary complication.Conclusion
Metachronous hybrid two-stage esophagectomy was associated with a low rate of cardio-pulmonary complications. It may be considered as an alternative to the one-stage esophagectomy, especially in low-volume centers, to decrease these high-risk cardio-pulmonary complications. 相似文献11.
Study Design
Case report.Introduction
Development of extensor tendon adhesions is a common complication after intra-articular metacarpal head fracture. Whenever these adhesions cannot be mobilized by rehabilitation, tenolysis should be considered. However, the decision for tenolysis is often delayed. When the rehabilitation program comes to a plateau and clinical examination may not be sufficient to find out the cause, dynamic ultrasound (US) can show where the gliding mechanism is disrupted and help clinicians to give an accurate decision for determining the next steps.Purpose of the Study
To determine the role of dynamic US during hand rehabilitation.Methods
A 22-year-old woman presented with a fifth metacarpal intra-articular head fracture. Ten days after the surgery (open reduction and internal fixation) the hand rehabilitation program was commenced. After the third week, the metacarpophalangeal (MP) joint range of motion (ROM) gradually diminished. Dynamic US near the level of fifth MP joint revealed diminished extensor tendon excursion and capsular thickening.Results
Considering physical and sonographic findings, surgical tenolysis and capsular release was planned. After surgery, the DIP, PIP and MP joints reached full passive ROM.Conclusion(s)
Ultrasound is a quick and practical way to diagnose tendon adhesions. With this report, the authors suggest that clinicians may use dynamic US, especially in times when the patient comes to plateau during hand rehabilitation.Level of Evidence
IV. 相似文献12.
Study Design
Case series.Introduction
A salvaged limb is one that has undergone a major traumatic injury, followed by repeated surgical attempts in order to avoid amputation. Psychological recovery for individuals with lower extremity limb salvage has been examined in a number of studies. However, psychosocial reactions for individuals with upper extremity (UE) limb salvage are understudied in the literature.Purpose of the Study
The purpose of this study was to explore the process of psychosocial adaptation for 3 trauma cases after UE limb salvage.Methods
The Reactions to Impairment and Disability Inventory was used to assess psychosocial adaptation. Physical function outcomes (pain, range of motion, edema, sensation, and dexterity) are presented. The Disabilities of the Arm, Shoulder, and Hand measure was used to assess perceived disability. Medical and rehabilitation history are discussed for each case, in order to provide in-depth understanding of the impact of these injuries.Results
Reactions to injury varied across the cases; however, outcomes suggest that psychosocial adaptation may be influenced by the experience of pain, the ability to participate in valued roles and activities, and having a supportive social network.Discussion
For this population, therapists may consider emphasizing pain management, focusing on client-centered goals and interventions, and facilitating peer support. Providers should closely monitor patients for signs of poor adaptation, such as hand-hiding behaviors.Conclusions
This study is among the first to examine psychological outcomes for the UE limb salvage population. Future research would be beneficial to provide deeper understanding of the psychosocial challenges for these individuals. 相似文献13.
Monica M. Betancourt-Garcia Kristina Vatcheva Prateek K. Gupta Ricardo D. Martinez Joseph B. McCormick Susan P. Fisher-Hoch R. Armour Forse 《American journal of surgery》2019,217(4):618-633
Background
Existing literature has shown racial/ethnic disparities between white and black surgical populations, however, surgical outcomes for Hispanic patients are limited in both scope and quantity.Methods
Data from the American College of Surgeons National Surgical Quality Improvement Program from 2007 to 2015 was used to analyze surgical outcomes in approximately 3.5 million patients.Results
Overall, Hispanics experienced lower odds of mortality compared to non-Hispanic White, non-Hispanic Black, and non-Hispanic American Indian or Alaska Native patients (all P?<?0.0001). No difference was found in mortality odds between Hispanics and non-Hispanic Asian or Native Hawaiian patients. Hispanics experienced minimal disparities in complications as compared to non-Hispanic White and non-Hispanic Black but had a higher rate of select complications when compared to Non-Hispanic Asian, Native Hawaiian, or Pacific Islander.Conclusion
Hispanics, in general, had lower odds of 30-day postoperative mortality and major morbidity compared to most of the races/ethnicities included in the ACS NSQIP database. 相似文献14.
Study Design
Case series.Introduction
Upper extremity (UE) trauma and subsequent immobilization affects functional performance.Purpose of the Study
Determine the usefulness and feasibility of unilateral hand training (UHT) on improving functional performance in patients with UE trauma.Methods
Nine participants received UHT within 10 days of immobilization. Functional performance, dexterity, grip, and pinch strength were measured at initial and 4-week visits. Qualitative interviews were coded to develop themes.Results
All Jebsen-Taylor hand function test subtests improved from pretest to post-test. Disabilities of the Arm, Shoulder and Hand scores of all 9 participants improved. Functional performance was more impaired for participants with dominant UE injury. Four themes emerged: participants were forced to alter or avoid most daily activities, had an increased dependency on others, took longer to perform activities, and felt UHT decreased the impact of UE trauma on function.Discussion
Functional performance was impaired for all participants. Participants believed that UHT was useful and contributed to improved function.Conclusion
This case series tracked a comprehensive intervention based on a holistic activities of daily living framework that considered the nuances of individual complexities of immobilization following hand trauma. Knowledge from this study supports an early intervention like UHT to educate clients on effective strategies to improve immediate activities of daily living functioning and potentially prevent longer term impairments. 相似文献15.
Joshua Lyons Lauren McCaulley Nicole Maronian Jeffrey M. Hardacre 《American journal of surgery》2019,217(3):419-422
Background
The timing of inpatient discharges can impact hospital throughput with later discharges leading to decreased patient satisfaction, increased length of stay (LOS), and longer boarding times.Methods
A 12-month targeted intervention that included both pre-operative and inpatient components was implemented across all surgical inpatient services to increase the proportion of patients discharged by noon.Results
Discharge by noon rates increased from 14.3% to 21.5% during the 12-month initiative (p?<?0.01). The case mix index adjusted LOS (aLOS) decreased from 2.17 to 2.02 days (p?<?0.01). ED, PACU, and ICU boarding times were all significantly lower during the initiative (p?<?0.01, p?<?0.01, p?=?0.03 respectively).Conclusions
A targeted initiative to discharge surgical patients earlier resulted in a 50% increase in the proportion of patients discharged by noon. Associated with this finding were improvements in hospital throughput as measured by aLOS and boarding times in the ED, ICUs, and PACU. 相似文献16.
Benjamin R. Veenstra Aleksandra Wojtowicz Nathan Walsh Jose M. Velasco 《American journal of surgery》2019,217(3):562-565
Background
Emergency surgical airway is a low frequency, high risk clinical scenario. Implementing a simulation-based curriculum may bridge the gap in surgical training and address quality assurance/performance improvement (QAPI) needs.Methods
We designed and implemented an Advanced Surgical Airway Curriculum (ASAC) modeled after proficiency-based training. General Surgery residents and student nurse anesthetists were enrolled. Evaluation consisted of cognitive tests, procedure checklists and questionnaire.Results
In total, 78 participants successfully completed the ASAC. Trainees agreed that the curriculum provided the cognitive and psychomotor skills necessary to perform both an open and needle cricothyroidotomy.Conclusions
In the age of increased patient safety concerns, QAPI initiatives can serve as a driver for simulation-based training curricula, with particular focus on individualized, active learning. This may be particularly useful in high risk, low frequency scenarios in which the traditional method of “See one, Do one, Teach one,” is not feasible. 相似文献17.
Stephanie A. Valente Yitian Liu Siddhi Upadhyaya Chao Tu Debra A. Pratt 《American journal of surgery》2019,217(3):514-518
Introduction
The aim of this study was to determine whether complications following mastectomy with immediate breast reconstruction (IBR) were associated with breast cancer recurrence.Methods
A retrospective review was performed of women diagnosed with stage I-III breast cancer who underwent mastectomy with IBR between 2005 and 2010. Patient demographics, tumor data, surgical wound complications, treatment details and timing were recorded and analyzed.Results
We identified 458 women with a median follow up time of 7.6 years. A total of 22% of patients experienced IBR complications. There was a delay in initiation of adjuvant therapy in patients who had a complication (52 vs 41 days, p?<?0.001). There was no significant difference in recurrences between groups with and without complications (p?=?0.65).Conclusions
In breast cancer patients who undergo mastectomy with IBR, wound complications delayed initiation of adjuvant systemic therapy, but were not associated with an increased risk of cancer recurrence. 相似文献18.
Nikolaus Johannes Wachter Martin Mentzel Gert D. Krischak Joachim Gülke 《Journal of hand therapy》2019,32(1):64-70
Study Design
A within-subject research design was used in this study. The difference of the range of motion (ROM) with and without ulnar nerve block was analyzed.Introduction
For the clinical evaluation of the functional effects of ulnar nerve palsy at the hand the relevance of clinical tests is in discussion.Purpose of the Study
The aim of the study was to evaluate the predictive value of 2 clinical tests for a simulated ulnar nerve lesion by motion analysis with a sensor glove.Methods
In 28 healthy subjects, dynamic measurements of the finger joints were performed by a sensor glove with and without ulnar nerve block at the wrist. In the 0° metacarpophalangeal (MCP) stabilization test, the subjects were asked to stabilize the MCP joints actively in 0° while moving the interphalangeal joints, whereas at the 90° MCP stabilization test, the subjects stabilized the MCP joints actively in the 90° position.Results
In the 0° MCP stabilization test, no remarkable changes of the ROM were found at the MCP joints; at the proximal interphalangeal joints 2-5, the ROM decreased with ulnar nerve block, significantly at the index, middle, and ring fingers (P < .05). In the 90° MCP stabilization test, the average ROM of the MCP joints 2-5 significantly increased with ulnar nerve block (P < .05), whereas at the PIP joints, the average ROM decreased (P < .05).Discussion
The 90° MCP stabilization test had a high predictive value for the discrimination between healthy subjects and subjects with a simulated peripheral ulnar nerve lesion.Conclusions
The results could be relevant for the determination of the functional effect of ulnar nerve palsy and the quantification of clawing in hand rehabilitation.Level of Evidence
II. 相似文献19.
Elise A. Dasinger Westyn Branch-Elliman Steven D. Pizer Hassen Abdulkerim Amy K. Rosen Martin P. Charns Mary T. Hawn Kamal M.F. Itani Hillary J. Mull 《American journal of surgery》2019,217(4):605-612
Background
Opioid-related adverse drug events are common following inpatient surgical procedures. Little is known about opioid prescribing after outpatient surgical procedures and if opioid use is associated with short term risks of outpatient surgical adverse events (AEs).Methods
VA Corporate Data Warehouse was used to identify opioid use within 48?h for FY2012-14 chart-reviewed cases from a larger VA study of AEs in outpatient surgeries. We estimated a multilevel logistic regression model to determine the effect of opioid exposure on risk of AEs between 2 and 30 days postoperatively.Results
Of the 1730 outpatient surgical cases, 628 (36%) had postoperative opioid use and 12% had an AE. Opioid use following outpatient surgery was not significantly associated with higher surgical AE rates after controlling for relevant covariates (OR?=?1.1 95% CI 0.79–1.54). Only procedure RVUs were associated with higher odds of postoperative AEs.Conclusions
Postoperative opioid use following outpatient surgery is not a significant driver of postoperative AEs. 相似文献20.
Joseph A. Gil Kerry Ebert Keri Blanchard Avi D. Goodman Joseph J. Crisco Julia A. Katarincic 《Journal of hand therapy》2019,32(1):80-85