The effects of surgical case duration and type of surgery on hourly clinical productivity of anesthesiologists

Surgical duration (hours per case; h/case) and type of surgery (ASA base units per case; base/case) determine the hourly clinical productivity (total ASA units per hour of anesthesia care; tASA/h) for anesthesiology groups. In previous studies, h/case negatively influenced tASA/h, but base/case did not differ significantly. However, when cases are grouped by surgical service, the mean base/case varies. In this study we evaluated the effect of h/case and base/case on tASA/h when these are grouped by surgical services. Data from one calendar year were collected from an academic anesthesiology department's billing database. All surgical cases for which the anesthesiology department provided care were included. Cases performed outside the main operating room, e.g., remote sites or obstetrics, were excluded. Any care not billed with ASA units was also excluded. Mean base/case and h/case were determined. For each service, tASA/h was calculated by dividing the sum of base/case and (4 x h/case) by h/case. A total of 12,769 cases were performed by 19 different surgical services. Mean base/case was 6.1 U, with a range of 4.0 U (orthopedics) to 16.0 U (cardiothoracic). Mean h/case was 2.9 h, with a range of 0.9 h (otolaryngology pediatric) to 5.4 h (orthopedic spine). Mean tASA/h was 6.35 U/h, with a range of 5.01 U/h (plastic surgery) to 9.71 U/h (otolaryngology pediatric). The services with high base/case did not necessarily have high tASA/h because of the longer h/case. The services with the shortest h/case had the highest tASA/h. The accurate prediction of both clinical and billing productivity requires inclusion of both base/case and surgical duration data. Anesthesiology groups should consider surgical duration when making strategic decisions.     

Day case haemorrhoidectomy

OBJECTIVE: Day case haemorrhoidectomy in a District General Hospital. We have investigated the uptake and outcome of day case haemorrhoidectomy in a small district general hospital. METHOD: Case note review with completion of standard proforma for all patients undergoing haemorrhoidectomy as day case (same day admission and discharge) or inpatient over a 4-year period. RESULTS: Sixty patients underwent day case closed haemorrhoidectomy, 2 day case stapled haemorrhoidectomy and 1 day case open haemorrhoidectomy, whilst 18 patients were treated as in-patients. One patient required re-admission within 31 days for reactionary haemorrhage after day case surgery. None suffered acute urinary retention. Concomitant medical disease or emergency admission were the only reasons for exclusion from day case haemorrhoidectomy. Of the 18 patients treated as in-patients haemorrhoidectomy two had unplanned readmission. CONCLUSION: Closed haemorrhoidectomy with same day discharge should be offered to all patients that require surgical treatment of haemorrhoids and do not have other contra-indications to day case surgery.     

腹腔镜阑尾切除术后再手术原因分析

目的 分析腹腔镜阑尾炎手术后再手术的原因,探讨腹腔镜阑尾炎手术中应注意的事项.方法 2003年5月~2013年3月,发生11例腹腔镜阑尾切除术后再手术.急性阑尾炎10例,慢性阑尾炎1例.再手术原因：腹腔脓肿4例,回盲部肿瘤1例,腹腔大出血并休克1例,腹膜后血肿1例,小肠漏1例,肠粘连1例,盆腔炎1例,胰腺炎1例.经保守治疗无效,8例行腹腔镜探查,3例开腹探查.结果 二次手术均成功.腹腔脓肿4例行腹腔镜脓肿清洗引流,腹腔大出血并休克1例行腹腔镜探查腹壁下动脉结扎,肠粘连1例行腹腔镜探查粘连带松解,盆腔炎1例行腹腔镜盆腔冲洗引流＋抗感染治疗,胰腺炎1例行腹腔镜胰腺被膜打开胰腺周围置管引流;小肠漏1例行腹腔镜探查＋开腹小肠肠管部分切除吻合术,腹膜后血肿1例行开腹探查阑尾动脉结扎,回盲部肿瘤1例行开腹右半结肠切除术（病理高分化腺癌）.术后7~21天痊愈出院.结论 腹腔镜下阑尾切除术后再手术的原因为：术前术中漏诊、误诊;术中脓液清洗不彻底,术后引流不通畅致腹腔脓肿形成;术中操作不规范,致腹壁下血管、阑尾动脉出血.腹腔镜阑尾切除术应注意规范操作,术中应探查仔细,防止漏诊、误诊.     

经尿道前列腺汽化电切术的并发症及防治

目的探讨经尿道前列腺汽化电切术并发症及原因,以提高治疗效果。方法对234例经尿道前列腺汽化电切术病例进行回顾性总结。结果术中术后出现的并发症为:包膜穿孔尿外渗7例(3%),电切综合征2例(0.9%),术中术后出血14例(6%),排尿困难5例(2.1%),尿道狭窄8例(3.4%),附睾炎3例(1.3%),暂时性尿失禁2例(0.9%),均经对症治疗治愈。结论经尿道前列腺汽化电切术时完善的术前检查、熟练的手术技巧可避免(或减少)并发症的发生,提高疗效。     

老年骨肉瘤10例治疗总结

目的探讨老年骨肉瘤（≥60岁）的临床特点和治疗效果。 方法回顾性分析2007年1月至2017年3月期间山东大学齐鲁医院骨科收治的≥60岁的骨肉瘤患者10例,女性8例,男性2例,年龄60~76岁,平均（66±6）岁,病变位于股骨5例、踝关节软组织1例、多中心1例、骨盆（Ⅲ区）1例、肱骨1例、距骨1例。确诊后行截肢术2例,截肢术结合化疗2例,广泛切除术1例,广泛切除术结合化疗3例,边缘切除结合放疗1例,单纯化疗1例。 结果10例患者中,4例就诊时病史已超过6个月,2例就诊时已出现肺转移,5例合并基础疾病,2例血清ALP水平升高（>125 U/L）。影像学方面,7例为混合型,1例为溶骨型,1例为成骨型,1例位于软组织。肿瘤组织类型方面,普通型骨肉瘤7例,骨旁骨肉瘤2例,髓内高分化性骨肉瘤1例。10例患者随访3.5~124个月,平均（40±37）个月。1例接受单纯化疗的肺转移患者于明确诊断后3.5个月死亡,另1例肺转移患者接受转移灶射频消融术,随访58个月带瘤生存,1例距骨骨肉瘤复发后行截肢术。其余7例均未出现肿瘤复发或远处转移。 结论老年骨肉瘤临床较为少见,具有不同于青少年骨肉瘤的临床特点和预后,应早期明确诊断,采取适合患者自身情况的治疗方法,以尽可能降低复发和转移的发生率,延长生存期。     

Validity and usefulness of a method to monitor surgical services’ average bias in scheduled case durations

PURPOSE: Unbiased prediction of case durations is an integral part of matching operating room (OR) staffing to workload. Monitoring systematic bias in surgeons' scheduled case durations can identify those services with estimates sufficiently inaccurate that statistical analysis of historical data may be useful in preference to the surgeons' estimates. We describe a method to monitor surgical services' average bias in scheduled case durations. METHODS: Actual case duration, predicted (scheduled) case duration, and service were obtained for all 58,291 cases during 39 four-week periods at an academic hospital. For each four-week period, a ratio was computed for each service. The numerator for each service equalled the sum of the differences in minutes between actual case duration and scheduled case duration. The denominator equalled the sum in hours of the actual durations of all of the service's cases. The ratio was multiplied by eight hours to yield the number of minutes of underestimated case duration per eight hours of OR time during the four-week period. RESULTS: The ratios followed a normal distribution for each service. Using the Student's t distribution, the 95% lower confidence bounds for the average underestimate of case duration ranged from three to 65 min per eight hours of used OR time. CONCLUSIONS: To reduce over-utilized OR time, we recommend monitoring each service's 95% lower confidence bound of the bias in scheduled case durations. For services consistently underestimating their case durations, schedule their cases using statistical estimates of case durations based on their historical data, and disregard their own estimates.     

Sequencing cases in the operating room: predicting whether one surgical case will last longer than another

A microscope will be used for the first case of the day in operating room (OR) 1 and then may be used in the second case of the day by a different surgeon in a different OR, OR 2. Provided that the probability is reasonably high that the first case of the day in OR 2 will last longer than the first case in OR 1, the OR manager can be confident in scheduling the microscope to be used by both surgeons on the same day. The OR manager can use statistical decision theory to sequence cases to decrease the impact of limitations in equipment or personnel on case scheduling. This increases utilization of both the capital equipment and OR time. In this study, we derived equations that can be programmed into a surgical services information system to reliably estimate the probability that one case will have a longer duration than another. We confirmed the accuracy of our method by using actual case duration data. IMPLICATIONS: Our statistical method uses historical case duration data from an operating room information system to estimate the actual probability to within 1.5% that the second case of a pair will last longer than the first case of a pair.     

Managing hypersexual disorders in brain-injured clients

Three case studies involving hypersexuality in brain-injured clients are illustrated. Two cases involved the inappropriate touching of the opposite sex, and the third case involved exhibitionism. In one case of touching, feedback was used to decrease inappropriate touching. In the other case of touching, scheduled massage was used to shift stimulus control to an appropriate setting. In the case of exhibitionism, a combination of self-monitoring, private self-stimulation and dating-skills training were used to suppress the behaviour.     

彩色多普勒超声对子宫瘢痕妊娠的临床价值

目的探讨彩色多普勒超声（彩超）在子宫瘢痕妊娠（CSP）的诊治中的临床价值。方法对住院治疗的9例CSP患者行彩超检查、动态观察;并在其治疗中通过彩超进行监测指导治疗。结果例8的彩超较典型,子宫前壁下段瘢痕部位见胎囊暗区,周边血流丰富;例6虽前壁下段有暗区,而暗区周边及内部却未见血流信号;例1～5和例9示子宫下段瘢痕部位不均质不规则团块,周边血流丰富,呈高速低阻血流图;例7子宫大,宫腔内多个不规则无回声区,示宫腔积血。例2、例8、例9治疗期间彩超动态观察,当提示包块周边血流不丰富时行清宫术。结论彩超可作为CSP主要的诊断依据;并在治疗中起指导作用。     

Renal lymphoma. Report of 2 cases and review of the literature]

Two cases of renal lymphoma were reported. Case 1 was a 73-year-old, and case 2 was a 59-year-old female. Their chief complaint was flank pain. The findings obtained by CT and angiography were not compatible with renal cancer. The tentative diagnosis of case 1 was inflammatory disease or soft tissue tumor, and that of case 2 was renal subcapsular tumor. Histological specimen was obtained by open biopsy from case 1, and by nephrectomy from case 2. Immunohistochemical surface marker study revealed both tumors were B cell lymphoma. Chemotherapy (CHOP-Bleo, or PPA) in both cases and additional radiotherapy in case 2 markedly reduced the tumor size. Nevertheless, case 1 died 5 months later from recurrence, and case 2 died 14 months later of gastrointestinal bleeding. At autopsy, the renal subcapsular layer was infiltrated by lymphoma cells in both cases, and lymphadenopathy was not observed. Reviewing 16 cases previously reported as renal lymphoma, the capsular or subcapsular diffuse infiltration to the kidney is considered to be a characteristic feature of renal lymphoma.     

肝癌射频消融治疗严重或少见并发症分析

目的分析射频消融(radiofrequency ablation,RFA)治疗肝癌的严重或少见并发症. 方法回顾分析2002年1月～2004年12月272例肝癌RFA治疗的严重或少见的并发症资料. 结果 272例肝癌行RFA 301次,严重或少见并发症10例,发生率为3.32% (10/301),其中2例导致死亡,病死率为0.66%(2/301).10例并发症包括:腹腔出血1例,感染2例(腹膜炎合并败血症1例,胆汁瘤继发肝脓疡1例),上消化道出血3例(其中1例为胆道出血),肝动静脉瘘1例,血气胸1例,食管胸膜瘘1例,肿瘤针道播散1例. 结论 RFA严重并发症依次为上消化道出血、感染、腹腔出血等.     

腹腔镜辅助结直肠癌切除术14例报告

目的:探讨腹腔镜技术在结直肠癌切除术中的应用。方法:回顾分析腹腔镜辅助结直肠癌切除术14例的临床资料。结果:本组右半结肠、横结肠、左半结肠以及乙状结肠根治性切除各1例,D ixon术5例,M iles术3例;1例左半结肠癌患者探查见左肾有浸润性转移而中转开腹;1例横结肠癌患者探查见肿瘤腹腔广泛转移而放弃手术;全组无手术死亡。术后1例Dukes D期患者因肿瘤转移死亡,1例Dukes C期患者1年后肠道复发,其余患者未见肿瘤复发及转移。结论:腹腔镜辅助结直肠癌根治术安全可行。     

Kaposi's visceral sarcoma in liver transplant recipients

We report three cases of Kaposi's sarcoma after orthotopic liver transplantation performed for cirrhosis related to hepatitis C virus (one case), ethanol (one case), or both (one case). All patients displayed disease within the first year after liver transplantation, and only in one case was the diagnosis obtained before the patient died. All three patients were on tacrolimus-steroid therapy, and in one case mycophenolate mofetil was added to treat acute persistent rejection.     

Acute occlusion of the iliac arteries due to blunt trauma

Two cases of acute iliac occlusion due to blunt trauma are presented. The cause of injuries were a fall from bicycle in case 1 and a compression between an automobile and a wall in case 2. The end-to-end anastomosis was possible in case 2, but an interposition of an artificial prosthesis was necessary because of the length of damaged artery in case 1. Both cases were associated with the pelvic fracture, adding the perforation of small bowels and the bladder in case 2. Postoperative course was almost uneventful except fasciotomy was needed for the compartment syndrome of the right lower extremity in case 2.     

Syringomyelia, its pathogenesis and surgical treatment based on 4 cases' experience

Four cases of syringomyelia, each were considered to have different pathogenesis of syrinx and presented different clinical and radiological pictures, are reported. Case I was associated with Chiari I malformation and the syrinx communicated with the fourth ventricle through the central canal, case 2 was associated with Chiari II malformation and the syrinx was not communicated with the fourth ventricle, case 3 was thought to be traumatic and case 4 to be arachnoiditis due to unknown etiology. Metrizamide CT myelography was most valuable diagnostic technique to disclose the syringomyelic cavity and its extension. The cases except case 1 showed central opacification without via fourth ventricle, suggesting transneural migration CSF as shown by Aubin et al. Surgical treatment, therefore, was different in each case to obtain normal CSF dynamics. Case 1 was treated by suboccipital craniectomy, muscle plugging to the obex and syringo-subarachnoid shunt. In case 2 syringo-cisternal shunt was done in addition to suboccipital craniectomy. In case 3 syringocisternal shunt was done after laminectomy. In case 4 syringo-peritoneal shunt was performed. All but case 4 were obtained favorable result and case 4 was unfavorable except the disappearance of girdle sensation. For traumatic or inflammatory syringomyelia with tight adhesion between pia and arachnoid membrane in subarachnoid space, syringocisternal shunt was good way to obtain normal CSF dynamics and was expected to relieve the neurological deterioration.     

Patient selection for day case surgery

Day surgery provides many benefits to patients and trusts. Currently, almost all surgery should be performed as day case or very short stay and as such the criteria for suitability for day case surgery have been much expanded over recent decades. Social and medical criteria should rarely prevent successful day case surgery; we present suggestions whereby historic barriers to discharge can be overcome. We discuss the suitability of surgical procedures to be performed as a day case and explain how emergency pathways can be utilised to enable an additional cohort of patients be treated as a day case. These suggestions will permit the vast majority of patients to reap the benefits of undergoing their procedure as a day case.     

人类免疫缺陷病毒感染伴肾病患者的临床病理分析

目的对行肾组织活检的人类免疫缺陷病毒(HIV)感染合并肾病患者进行病理分析。方法纳入2011年1月至2018年12月四川大学华西医院肾内科接受肾组织活检的HIV合并肾病患者,分析其病理特征、干预措施和预后等。结果共纳入9例患者,其中肾病综合征患者6例,急性肾功能损伤患者1例,慢性肾炎综合征患者2例。组织学诊断:肾小球微小病变患者3例,膜性肾病患者1例,塌陷型局灶节段性肾小球肾炎(FSGS)伴膜性肾病患者1例,FSGS非特异型(NOS)患者1例,急性间质性肾炎患者1例,Ig A肾病患者1例,糖尿病肾病患者1例。5例患者在肾组织活检时首诊HIV感染(其中塌陷型FSGS伴膜性肾病、糖尿病肾病、急性间质性肾炎各1例,2例为肾小球微小病变),其余4例在HIV感染确诊后的不同时期(均行抗逆转录病毒治疗)发病。并发症:糖尿病1例,梅毒感染1例,甲状腺功能减退2例,乙型肝炎病毒感染3例。随访情况:3例患者失访,6例患者随访期间未发生严重感染,其中2例仍有大量蛋白尿,其余4例患者血尿消失,肾功能恢复正常水平,复查尿蛋白定量显著减少至可疑阳性或24 h定量<300 mg/d。结论HIV感染者出现肾脏损伤的临床表现多样,可出现不同程度蛋白尿和(或)血尿,伴或不伴肾功能不全,病理类型不仅限于人类免疫缺陷病毒相关性肾病(HIVAN),可出现糖尿病肾病、肾小球轻微病变、膜性肾病、非塌陷型FSGS、急性间质性肾炎、Ig A肾病。肾组织活检有助于明确诊断。抗逆转录病毒治疗有效情况下,依据患者的病理诊断,有针对性地给予糖皮质激素及细胞毒药物,并加强随访,有助于改善患者预后。肾病患者应加强HIV筛查。