Radical prostatectomy for carcinoma: 30-year experience and 15-year survivals.

Three strata of medical care are shown in this series of patients undergoing radical prostatectomy for carcinoma: (1) Medical School Hospital patients had an average age 4 years greater than patients in the other 2 groups and the lowest 15-year survival rate of 15 per cent. 2) The Veterans Hospital patients had an average age 4 years younger than patients in the Medical School Hospital group but there was little opportunity for preventive care by early diagnosis and they had a 15-year survival rate of 26 per cent. 3) The Emanuel series of private patients had good preventive private medical care, allowing for earlier diagnosis in a patient population without other serious medical problems, and a 15-year survival rate of 61 per cent. The 15-year survival figures for other modalities of therapy, including various types of radiation, chemotherapy and immunotherapy, are necessary for meaningful evaluation of efficacy.     

Pancreaticojejunostomy versus alternative treatment of the pancreatic stump after pancreaticoduodenectomy: a comparative analysis of early postoperative outcome

The operative management of the pancreatic stump after pancreaticoduodenectomy has been shown to be an important factor influencing the postoperative development of pancreatic fistula. Thus far, there is no ideal technique for reconstruction, and end-to-end pancreaticojejunostomy (PJS) represents the preferable method. Comparative analysis of early postoperative outcome was done between two groups of patients who underwent either end-to-end PJS or pancreatic remnant ligation (PRL) after pancreaticoduodenectomy. Between January 1997 and December 2001, 39 consecutive patients underwent pancreaticoduodenectomy at the 1st Department of Surgery, University of Athens Medical School. All operations were performed or supervised by two senior surgeons, and all patients underwent a Whipple's procedure. After pancreaticoduodenectomy, 23 patients underwent end-to-end PJS (PJS group), whereas the remaining 16 patients underwent PRL without pancreatic reconstruction (PRL group). We compared the two groups in terms of patients' characteristics, clinical presentation, serum laboratory values on admission, operative details, and postoperative course. The morbidity and mortality rates were 15.4% and 5.1%, respectively, for the whole series. In the PJS group, the morbidity rate was 8.7%, the pancreatic fistula formation rate was 4.3%, and the mortality rate was 4.3%. In the PRL group, the morbidity rate was 25%, the pancreatic fistula formation rate was 12.5%, and the mortality rate was 6.25%. These differences were not statistically significant. There were two deaths in the whole series (one in each group); however, none of the deaths were related to pancreatic fistula formation. Hospital stay was similar in both groups. Both PJS and PRL are valid surgical options that correlate with acceptable postoperative incidence of pancreatic fistula formation, morbidity, and mortality rates. Although PRL avoids the construction of the most risky anastomosis, the results of this study show that early postoperative results after PRL are not superior to PJS; therefore, the method should not be considered as the treatment of choice for the pancreatic stump after a Whipple's procedure. Meticulous surgical technique, surgical experience, and close postoperative care are essential for a successful outcome after this major abdominal operation.     

Multidisciplinary team approach in the management of tracheostomy patients

Objective To examine whether the implementation of a multidisciplinary percutaneous tracheostomy team decreases complications, improves efficiency in patient care, and reduces length of stay and cost in patients undergoing percutaneous tracheostomy. Study Design Case series with planned data collection. Setting Urban, academic, tertiary care medical center. Subjects and Methods Patients who underwent a percutaneous tracheostomy in 2004 and 2008, before and after the formation of a multidisciplinary percutaneous tracheostomy team, were included in the study. Data for the study were retrieved from a tracheostomy database. Measured outcomes include complications, efficiency, length of stay, and cost. Results Complications such as airway bleeding and physiological disturbances decreased significantly in 2008 as compared with 2004. The percentage of patients who received a tracheostomy within 2 days increased from 42.3% to 92% (2004 vs 2008), showing improvement in efficiency of care. There was no significant difference between the groups in terms of infection rate, length of stay, or mortality. However, in a subanalysis, the length of stay was found to be decreased in patients whose primary diagnosis was a neurological disorder. Finally, despite the necessity of a hospital-based subsidy, the team approach yielded substantial financial benefit to the medical center. Conclusions Airway bleeding, physiological disturbances, and efficiency of care improved after the institution of a multidisciplinary percutaneous tracheostomy team approach and may have a favorable impact on health care costs.     

Impact of a physician – critical care practitioner pre-hospital service in Wales on trauma survival: a retrospective analysis of linked registry data

The Emergency Medical Retrieval and Transfer Service for Wales launched in 2015. This service delivers senior pre-hospital doctors and advanced critical care practitioners to the scene of time-critical life- and limb-threatening incidents to provide advanced decision-making and pre-hospital clinical care. The impact of the service on 30-day mortality was evaluated retrospectively using a data linkage system. The study included patients who sustained moderate-to-severe blunt traumatic injuries (injury severity score ≥ 9) between 27 April 2015 and 30 November 2018. The association between pre-hospital management by the Emergency Medical Retrieval and Transfer Service and 30-day mortality was assessed using multivariable logistic regression. In total, data from 4035 patients were analysed, of which 412 (10%) were treated by the Emergency Medical Retrieval and Transfer Service. A greater proportion of patients treated by the Emergency Medical Retrieval and Transfer Service had an injury severity score ≥ 16 and Glasgow coma scale ≤ 12 (288 (70%) vs. 1435 (40%) and 126 (31%) vs. 325 (9%), respectively). The unadjusted 30-day mortality rate was 11.7% for patients managed by the Emergency Medical Retrieval and Transfer Service compared with 9.6% for patients managed by standard pre-hospital care services. However, after adjustment for differences in case-mix, the 30-day mortality rate for patients treated by the Emergency Medical Retrieval and Transfer Service was 37% lower (adjusted odds ratio 0.63 (95%CI 0.41–0.97); p = 0.037). The introduction of an emergency medical retrieval service was associated with a reduction in 30-day mortality for patients with blunt traumatic injury.     

Intermediate outcome of medical patients after intensive care

Medical patients suffer a high mortality after critical illness; however, the causes of mortality after intensive care management are unclear. This study's aims were to (a) explore what factors affect outcome after intensive care and (b) identify medical patients at particularly high risk of mortality. During one year, all patients admitted with a medical cause to the Critical Care Complex were enrolled. Diagnosis on admission was recorded, and whether the reason for admission was a new clinical problem or an exacerbation of existing chronic illness. All patients were followed for a minimum of one year. A total of 186 medical patients were included in the study. Fifty-four medical patients died on intensive care (28.4% mortality), a further 16 died on the general ward after intensive care unit discharge (hospital mortality 36.8%) and six following discharge home (1 year's mortality 40.9%). Of the 16 patients who died on the general ward, 12 had been admitted to the intensive care unit with a new, previously unrecognised problem rather than exacerbation of a chronic pre-existing problem. However, on the general ward, 'Do Not Resuscitate' orders were placed on seven of these 12 patients. It would appear that some of the high post intensive care hospital mortality might be due to changes in resuscitation status in patients expected to survive following intensive care unit discharge.     

Open-heart repair of ventricular septal defect in infancy by means of surface-induced hypothermia and coronary perfusion

Summary This is a follow-up study of the second consecutive series of 71 infants during the year of 1965 through 1970. Over-all mortality rate was 15.5 per cent. In the last two years, the result has improved markedly as exemplified by only one death occuring in 33 patients (3 per cent) operated. The striking decrease in the mortality rate during this period was mainly due to the intensive care of postoperative respiratory dysfunction and prevention of low cardiac output especially in infants under one year of age. Permanent heart block and complications of the central nervous system have not been observed in this series. In conclusion, patients with VSD and pulmonary hypertension should be advised to undergo radical operation even in early stage of infancy.     

Health insurance system and payments provided to patients for the management of severe acute pancreatitis in Japan

The health insurance system in Japan is based upon the Universal Medical Care Insurance System, which gives all citizens the right to join an insurance scheme of their own choice, as guaranteed by the provisions of Article 25 of the Constitution of Japan, which states: “All people shall have the right to maintain the minimum standards of wholesome and cultured living.” The health care system in Japan includes national medical insurance, nursing care for the elderly, and government payments for the treatment of intractable diseases. Medical insurance provisions are handled by Employee's Health Insurance (Social Insurance), which mainly covers employees of private companies and their families, and by National Health Insurance, which provides for the needs of self-employed people. Both schemes have their own medical care service programs for retired persons and their families. The health care system for the elderly covers people 75 years of age and over and bedridden people 65 years of age and over. There is also a system under which the government pays all or part of medical expenses, and/or pays medical expenses not covered by insurance. This is referred to collectively as the “medical expenses payment system” and includes the provision of medical assistance for specified intractable diseases. Because severe acute pancreatitis has a high mortality rate, it is specified as an intractable disease. In order to lower the mortality rate of various diseases, including severe acute pancreatitis, the specification system has been adopted by the government. The cost of treatment for severe acute pancreatitis is paid in full by the government from the date the application is made for a certificate verifying that the patient has an intractable disease.     

Immediate operation for acute non-variceal gastrointestinal haemorrhage in patients aged 50 years and over

A prospective trial of immediate operation was carried out on all 123 patients aged 50 years and over who presented with acute non-variceal bleeding as shown endoscopically. The mortality rate was 11.4%. Four hundred and sixty-seven similar patients treated by a conventional and more conservative approach, viz., surgery only for massive, continuous or recurrent bleeding, over an earlier period of three years, had a mortality rate of 6.4% during the acute bleeding episode. In the latter series, the mortality for the 161 patients with emergency surgery was 11.8%. The aggressive approach carries no advantage over the conservative approach and is not to be recommended. In both series surgery for haemorrhage with associated medical illness carried a similarly high mortality (27.3% and 26.3% respectively), indicating that the timing of surgery in such patients, whether it is done as early or as late as possible, does not influence the outcome. This mortality rate of immediate Billroth gastrectomy for gastric ulcer was low (4.8%), so that operation in such patients should not be delayed.     

Mortality in Perforated Peptic Ulcer Patients After Selective Management of Stratified Poor Risk Cases

Introduction Perforated peptic ulcer disease continues to inflict high morbidity and mortality. Although patients can be stratified according to their surgical risk, optimal management has yet to be described. In this study we demonstrate a treatment option that improves the mortality among critically ill, poor risk patients with perforated peptic ulcer disease. Methods In our study, two series were retrospectively reviewed: group A patients (n = 522) were treated in a single surgical unit at the Dhaka Medical College Hospital, Dhaka, Bangladesh during the 1980s. Among them, 124 patients were stratified as poor risk based on age, delayed presentation, peritoneal contamination, and coexisting medical problems. These criteria were the basis for selecting a group of poor risk patients (n = 84) for minimal surgical intervention (percutaneous peritoneal drainage) out of a larger group of patients, group B (n = 785) treated at Khulna Medical College Hospital during the 1990s. Results In group A, 479 patients underwent conventional operative management with an operative mortality of 8.97%. Among the 43 deaths, 24 patients were >60 years of age (55.8%), 12 patients had delayed presentation (27.9%), and 7 patients were in shock or had multiple coexisting medical problems (16.2%). In group B, 626 underwent conventional operative management, with 26 deaths at a mortality rate of 4.15%. Altogether, 84 patients were stratified as poor risk and were managed with minimal surgical intervention (percutaneous peritoneal drainage) followed by conservative treatment. Three of these patients died with an operative mortality of 3.5%. Conclusions Minimal surgical intervention (percutaneous peritoneal drainage) can significantly lower the mortality rate among a selected group of critically ill, poor risk patients with perforated peptic ulcer disease.     

Excess mortality reduction given a “reduce patient mortality at all costs” scenario for mass burn casualties

ObjectiveThe aim of this study was to estimate the effect on medical resource use and mortality of full financial support from the government for treatment costs after a mass burn casualty event in Taiwan.MethodsAll patients with burn injuries from the event were included (n = 483). Each burn patient from this incident was matched to a separate burn patient identified from the National Health Insurance database. Medical care usage and mortality were compared between groups at 1-, 3-, 6-, 9-, and 12-month intervals.ResultsRegarding outpatient expenditure, burn patients from the mass casualty event had significantly higher levels of medical expenditure compared with their control counterparts at all intervals and levels of medical institution. For inpatient expenditure, patients from the mass casualty event only had higher expenditure for the first month, and excess procedures used by these patients mainly consisted of nonvital procedures such as rehabilitation training. The mortality rate was only slightly lower for this group of burn patients compared with their control counterparts.ConclusionsFull financial support by the government in terms of medical treatment may engender only marginal additional benefits in terms of mortality if burn treatment procedures are already well established in the country.     

What are the requirements for medical cover at motor racing circuits?

Motor racing is perceived as a dangerous sport but few data are available on the incidence and nature of injuries sustained. The medical service requirement at one regional motor racing circuit was assessed by determining the incidence of injuries, the medical interventions required and the need for hospital referral and admission over a 5-year period. Five hundred and twenty-one patients, including support staff and spectators, attended the medical centre, of whom 14% were referred to hospital and 4% required admission. Each competitor had a 4% chance of requiring on-circuit medical attention, 0.6% chance of hospital referral and 0.17% chance of admission per race. Most major accidents involved more than two drivers. Twenty sustained major trauma including five pelvic fractures and two intraabdominal haemorrhages. Emergency intervention included intubation and ventilation in five. There were three deaths from a total of 9000 competitors (mortality rate 0.033%). This study shows that despite the nature of the sport, the mortality rate remains low with prompt skilled medical intervention. Medical personnel should include those competent in dealing with minor medical complaints as well as those with advanced airway management and resuscitation skills. Although national motor sport guidelines recommend a minimum of two attending doctors this would have been insufficient for multivehicle accidents.     

Elective abdominal aortic aneurysm operations--the results of a single surgeon series of 243 consecutive operations from a district general hospital

BACKGROUND: There are few data on the morbidity and mortality of planned elective surgery for infrarenal abdominal aortic aneurysm (AAA) as a single surgeon series. This audit is of a consecutive series of AAA operations performed by one surgeon in one district general hospital over a 13-year period. METHODS: 243 patients were operated on for AAA between 1985 and 1998. Data were collected on the majority of patients prospectively. A reliable method was devised to identify all patients. Any missing complication and mortality data were then collected retrospectively. RESULTS: 13 patients died as a result of their operation (5.3%). In patients over the age of 80 years (36), five patients died (14%) and in the 207 patients under the age of 80 years, eight died (3.8%). Cardiac deaths were the most frequent cause (38%); 82 patients had recorded complications (34%). The operative mortality rate has increased in later years, (2.2% to 7.1%), largely due to an increase in the very elderly accepted for operation (12% to 16%), and a possible increase in co-morbidity. CONCLUSIONS: An acceptable and comparable mortality rate can be achieved in a district general hospital. The complication rate is high indicating the need for very intense medical and nursing care for these patients postoperatively. There is a considerable variance in mortality rates with age and risk even in the practice of one surgeon, indicating a need to be very knowledgeable and cautious in interpreting postoperative mortality data. This is the largest single surgeon series to date in the UK.     

Promoting major pediatric surgical care in a low-income country: a 4-year experience in Eritrea

Background  

Access to pediatric surgical care in many sub-Saharan African countries is strongly limited by lack of medical facilities, adequate transport system, and trained medical and nursing manpower. The mortality rate for major congenital abnormalities remains extremely elevated in this area of the world. Strong efforts have been spent during the past decades to elevate the level of pediatric surgery standards in these countries through cooperation programs acting through periodical medical missions or supporting local medical teaching institutions. This is a report of a partnership between an Italian Medical Institution and the Eritrean Ministry of Health with the goal to improve pediatric surgical standard of care in the country.     

再次肝移植术后早期与死亡率相关的危险因素分析

目的 探讨再次肝移植术后早期与死亡率相关的独立危险因素.方法 回顾性分析2004年1月至2007年12月间的36例再次肝移植的资料.根据再次肝移植术后早期(术后3个月内)的转归,将患者分为死亡组和存活组.收集两组患者术前及术中常用的15项临床或实验室指标作为可能影响死亡率的危险因素进行单因素分析,将有统计学意义的危险因素再进行Logistic回归分析,筛选出与术后早期死亡率相关的独立危险因素.结果 再次肝移植术后早期死亡率为25%(9/36),死亡原因为:严重感染5例(55.6%),急性肾功能衰竭2例(22.2%),心肌梗死和脑出血各1例(各11.1%).经单因素分析显示,死亡组和存活组间术前肌酐水平、终末期肝病模型评分、感染、重症监护室(ICU)监护时间、机械通气时间以及再次肝移植的手术时间和术中出血量的差异有统计学意义(P<0.05),Logistic多元回归分析显示,术前ICU监护时间和术中出血量是术后早期与死亡率相关的独立危险因素.结论 再次肝移植术前ICU监护时间和术中出血量与术后早期死亡率密切相关.     

Acute mesenteric vascular occlusion: A review of thirty-two patients.

High mortality rates associated with mesenteric occlusion are a tremendous challenge. We reviewed 32 patients admitted to Beckley Appalachian Regional Hospital during the years 1965 to 1974. The majority of the patients were men. There was quite a variation in the symptoms and physical signs, with heart disease commonly associated with mesenteric occlusion. Massive gangrene involving the small and large bowels had the worst prognosis. Thrombectomy and anticoagulation did not prove beneficial in our series. Patients who survived massive resection are having intermittent diarrhea, responsive to medical treatment. The mortality rate in this series of 32 patients was 81.3 percent. It is hoped that with increased use of mesenteric angiography, early diagnosis, and prompt management the mortality rate can be brought down to acceptable levels.     

Nonoperative treatment of hip fractures

We retrospectively reviewed a population database and a case series to compare the mortality of operative and nonoperative treatment of hip fractures in patients with severe comorbidity. Nonoperative treatment of hip fractures (bed rest or early weight bearing) was administered based on medical assessment of perioperative risk. Comparison of 30-day mortality was performed between the nonoperatively and operatively treated groups. We found that of 50,235 of hip fractures that occurred between 1992 and 1998, 89.4% were treated operatively. Thirty-day mortality rate in the nonoperatively treated patients (18.8%) was higher than the rate in operatively treated patients (11.0%) (odds ratio 1.7 times, 95% confidence interval (CI) 1.6, 1.8). In the case series, of 62 elderly patients with severe comorbidity treated nonoperatively, 41 had bed rest/traction, while 21 were mobilized early. A group of operatively treated patients (n=108) was compared to nonoperatively treated patients. Mortality with nonoperative treatment was higher with bed rest (73%) compared to early mobilization (odds ratio 3.8, 95% CI 1.1-14.0). There was no significant difference in mortality between operatively treated patients (29%) and patients treated nonoperatively with immediate mobilization (19%). Bed rest was 2.5 times more likely to be associated with mortality compared to operative treatment (95% CI 1.1-5.5).     

Perioperative complications of radical cystectomy in a contemporary series

OBJECTIVES: Radical cystectomy is the preferred standard treatment for patients with muscle-invasive bladder cancer. With improvements in intra- and perioperative care lower complication rates have been reported. We retrospectively evaluated our series of patients who underwent radical cystectomy for advanced bladder cancer for perioperative complications as well as operative time, postoperative hospital stay and transfusion rates. PATIENTS AND METHODS: Between April 1993 and August 2005, 516 radical cystectomies were performed for muscle infiltrating transitional cell carcinoma and other types of neoplastic diseases of the bladder at our institution. The average age was 66.3 yr (31-89). RESULTS: The perioperative mortality rate was 0.8%. A total of 141 patients (27.3%) developed at least one perioperative complication. The most frequent medical complications were subileus in 20 (3.9%) patients, deep venous thrombosis in 24 (4.7%), and enterocolitis in 10 (1.9%). Surgical complications included pelvic lymphoceles in 42 (8.1%) patients, wound dehiscence in 46 (8.9%), pelvic hematoma in 4 (0.8%), peritonitis in 4 (0.8%) and small bowel obstruction in 4 (0.8%). The total early reoperation rate was 6.2%. Operative time, postoperative hospital stay and average number of blood units transfused decreased over the period 1993-2005. CONCLUSIONS: Radical cystectomy today is a procedure with an acceptable rate of perioperative morbidity and mortality. Improvements in surgical technique and anaesthesia as well as increased quality of perioperative care in recent years have resulted in reduced morbidity and shorter hospital stay.     

Gangrène cutanée des organes génitaux externes. A propos de 44 cas

Study aimThe aim of this study is to report 44 cases of male external genitalia cutaneous gangrene which have been observed at the Principal Hospital of Dakar (Senegal) during a 4-year period.Patients and methodsThe patients all belonged to a black and poor population (mean age: 60 years). Diabetes was present in 11% of the patients. In ten patients, no aetiology was found. The other 34 cases were secondary mainly to urogenital pathology (50%). In 50% of the cases, the lesions were localised on the external genitalia, in the other 50%, the lesions had spread to the hypogastrium and/or the perineum. Medical treatment included intensive care and triple antibiotic therapy, penicillin, gentamycin and metronidazole. A hyperbaric oxygen therapy was associated in 25% of the cases. The surgical treatment in the acute period included incising, debridement, paring, draining, urinary derivation (n = 36), and colostomy (n = 5). Thirteen patients had the benefit of sequential and prospective bacteriological tests.ResultsSpontaneous healing was obtained in 48% of the patients within 2 to 3 months. Secondary reconstructive surgery consisted mainly in cutaneous grafts. Global mortality rate was 34%, mortality rate was 30% in the secondary gangrenes, 40% in the primitive gangrenes. Mean hospitalisation duration was 6 weeks. Main sequelae were cheiloïd scars.ConclusionsThe authors try to clarify the nosological imprecisions of this pathology by distinguishing between the secondary types and the primitive types corresponding to Fournier's gangrene, which still inspires many questions concerning its etio-pathogenesis. The surgical treatment must eradicate all necrosis by suited iterative procedures, associated with local care. Hyperbaric oxygen therapy was not efficient in this series. This pathology, although rare, needs to be better known, because only an early and efficient surgical and medical treatment will be able to decrease the exceptional gravity of the prognosis.     

结直肠癌围手术期加速康复外科治疗的安全性及有效性研究

目的观察加速康复外科（FTS）治疗在结直肠癌手术患者中的安全性和有效性。方法30例结直肠癌患者分为两组,每组15例。对照组采用传统的围手术期处理方法;FST组采用FST程序,主要措施包括缩短患者术前的禁食时间,术前口服含碳水化合物的液体,不放置鼻胃减压管,不放置腹腔引流管,术后早期口服饮食,加强术后止痛,尽早下床活动等。观察比较两组手术及术后住院时间、营养状态、肠道功能、并发症发生及费用等情况。结果两组比较,FST组比对照组术后住院时间缩短、治疗费用减少、术后肠排气时间提前、停止静脉输液时间提前、手术后体重下降减轻,以上指标两组差异均有统计学意义。FST组的并发症并未增加。结论结直肠癌患者按FST治疗安全、有效,可以减少住院时间与费用,加速患者的康复。