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1.
Background
Surgical site infections (SSI) are a major cause of morbidity and mortality in surgical patients. Postoperative and total hospital length of stay (LOS) are known to be prolonged by the occurrence of SSI. Preoperative LOS may increase the risk of SSI. This study aims at identifying the associations of pre- and postoperative LOS in hospital and intensive care with the occurrence of SSI.Methods
This observational cohort study includes general, orthopedic trauma and vascular surgery patients at two tertiary referral centers in Switzerland between February 2013 and August 2015. The outcome of interest was the 30-day SSI rate.Results
We included 4596 patients, 234 of whom (5.1%) experienced SSI. Being admitted at least 1 day before surgery compared to same-day surgery was associated with a significant increase in the odds of SSI in univariate analysis (OR 1.65, 95% CI 1.25–2.21, p?<?0.001). More than 1 day compared to 1 day of preoperative hospital stay did not further increase the odds of SSI (OR 1.08, 95% CI 0.77–1.50, p?=?0.658). Preoperative admission to an intensive care unit (ICU) increased the odds of SSI as compared to hospital admission outside of an ICU (OR 2.19, 95% CI 0.89–4.59, p?=?0.057). Adjusting for potential confounders in multivariable analysis weakened the effects of both preoperative admission to hospital (OR 1.38, 95% CI 0.99–1.93, p?=?0.061) and to the ICU (OR 1.89, 95% CI 0.73–4.24, p?=?0.149).Conclusion
There was no significant independent association between preoperative length of stay and risk of SSI while SSI and postoperative LOS were significantly associated.2.
E. St-Louis M. Sudarshan M. Al-Habboubi M. El-Husseini Hassan D. L. Deckelbaum T. S. Razek L. S. Feldman K. Khwaja 《European journal of trauma and emergency surgery》2016,42(1):107-113
Introduction
Elderly patients form a growing subset of the acute care surgery (ACS) population. Older age may be associated with poorer outcomes for some elective procedures, but there are few studies focusing on outcomes for the elderly ACS population. Our objective is to characterize differences in mortality and morbidity for acute care surgery patients >80 years old.Methods
A retrospective review of all ACS admissions at a large teaching hospital over 1 year was conducted. Patients were classified into non-elderly (<80 years old) and elderly (≥80 years old). In addition to demographic differences, outcomes including care efficiency, mortality, postoperative complications, and length of stay were studied. Data analysis was completed with the Student’s t test for continuous variables and Fisher’s exact test for categorical variables using STATA 12 (College Station, TX, USA).Results
We identified 467 non-elderly and 60 elderly patients with a mean age-adjusted Charlson score of 3.2 and 7.2, respectively (p < 0.001) and a mortality risk of 1.9 and 11.7 %, respectively (p < 0.001). The elderly were at risk of longer duration (>4 days) hospital stay (p = 0.05), increased postoperative complications (p = 0.002), admission to the ICU (p = 0.002), and were more likely to receive a non-operative procedure (p = 0.003). No difference was found (p = NS) for patient flow factors such as time to consult general surgery, time to see consult by general surgery, and time to operative management and disposition.Conclusions
Compared to younger patients admitted to an acute care surgery service, patients over 80 years old have a higher risk of complications, are more likely to require ICU admission, and stay longer in the hospital.3.
Jessica L. Reynolds Joerg Zehetner Angela Nieh Nikolai Bildzukewicz Kulmeet Sandhu Namir Katkhouda John C. Lipham 《Surgical endoscopy》2016,30(8):3225-3230
Background
Magnetic sphincter augmentation (MSA) is approved for uncomplicated GERD. Multiple studies have shown MSA to compare favorably to laparoscopic Nissen fundoplication (LNF) in terms of symptom control with results out to 5 years. The MSA device itself, however, is an added cost to an anti-reflux surgery, and direct cost comparison studies have not been done between MSA and LNF. The aim of the study was to compare charges, complications, and outcome of MSA versus LNF at 1 year.Methods
This is a retrospective analysis of all patients who underwent MSA or LNF for the treatment of GERD between January 2010 and June 2013. Patient charges were collected for the surgical admission. We also collected data on 30-day complications and symptom control at 1 year assessed by GERD-HRQL score and PPI use.Results
There were 119 patients included in the study, 52 MSA and 67 LNF. There was no significant difference between the mean charges for MSA and LNF ($48,491 vs. $50,111, p = 0.506). There were significant differences in OR time (66 min MSA vs. 82 min LNF, p < 0.01) and LOS (17 h MSA vs. 38 h LNF, p < 0.01). At 1-year follow-up, mean GERD-HRQL was 4.3 for MSA versus 5.1 for LNF (p = 0.47) and 85 % of MSA patients versus 92 % of LNF patients were free from PPIs (p = 0.37). MSA patients reported less gas bloat symptoms (23 vs. 53 %, p ≤ 0.01) and inability to belch (10 vs. 36 %, p ≤ 0.01) and vomit (4 vs. 19 %, p ≤ 0.01).Conclusion
The side effect profile of MSA is better than LNF as evidenced by less gas bloat and increase ability to belch and vomit. LNF and MSA are comparable in symptom control, safety, and overall hospital charges. The charge for the MSA device is offset by less charges in other categories as a result of the shorter operative time and LOS.4.
Stephen S. Ttendo Adam Was Mark A. Preston Emmanuel Munyarugero Vanessa B. Kerry Paul G. Firth 《World journal of surgery》2016,40(12):2847-2856
Background
We describe delivery and outcomes of critical care at Mbarara Regional Referral Hospital, a Ugandan secondary referral hospital serving a large, widely dispersed rural population.Methods
Retrospective observational study of ICU admissions was performed from January 2008 to December 2011.Results
Of 431 admissions, 239 (55.4 %) were female, and 142 (33.2 %) were children (<18 years). The median length of stay was 2 (IQR 1–4) days, with 365 patients (85 %) staying less than 8 days. Indications for admission were surgical 49.3 % (n = 213), medical/pediatric 27.4 % (n = 118), or obstetrical/gynecological 22.3 % (n = 96). The overall mortality rate was 37.6 % (162/431) [adults 39.3 % (n = 113/287), children 33.5 % (n = 48/143), unspecified age 100 % (n = 1/1)]. Of the 162 deaths, 76 (46.9 %) occurred on the first, 20 (12.3 %) on the second, 23 (14.2 %) on the third, and 43 (26.5 %) on a subsequent day of admission. Mortality rates for common diagnoses were surgical abdomen 31.9 % (n = 29/91), trauma 45.5 % (n = 30/66), head trauma 59.6 % (n = 28/47), and poisoning 28.6 % (n = 10/35). The rate of mechanical ventilation was 49.7 % (n = 214/431). The mortality rate of ventilated patients was 73.5 % (n = 119/224). The multivariate odd ratio estimates of mortality were significant for ventilation [aOR 6.15 (95 % CI 3.83–9.87), p < 0.0001] and for length of stay beyond seven days [aOR 0.37 (95 % CI 0.19–0.70), p = 0.0021], but not significant for decade of age [aOR 1.06 (95 % CI 0.94–1.20), p = 0.33], gender [aOR 0.61(95 % CI 0.38–0.99), p = 0.07], or diagnosis type [medical vs. surgical aOR 1.08 (95 % CI 0. 63–1.84), medical vs. obstetric/gynecology aOR 0.73 (95 % CI 0.37–1.43), p = 0.49].Conclusions
The ICU predominantly functions as an acute care unit for critically ill young patients, with most deaths occurring within the first 48 h of admission. Expansion of critical care capacity in low-income countries should be accompanied by measurement of the nature and impact of this intervention.5.
Deborah S. Keller Conor P. Delaney Lobat Hashemi Eric M. Haas 《Surgical endoscopy》2016,30(10):4220-4228
Background
Surgical value is based on optimizing clinical and financial outcomes. The clinical benefits of laparoscopic surgery are well established; however, many patients are still not offered a laparoscopic procedure. Our objective was to compare the modern clinical and financial outcomes of laparoscopic and open colorectal surgery.Methods
The Premier Perspective database identified patients undergoing elective colorectal resections from January 1, 2013 to December 31, 2013. Cases were stratified by operative approach into laparoscopic and open cohorts. Groups were controlled on all demographics, diagnosis, procedural, hospital characteristics, surgeon volume, and surgeon specialty and then compared for clinical and financial outcomes. The main outcome measures were length of stay (LOS), complications, readmission rates, and cost by surgical approach.Results
A total of 6343 patients were matched and analyzed in each cohort. The most common diagnosis was diverticulitis (p = 0.0835) and the most common procedure a sigmoidectomy (p = 0.0962). The LOS was significantly shorter in laparoscopic compared to open (mean 5.78 vs. 7.80 days, p < 0.0001). The laparoscopic group had significantly lower readmission (5.82 vs. 7.68 %, p < 0.0001), complication (32.60 vs. 42.28 %, p < 0.0001), and mortality rates (0.52 vs. 1.28 %, p < 0.0001). The total cost was significantly lower in laparoscopic than in open (mean $17,269 vs. $20,552, p < 0.0001). By category, laparoscopy was significantly more cost-effective for pharmacy (p < 0.0001), room and board (p < 0.0001), recovery room (p = 0.0058), ICU (p < 0.0001), and laboratory and imaging services (both p < 0.0001). Surgical supplies (p < 0.0001), surgery (p < 0.0001), and anesthesia (p = 0.0053) were higher for the laparoscopic group.Conclusions
Laparoscopy is more cost-effective and produces better patient outcomes than open colorectal surgery. Minimally invasive colorectal surgery is now the standard that should be offered to patients, providing value to both patient and provider.6.
Background
Major blunt chest injury usually leads to the development of retained hemothorax and pneumothorax, and needs further intervention. However, since blunt chest injury may be combined with blunt head injury that typically requires patient observation for 3–4 days, other critical surgical interventions may be delayed. The purpose of this study is to analyze the outcomes of head injury patients who received early, versus delayed thoracic surgeries.Materials and methods
From May 2005 to February 2012, 61 patients with major blunt injuries to the chest and head were prospectively enrolled. These patients had an intracranial hemorrhage without indications of craniotomy. All the patients received video-assisted thoracoscopic surgery (VATS) due to retained hemothorax or pneumothorax. Patients were divided into two groups according to the time from trauma to operation, this being within 4 days for Group 1 and more than 4 days for Group 2. The clinical outcomes included hospital length of stay (LOS), intensive care unit (ICU) LOS, infection rates, and the time period of ventilator use and chest tube intubation.Result
All demographics, including age, gender, and trauma severity between the two groups showed no statistical differences. The average time from trauma to operation was 5.8 days. The ventilator usage period, the hospital and ICU length of stay were longer in Group 2 (6.77 vs. 18.55, p = 0.016; 20.63 vs. 35.13, p = 0.003; 8.97 vs. 17.65, p = 0.035). The rates of positive microbial cultures in pleural effusion collected during VATS were higher in Group 2 (6.7 vs. 29.0%, p = 0.043). The Glasgow Coma Scale score for all patients improved when patients were discharged (11.74 vs. 14.10, p < 0.05).Discussion
In this study, early VATS could be performed safely in brain hemorrhage patients without indication of surgical decompression. The clinical outcomes were much better in patients receiving early intervention within 4 days after trauma.7.
Colleen M. Trevino Karina M. Katchko Amy L. Verhaalen Marie L. Bruce Travis P. Webb 《World journal of surgery》2016,40(4):856-862
Background
Fast-track protocols (FTPs) are used to decrease length of stay (LOS) and hospital costs for elective outpatient procedures. Few institutions have implemented FTP for urgent procedures such as laparoscopic cholecystectomy (LC) and laparoscopic appendectomy (LA).Study design
This is a retrospective single-institution cohort study including all patients undergoing urgent LC or LA between July 1, 2010 and May 1, 2013. Exclusion criteria included conversion to open procedure, perforated appendicitis, or procedure related to intra-abdominal injury. Analysis included a comparison of the three study groups: (1) before (PRE) and after (POST) implementation of the fast-track protocol (FTP), (2) fast-track cohort (FT) and non-fast-track cohort (NFT), and (3) those completing the fast-track pathway (FT-C) and those who began but failed to complete the pathway (FT-F).Results
There were significant reductions in LOS between all study groups compared: between PRE (n = 256) and POST (n = 472) cohorts by half a day (2.0 vs. 1.5 days, p < 0.02); between FT and NFT (0.68 vs. 1.82 days, p < 0.01); and FT-C and FT-F (0.49 vs. 1.05 days, p < 0.01). Total hospital charges were significantly reduced in FT compared with NFT ($22,347 vs. $30,868, p < 0.01) with an average savings of $8521. Total hospital charges were decreased in the FT-C compared with FT-F cohorts ($21,971 vs. $22,939, p = 0.3) with an average savings of $968. Readmissions, complications, and satisfaction were similar for all comparison groups.Conclusions
FTPs for urgent appendectomies and cholecystectomies can significantly reduce hospital costs by reducing LOS without compromising patient outcomes.8.
Background
In high-resource settings, even mild anaemia is associated with an increased risk of post-operative complications. Whether this is true in low-resource settings is unclear. We aimed to evaluate the effect of anaemia on surgical outcomes in the Republic of Congo and Madagascar.Method
It is a retrospective chart review of 2064 non-pregnant patients undergoing elective surgery with Mercy Ships. Logistic regression was used to determine the association between pre-operative anaemia and pre-defined surgical complications, adjusted for age, gender, surgical specialty, and country.Results
The average age of patients was 27.2 years; 56.7% were male. Sixty-two percent of patients were not anaemic, and 22.7, 13.9 and 1.4% met sex-related criteria for mild, moderate and severe anaemia, respectively. In adjusted analyses, the severe anaemia group had an 8.58 [3.65, 19.49] higher odds of experiencing any surgical complication (p < 0.001) compared to non-anaemic patients. Analysis of each complication showed a 33.13 [9.57, 110.39] higher odds of unexpected ICU admission (p < 0.001); a 7.29 [1.98, 21.45] higher odds of surgical site infection (p < 0.001); and 7.48 [1.79, 25.78] higher odds of requiring hospital readmission (p < 0.001). Evaluating other anaemia categories, only those with moderate anaemia had a higher risk of requiring ICU admission (odds ratio 2.75 [1.00, 7.04], p = 0.04) compared to those without anaemia.Conclusion
Our results indicate that in low-income settings, severe anaemia is associated with an increased risk of post-operative complications including unexpected ICU admission, surgical site infection and hospital readmission, whereas mild anaemia was not associated with increased post-operative complications.9.
Purpose
To evaluate if the widespread adoption of a minimally invasive approach to radical nephrectomy has affected short- and long-term patient outcomes in the modern era.Methods
A retrospective cohort study of patients who underwent radical nephrectomy from 2001 to 2012 was conducted using the US National Cancer Institute Surveillance Epidemiology and End Results (SEER) Program and Medicare insurance program database. Patients who underwent open surgery were compared to those who underwent minimally invasive surgery using propensity score matching.Results
10,739 (85.9%) underwent open surgery and 1776 (14.1%) underwent minimally invasive surgery. Minimally invasive surgery increased from 18.4% from 2001–2004 to 43.5% from 2009 to 2012. After median follow-up of 57.1 months, minimally invasive radical nephrectomy conferred long-term oncologic efficacy in terms of overall (HR 0.84; 95% CI 0.75–0.95) survival and cancer-specific (HR 0.68; 95% CI 0.54–0.86) survival compared to open radical nephrectomy. Minimally invasive surgery was associated with lower risk of inpatient death [risk ratio (RR) 0.45 with 95% CI: (0.20–0.99), p = 0.04], deep vein thrombosis [RR: 0.35 (0.18–0.69), p = 0.002], respiratory complications [RR: 0.73 (0.60–0.89), p = 0.001], infectious complications [RR: 0.35 (0.14–0.90), p = 0.02], acute kidney injury [RR: 0.66 (0.52–0.84), p < 0.001], sepsis [RR: 0.55 (0.31–0.98), p = 0.04], prolonged length of stay (18.6 vs 30.0%, p < 0.001), and ICU admission (19.7 vs 26.3%, p < 0.001). Costs were similar between the two approaches (30-day costs $15,882 vs $15,564; p = 0.70).Conclusion
After widespread adoption of minimally invasive approaches to radical nephrectomy across the United States, oncologic standards remain preserved with improved perioperative outcomes at no additional cost burden.10.
Ismail Labgaa Ghada Jarrar Gaëtan-Romain Joliat Pierre Allemann Sylvain Gander Catherine Blanc Martin Hübner Nicolas Demartines 《World journal of surgery》2016,40(5):1082-1091
Background
Enhanced recovery after surgery (ERAS) reduces complications and hospital stay in colorectal surgery. Thereafter, ERAS principles were extended to liver surgery. Previous implementation of an ERAS program in colorectal surgery may influence patients undergoing liver surgery in a non-ERAS setting, on the same ward. This study aimed to test this hypothesis.Methods
Retrospective analysis based on prospective data of the adherence to the institutional ERAS-liver protocol (compliance) in three cohorts of consecutive patients undergoing elective liver surgery, between June 2010 and July 2014: before any ERAS implementation (pre-ERAS n = 50), after implementation of ERAS in colorectal (intermediate n = 50), and after implementation of ERAS in liver surgery (ERAS-liver n = 74). Outcomes were functional recovery, postoperative complications, hospital stay, and readmissions.Results
The three groups were comparable for demographics; laparoscopy was more frequent in ERAS-liver (p = 0.009). Compliance with the enhanced recovery protocol increased along the three periods (pre-ERAS, intermediate, and ERAS-liver), regardless of the perioperative phase (pre-, intra-, or postoperative). ERAS-liver group displayed the highest overall compliance rate with 73.8 %, compared to 39.9 and 57.4 % for pre-ERAS and intermediate groups (p = 0.072/0.056). Overall complications were unchanged (p = 0.185), whereas intermediate and ERAS-liver groups showed decreased major complications (p = 0.034). Consistently, hospital stay was reduced by 2 days (p = 0.005) without increased readmissions (p = 0.158).Conclusions
The previous implementation of an ERAS protocol in colorectal surgery may induce a positive impact on patients undergoing non-ERAS-liver surgery on the same ward. These results suggest that ERAS is safely applicable in liver surgery and associated with benefits.11.
Evgeni Brotfain Yoram Klein Ronen Toledano Leonid Koyfman Dmitry Frank Micha Y. Shamir Moti Klein 《World journal of emergency surgery : WJES》2017,12(1):41
Background
The urine output is an important clinical parameter of renal function and blood volume status, especially in critically ill multiple trauma patients. In the present study, the minute-to-minute urine flow rate and its variability were analyzed in hypotensive multiple trauma patients during the first 6 h of their ICU (intensive care unit) stay. These parameters have not been previously reported.Methods
The study was retrospective and observational. Demographic and clinical data were extracted from the computerized Register Information Systems. A total of 59 patients were included in the study. The patients were divided into two study groups. Group 1 consisted of 29 multiple trauma patients whose systolic blood pressure was greater than 90 mmHg on admission to the ICU and who were consequently deemed to be hemodynamically compromised. Group 2 consisted of 30 patients whose systolic blood pressure was less than 90 mmHg on admission to the ICU and who were therefore regarded as hemodynamically uncompromised.Results
The urine output and urine flow rate variability during the first 6 h of the patients’ ICU stay was significantly lower in group 2 than in group 1 (p < 0.001 and 0.006 respectively). Statistical analysis by the Pearson method demonstrated a strong direct correlation between decreased urine flow rate variability and decreased urine output per hour (R = 0.17; P = 0.009), decreased mean arterial blood pressure (R = 0.24; p = 0.001), and increased heart rate (R = 0.205; p = 0.001).Conclusion
These findings suggest that minute-to-minute urine flow rate variability is a reliable incipient marker of hypovolemia and that it should therefore take its place among the parameters used to monitor the hemodynamic status of critically ill multiple trauma patients.12.
Purpose
Severe scoliosis is primarily managed with surgery. This cohort study describes the incidence of surgically treated scoliosis among Swedish youth and young adults, stratified by age, sex, scoliosis type, and surgical approach and identifies changes in incidence rate and hospital length of stay (LOS), infections requiring re-surgery and mortality within 90 days.Methods
Swedish youth, 0–21 years, (n = 3062) with a diagnostic code for scoliosis and spine surgery between 2000 and 2013 were selected from the National Patient Register. Incidence was computed by comparing individuals with surgically treated scoliosis to the total at risk population. Linear regression models and Spearman correlation coefficients analyzed trends over time.Results
Overall annual incidence per 100,000 individuals was 9.1 (5.9 males/12.5 females). Annual incidence increased over 14 years from 5.1 to 9.8; an average 4.6% per year (p < 0.001). Adolescent idiopathic scoliosis was most common (4.5 per 100,000; n = 1516) followed by neuromuscular 2.7 (n = 913) and congenital 0.7 (n = 236). Average LOS decreased among scoliosis types except infantile and neuromuscular scoliosis. Posterior fusion was the most common surgical approach (75%) followed by anterior (18%) and anteroposterior fusion (7%). Posterior fusions significantly increased with a resultant decrease in anterior and anteroposterior fusion over time. Individuals with neuromuscular scoliosis exhibited the highest mortality (n = 12; 1.3%) and (n = 59; 6%) of individuals with neuromuscular scoliosis and (n = 12; 15%) with scoliosis related to MMC required revision surgery due to post-op infection.Conclusions
Surgical management of scoliosis is increasing with a concurrent decrease in hospital LOS. Surgical management of neuromuscular scoliosis is associated with high 90-day post-operative infections and mortality rate.13.
Giancarlo D’Ambrosio Alessandro M. Paganini Andrea Balla Silvia Quaresima Pietro Ursi Paolo Bruzzone Andrea Picchetto Fabrizio I. Mattei Emanuele Lezoche 《Surgical endoscopy》2016,30(2):504-511
Background
In selected patients with N0 rectal cancer, endoluminal loco-regional resection (ELRR) by transanal endoscopic microsurgery (TEM) may be an alternative treatment option to laparoscopic total mesorectal excision (LTME). Aim of this study is to evaluate the short- and medium-term quality of life (QoL) from a retrospective analysis of prospectively collected data in patients with iT2–iT3 N0-N+ rectal cancer, who underwent ELRR by TEM or LTME after neoadjuvant radio-chemotherapy (n-RCT).Methods
Thirty patients with iT2–iT3 rectal cancer who underwent ELRR by TEM (n = 15) or LTME (n = 15) were enrolled in this study. The choice for one operation or the other was made on the basis of predefined criteria. QoL was evaluated by EORTC QLQ-C30 and QLQ-CR38 questionnaires at admission, after n-RCT and 1, 6, and 12 months after surgery.Results
No statistically significant differences in QoL evaluation were observed between the two groups, both at admission and after n-RCT. At 1 month after surgery, significantly better results in the ELRR group were observed by QLQ-C30 in: Nausea/Vomiting (p = 0.05), Appetite Loss (p = 0.003), Constipation (p = 0.05), and by QLQ-CR38 in: Body Image (p = 0.05), Sexual Functioning (p = 0.03), Future Perspective (p = 0.05) and Weight Loss (p = 0.036). At 6 months after surgery, a statistically significant worse impact after LTME was observed by QLQ-C30 in: Global Health Status (p = 0.05), Emotional Functioning (p = 0.021), Dyspnea (p = 0.008), Insomnia (p = 0.012), Appetite Loss (p = 0.014) and by QLQ-CR38 in Body Image (p = 0.05) and Defecation Problems (p = 0.001). At 1 year, the two groups were homogenous as assessed by QLQ-C30, whereas the QLQ-CR38 still showed better results of ELRR versus LTME in Body Image (p = 0.006), Defecation Problems (p = 0.01), and Weight Loss (p = 0.005).Conclusions
Based on the present series, in selected patients, earlier restoration of patients’ functions is observed after ELRR by TEM than after LTME.14.
Laurent Brunaud Stephanie Polazzi Jean-Christophe Lifante Lea Pascal David Nocca Antoine Duclos 《Obesity surgery》2018,28(4):923-931
Purpose
The volume of bariatric surgery has significantly increased over the past decade with concomitant postoperative outcomes improvement. The goal of this nationwide study was to estimate the volume-outcome relationship in bariatric surgery at the hospital level.Materials and Methods
A cross-sectional analysis of all patients who underwent bariatric surgery procedure in France from January 2011 to December 2014 was designed. Volume-outcome relationship was analyzed using generalized estimating equations.Results
We identified 184,332 inpatient stays for bariatric surgical procedures performed in 606 hospitals. Health care institutions performing more than 200 bariatric cases per year were significantly associated with shorter average length of stay (p < 0.001) and less frequent need for intensive or critical care unit (p = 0.003) during the index stay in comparison with lower volume institutions. Reoperations rate increased from 3.1% [95% CI, 2.8–3.3] (n = 5627) at 1 month to 4.9% [4.6–5.2] at 3 months and 8.2% [7.8–8.7] at 6 months. The risk of reoperation after gastric bypass was 1.37 times less frequent in higher volume institutions (≥ 200 inpatient stays per year, p = 0.003), while it was 1.26 times more frequent after gastric banding in higher volume institutions (p = 0.057) and was unaltered regarding sleeve gastrectomy (p = 0.819).Conclusion
This study showed for the first time in bariatric surgery that reoperation rate after gastric bypass or sleeve significantly increased at 3 and 6 months postoperatively. Health care institutions performing more than 200 bariatric cases per year were significantly associated with improved postoperative outcomes and less frequent need for reoperation.15.
G. Soliani A. De Troia M. Portinari S. Targa P. Carcoforo G. Vasquez P. M. Fisichella C. V. Feo 《Hernia》2017,21(4):609-618
Purpose
To compare clinical outcomes and institutional costs of elective laparoscopic and open incisional hernia mesh repairs and to identify independent predictors of prolonged operative time and hospital length of stay (LOS).Methods
Retrospective observational cohort study on 269 consecutive patients who underwent elective incisional hernia mesh repair, laparoscopic group (N = 94) and open group (N = 175), between May 2004 and July 2014.Results
Operative time was shorter in the laparoscopic versus open group (p < 0.0001). Perioperative morbidity and mortality were similar in the two groups. Patients in the laparoscopic group were discharged a median of 2 days earlier (p < 0.0001). At a median follow-up over 50 months, no difference in hernia recurrence was detected between the groups. In laparoscopic group total institutional costs were lower (p = 0.02). At Cox regression analysis adjusted for potential confounders, large wall defect (W3) and higher operative risk (ASA score 3–4) were associated with prolonged operative time, while midline hernia site was associated with increased hospital LOS. Open surgical approach was associated with prolongation of both operative time and LOS.Conclusions
Laparoscopic approach may be considered safely to all patients for incisional hernia repair, regardless of patients’ characteristics (age, gender, BMI, ASA score, comorbidities) and size of the wall defect (W2-3), with the advantage of shorter operating time and hospital LOS that yields reduced total institutional costs. Patients with higher ASA score and large hernia defects are at risk of prolonged operative time, while an open approach is associated with longer duration of surgical operation and hospital LOS.16.
Amer F. Samdani Eric J. Belin James T. Bennett Firoz Miyanji Joshua M. Pahys Suken A. Shah Peter O. Newton Randal R. Betz Patrick J. Cahill Paul D. Sponseller 《European spine journal》2016,25(3):795-800
Purpose
A prospective, longitudinal cohort was studied to determine the incidence, consequences, and risk factors of major perioperative complications in patients with cerebral palsy (CP) treated with spinal fusion. There is a wide variety of data available on the complications of spine surgery; however, little exists on the perioperative complications in patients with CP.Methods
A prospective multicenter dataset of consecutive patients with CP treated with spinal fusion was evaluated. All major perioperative complications were identified and stratified into categories: pulmonary, gastrointestinal, other medical, wound infection, neurological, instrumentation related, and unplanned staged surgery. Univariate and multivariate analyses were performed to identify various risk factors for major perioperative complications.Results
127 patients were identified with a mean age of 14.3 ± 2.6 years. Overall, 39.4 % of the patients had a major perioperative complication. Occurrence of a complication [no complication (NC), yes complication (YC)] resulted in significantly increased intensive care unit (ICU) (NC = 3.2 days, YC = 7.8 days, p < 0.05) and hospital stays (NC = 7.7 days, YC = 15.6 days, p < 0.05). Variables associated with greater risk of a complication included: increased estimated blood loss (EBL) (p < 0.001), larger preoperative kyphosis (p = 0.05), staged procedures (p < 0.05), a lack of antifibrinolytic use (p < 0.05), and a trend toward lower body mass index (BMI) (p = 0.08). Multivariate regression analysis revealed an increased EBL as independently associated with a major perioperative complication (p < 0.05).Conclusions
In this cohort of patients with CP who underwent spinal fusion, 39.4 % experienced a major perioperative complication, with pulmonary being the most common. The occurrence of a major perioperative complication lengthened both ICU and hospital stay. Risk factors for major perioperative complications included greater preoperative kyphosis, staged procedures, a lack of antifibrinolytic use, and increased EBL, with the latter being an independent predictor of a major perioperative complication.Level of evidence
2.17.
Purpose
We retrospectively investigated the incidence of postoperative nightmares and evaluated the impact of postoperative intensive care on the incidence of during subsequent hospital stay. To reduce the effect of selection bias, we compared the incidence of nightmares in propensity-matched pairs with postoperative management in ICUs or in surgical wards.Methods
This is a retrospective review of an institutional registry containing 21,606 anesthesia cases and was conducted with ethics board approval. Outcomes of surgical patients treated in ICUs and in postsurgical wards (ICU admission vs non ICU admission) were compared first for nightmares using the initial 12,508 patients. To avoid channeling bias, propensity score analysis was used to generate a set of matched cases (ICU admission) and controls (non ICU admission), yielding 642 matched patient pairs. The incidence rate of nightmares was compared as the primary outcome.Results
Before adjusting patients’ characteristics, ICU environment exposure increased the incidence of nightmares compared with non-ICU environment during subsequent hospital stay [ICU vs non-ICU: 101/718 (12.3 %) vs 1147/10,542 (9.81 %)]. The odds ratio (95 % CIs) for ICU was 1.29 (1.03–1.61) for nightmares (p = 0.022). After propensity score matching, however, an equal rate of nightmares occurred in the ICU environment exposure compared to the non-ICU environment [ICU vs non-ICU: 81/561 (12.6 %) vs 73/569 (11.4 %)]. The odds ratio and 95 % CIs for ICU were 1.13 (0.80–1.58) for nightmares (p = 0.54).Conclusions
The incidence of nightmares did not become more evident during subsequent hospital stay after ICU environment exposure.18.
Background
Open abdomen (OA) permits the application of damage control surgery principles when abdominal trauma, sepsis, severe acute peritonitis and abdominal compartmental syndrome (ACS) occur.Methods
Non-traumatic patients treated with OA between January 2010 and December 2015 were identified in a prospective database, and the data collected were retrospectively reviewed. Patients’ records were collected from charts and the surgical and intensive care unit (ICU) registries. The Acosta “modified” technique was used to achieve fascial closure in vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) patients. Sex, age, simplified acute physiology score II (SAPS II), abdominal compartmental syndrome (ACS), cardiovascular disease (CVD) and surgical technique performed were evaluated in a multivariate analysis for mortality and fascial closure prediction.Results
Ninety-six patients with a median age of 69 (40–78) years were included in the study. Sixty-nine patients (72%) underwent VAWCM. Forty-one patients (68%) achieved primary fascia closure: two patients (5%) were treated with VAWC (37 median days) versus 39 patients (95%) who were treated with VAWCM (10 median days) (p = 0.0003). Forty-eight patients underwent OA treatment due to ACS, and 24 patients (50%) survived compared to 36 patients (75%) from the “other reasons” group (p = 0.01). The ACS group required longer mechanical ventilator support (p = 0.006), length of stay in hospital (p = 0.005) and in ICU (p = 0.04) and had higher SAPS II scores (p = 0.0002).Conclusions
The survival rate was 62%. ACS (p = 0.01), SAPS II (p = 0.004), sex (p = 0.01), pre-existing CVD (p = 0.0007) and surgical technique (VAWC vs VAWCM) (p = 0.0009) were determined to be predictors of mortality. Primary fascial closure was obtained in 68% of cases. VAWCM was found to grant higher survival and primary fascial closure rate.19.
20.
Thuy B. Tran Monica M. Dua David J. Worhunsky George A. Poultsides Jeffrey A. Norton Brendan C. Visser 《Surgical endoscopy》2016,30(5):1778-1783