Patient-reported body image and cosmesis outcomes following kidney surgery: comparison of laparoendoscopic single-site, laparoscopic, and open surgery

Background

Laparoendoscopic single-site surgery (LESS) is reported to result in superior cosmesis versus alternative surgical approaches, based solely on surgeon assessment or anecdotal evidence.

Objective

Evaluate patient-reported body image and cosmesis outcomes following kidney surgery.

Design, setting, and participants

We conducted a prospective and retrospective observational cohort study involving patients who underwent kidney surgery (n = 114) via LESS (n = 35), laparoscopic (n = 52), or open (n = 27) approaches. Cosmesis was evaluated using a comprehensive survey administered ≥3 mo postoperatively.

Measurements

Survey components were a body image questionnaire (BIQ) consisting of body image and cosmesis subscales, a photo-series questionnaire (PSQ) assessing scar preferences after knowledge of scar outcomes for alternative surgical approaches, and query of preference for future surgical approach using a trade-off method. Body image, cosmesis, and PSQ scales ranged from 5 to 20, 3 to 24, and 1 to 10, respectively.

Results and limitations

Median BIQ component scores did not significantly differ across surgical approaches. Median ratings for the LESS, laparoscopy, and open scar photographs were 8, 5, and 5, respectively (p = 0.0001). Before viewing photographs, median self-scar ratings for LESS, laparoscopy, and open approaches were 9, 5, and 6.5, respectively (p = 0.02); after photographs, ratings were 9, 7, and 7, respectively (p = 0.008). Assuming equivalent surgical risk among the approaches, overall preference for future LESS, laparoscopy, or open surgery was 39%, 33%, or 4%, respectively. As theoretical risk of LESS was raised, preference for LESS decreased, whereas preference for laparoscopy and open surgery increased. Study limitations are a nonrandomized design and the use of a nonvalidated scale.

Conclusions

Urologic patients favor LESS cosmesis outcomes over those for laparoscopy or open surgery. Considering the superior scar satisfaction among LESS patients, who were younger and more likely to be undergoing surgery for benign disease, we infer that this demographic most values the cosmetic advantages of LESS.     

Laparoendoscopic single-site upper urinary tract surgery: assessment of postoperative complications and analysis of risk factors

Background

Laparoendoscopic single-site surgery (LESS) has been developed in an attempt to minimise the morbidity and scarring associated with surgical intervention.

Objective

To evaluate the incidence of and the risk factors for complications in patients undergoing LESS upper urinary tract surgery.

Design, setting, and participants

Between September 2007 and February 2011, 192 consecutive patients underwent LESS for upper urinary tract diseases at four institutions.

Measurements

All complications occurring at any time after surgery were captured, including the inpatient stay as well as in the outpatient setting. They were classified as early (onset <30 d), intermediate (onset 31-90 d), or late (onset >90 d) complications, depending on the date of onset. All complications were graded according to the modified Clavien classification.

Results and limitations

The patient population was generally young (mean: 55 ± 18 yr of age), nonobese (mean body mass index [BMI]: 26.5 ± 4.8 kg/m²), and healthy (mean preoperative American Society of Anaesthesiologists [ASA] score: 2 ± 1). Forty-six patients had had prior abdominal surgery. Mean operative time was 164 ± 63 min, with a mean estimated blood loss (EBL) of 147 ± 221 ml. In 77 cases (40%), the surgeons required additional ports, with a standard laparoscopy conversion rate of 6%. Mean hospital stay was 3.3 ± 2.3 d, and the mean visual analogue scale (VAS) score at discharge was 1.7 ± 1.43. Thirty-three complications were recorded—30 early, 2 intermediate, and 1 late—for an overall complication rate of 17%. Statistically significant associations were noted between the occurrence of a complication and age, ASA score, EBL, length of stay (LOS), and malignant disease at pathology. Univariable and the multivariable analyses showed that a higher ASA score (incidence rate ratio [IRR]: 1.4; 95% confidence interval [CI], 1.0-2.1; p = 0.034) and malignant disease at pathology (IRR: 2.5; 95% CI, 1.3-4.7; p = 0.039) represented risk factors for complications. Poisson regression analysis over time showed a 23% non-statistically significant reduction in risk of complications every year (IRR: 0.77; 95% CI, 0.5-1.19; p = 0.242).

Conclusions

Malignant disease at pathology and high ASA score represent a predictive factor for complication after LESS for upper urinary tract surgery. Thus, surgeons approaching LESS should start with benign diseases in low-surgical-risk patients to minimise the likelihood of postoperative complications.     

Laparoscopic diagnosis and treatment of postoperative complications

Background

There is no unequivocal attitude to a laparoscopy as to the means in the diagnosis and treatment of postoperative surgical complications. Our study sought to determine the role of laparoscopy in the management of suspected postoperative complications.

Methods

We performed a retrospective review of the patients who underwent laparoscopy for complications of previous surgery over a 6-year period.

Results

Sixty-four patients underwent laparoscopy for complications during the study period including 49 laparoscopies, 14 laparotomies, and 1 endoscopic procedure. The median delay between operations was 2 ± 4.5 days. In 18 (28.1%) patients, laparoscopy did not find intra-abdominal pathology. The conversion to open surgery was necessary in 9 (14.1%) patients. Seven patients underwent more than 1 relaparoscopy. No cases of misdiagnosis were observed. Morbidity was 12.5%. There was no laparoscopy-related death.

Conclusions

Laparoscopy is an effective tool for the management of postoperative complications after open and laparoscopic surgery. It avoids diagnostic delay and unnecessary laparotomy.     

Risk factors for acute chest syndrome in children with sickle cell disease undergoing abdominal surgery

Background/purpose

The reported incidence of acute chest syndrome (ACS) in children with sickle cell disease (SCD) is 15% to 20%. Our current objective was to assess risk factors and morbidity associated with ACS.

Methods

The authors reviewed the outcome of children with SCD undergoing abdominal surgery over a 10-year period.

Results

From 1991 to 2003, 60 children underwent laparoscopic cholecystectomy (LC; n = 29), laparoscopic splenectomy (LS; n = 28), or both (LB; n = 3). Mean age was 8.6 (0.7 to 20) years, and 35 (58%) were boys. Fifty-four (90%) had a preoperative hemoglobin greater than 10 g/dL, but only 22 (37%) received routine oxygen after surgery. No surgery was converted to an open procedure. Four children (6.6%), all of whom underwent either LS or LB, had ACS associated with an increased length of stay (7.4 ± 2.4 days) but no mortality. Factors associated with the development of ACS were age (3.0 ± 1.7 v 9.4 ± 5.7 years; P = .03), weight (12.1 ± 3.0 v 32.6 ± 18.2 kg; P = .04), operative blood loss (3.2 ± 0.5 v 1.4 ± 1.2 mL/kg; P = .03), and final temperature in the operating room (OR; 36.2 ± 0.4 v 37.6 ± 0.4 °C; P = .01). ACS was not significantly related to duration of surgery, OR fluids, or oxygen usage.

Conclusions

Younger children with greater blood and heat loss during surgery appear more prone to ACS. Splenectomy also seems to increase the risk of ACS. The authors’ current incidence (6.6%) of ACS in children with SCD undergoing abdominal surgery is much lower than previously reported. This may be explained by the aggressive use of preoperative blood transfusion or more routine use of laparoscopy.     

A prospective study comparing operative time in conventional laparoscopic and robotically assisted Thal semifundoplication in children

Background

It is not clear if robotically assisted surgery (providing articulating instruments, 3-dimensional vision, intuitive ergonomics) performed in pediatric patients offers the same advantages over conventional surgery as in adult patients. In the laboratory setting, robots require less time to perform certain tasks. Accordingly, we tested the hypothesis that the time required to perform a robotically assisted laparoscopic Thal semifundoplication is different compared with a conventional laparoscopic procedure in children.

Methods

The time required to perform single operative steps was prospectively recorded in 10 consecutively performed Thal semifundoplications with the use of a robot (da Vinci) and in 10 consecutively performed operations done by conventional laparoscopy.

Results

No conversion to an open operation was necessary, and there were no intraoperative complications throughout the study and no postoperative complications up to 14 months after surgery. Total operative time was similar in both groups. In the robotically assisted group, time for setup was significantly longer (20.8 ± 7.5 vs 34.6 ± 9.2 minutes, P < .05), but dissection of the hiatal region as the most challenging operative step was accomplished 34% faster in the robotically assisted group (30.8 ± 8.7 vs 20.2 ± 5.3 minutes, P < .05).

Conclusion

At the current level of technology, the robotic system is superior compared with established standard laparoscopic techniques requiring tissue preparation; however, the potential benefit in operating time is counterbalanced by the increased complexity of setting up the system.     

Renal cell carcinoma (RCC) in patients with end-stage renal disease exhibits many favourable clinical, pathologic, and outcome features compared with RCC in the general population

Background

Patients with end-stage renal disease (ESRD) are at risk of developing renal tumours.

Objective

Compare clinical, pathologic, and outcome features of renal cell carcinomas (RCCs) in ESRD patients and in patients from the general population.

Design, setting, and participants

Twenty-four French university departments of urology participated in this retrospective study.

Intervention

All patients were treated according to current European Association of Urology guidelines.

Measurements

Age, sex, symptoms, tumour staging and grading, histologic subtype, and outcome were recorded in a unique database. Categoric and continuous variables were compared by using chi-square and student statistical analyses. Cancer-specific survival (CSS) was assessed by Kaplan-Meier and Cox methods.

Results and limitations

The study included 1250 RCC patients: 303 with ESRD and 947 from the general population. In the ESRD patients, age at diagnosis was younger (55 ± 12 yr vs 62 ± 12 yr); mean tumour size was smaller (3.7 ± 2.6 cm vs 7.3 ± 3.8 cm); asymptomatic (87% vs 44%), low-grade (68% vs 42%), and papillary tumours were more frequent (37% vs 7%); and poor performance status (PS; 24% vs 37%) and advanced T categories (≥3) were more rare (10% vs 42%). Consistently, nodal invasion (3% vs 12%) and distant metastases (2% vs 15%) occurred less frequently in ESRD patients. After a median follow-up of 33 mo (range: 1-299 mo), 13 ESRD patients (4.3%), and 261 general population patients (27.6%) had died from cancer. In univariate analysis, histologic subtype, symptoms at diagnosis, poor PS, advanced TNM stage, high Fuhrman grade, large tumour size, and non-ESRD diagnosis context were adverse predictors for survival. However, only PS, TNM stage, and Fuhrman grade remained independent CSS predictors in multivariate analysis. The limitation of this study is related to the retrospective design.

Conclusions

RCC arising in native kidneys of ESRD patients seems to exhibit many favourable clinical, pathologic, and outcome features compared with those diagnosed in patients from the general population.     

Preoperative predictive factors of ambulatory laparoscopic cholecystectomy

Background:

The aim of our study was to review our experience and to determine preoperative predictive factors for ambulatorization of laparoscopic cholecystectomy (LC).

Methods:

Between January 1999 and June 2002, 305 consecutive LC were performed as outpatient procedures. We performed univariant and multivariant analysis of preoperative clinical, analytical and ultrasonographic variables. The preoperative scoring system developed allowed us to calculate the ambulatorization probability of LC in each individual patient.

Results:

265 patients were strictly ambulatory (86.8%). Thirty-five patients required overnight admission (11.4%), most of them due to social factors, and five patients were admitted. Preoperative factors related to overnight stay or admission were: age over 65 years (p = 0.011), past history of biliary complications (p = 0.001), previous admission due to complicated biliary disease (p = 0.001), previous supramesocholic abdominal surgery (p = 0.011) and ultrasonographic findings of gallbladder thickened wall and/or shrunken gallbladder (p = 0.041). Right classification index of the predictive system was 87.5% reaching a sensibility of 87.8% and specificity of 56.6%.

Conclusions:

Outpatient LC is safe and feasible. Age, previous biliary history and ultrasonographic findings are independent preoperative factors influencing ambulatorization rate.     

Laparoendoscopic Single-site Partial Nephrectomy Without Ischemia for Very Small,Exophytic Renal Masses: Surgical Details and Functional Outcomes

Background

Laparoendoscopic single-site surgery (LESS) has emerged as a natural progression from standard laparoscopy aiming to further minimize the morbidity of urologic procedures.

Objective

To describe our technique and report the surgical and functional outcomes of unclamped LESS partial nephrectomy (PN) in the treatment of small renal masses (SRMs).

Design, setting, and participants

Prospective evaluation of pre- and postoperative variables of patients undergoing the LESS-PN without ischemia between 2009 and 2012. The indications were single exophytic SRMs.

Surgical procedure

Unclamped LESS-PN was performed through a transperitoneal approach. A pararectal Hasson access technique was preferred. Single-port access was achieved via different single-port devices. A combination of straight and articulating laparoscopic instruments was used. The tumor was excised using bipolar scissors during normal renal perfusion. Hemostasis was achieved by bipolar electrocautery, parenchymal stitches, and hemostatic agents.

Outcome measurements and statistical analysis

Demographic, operative, postoperative, and pathologic outcomes data were recorded and analyzed.

Results and limitations

A total of 21 LESS-PN were performed (operative time: 111 ± 41 min; blood loss: 196 ± 195 ml: tumor size: 2.0 ± 0.3 cm). Neither conversion to open surgery nor transfusions occurred. Three patients required conversion to standard laparoscopy. Postoperatively, three complications (Clavien grades 2, 3a, and 4) were recorded. Pathologic examination revealed 14 clear cell carcinomas, four renal cysts, two oncocytomas, and one angiomyolipoma. Hospital stay was 4.4 ± 1.9 d. At the last follow-up (mean: 17 ± 11.5 mo), no port-site, local, or distant recurrences were detected. No significant variation in serum creatinine and estimated glomerular filtration rate was observed. Subjective scar evaluation indicated 66% of patients were very satisfied/enthusiastic. Study limitations include the small sample size, the lack of a control group, the short follow-up period, and the arbitrary measure of patient's scar perception.

Conclusions

Unclamped LESS-PN for selected SRMs is a safe and feasible procedure providing favorable postoperative outcomes and ensuring high levels of subjective, cosmetic satisfaction.     

Impact of biventricular and left ventricular pacing on hemodynamics and left ventricular dyssynchrony compared with right ventricular pacing in the early postoperative period following cardiac surgery

Objectives

The aims of this study were to test the hypotheses that in the postoperative period following corrective surgery for congenital heart defects: (i) atrio-right ventricular (RA-RV) pacing decreases cardiac output (CO) compared with right atrial (RA) pacing, (ii) atrio-biventricular (RA-BiV) and left ventricular (RA-LV) pacing improves CO compared with RA-RV pacing.

Study design

Prospective observational study.

Patients

Children 0-2 years of age referred for surgery of congenital heart defects were studied during intrinsic rhythm and atrial, atrio-right ventricular, atrio-left ventricular and atrio-biventricular pacing. CO, extrapolated from mean systolic aortic velocity (MSAV), and left ventricular dyssynchrony were assessed using transthoracic echocardiography.

Results

RA-RV pacing induced a significant decrease in CO (MSAV 0.52 ± 0.19 m/s to 0.46 ± 0.16 m/s, p = 0.01) and a significant increase in LV dyssynchrony (8.7 ± 7.9 ms to 33 ± 21 ms, p = 0.001). RA-BiV pacing induced a significant increase in CO (MSAV 0.46 ± 0.16 m/s to 0.52 ± 0.18 m/s, p = 0.01) and a significant decrease in LV dyssynchrony (33 ± 21 ms to 7 ± 4 ms, p = 0.0003) compared with RA-RV pacing. RA-LV pacing induced a significant decrease in LV dyssynchrony (33 ± 21 ms to 9 ± 7 ms, p = 0.0007) without a significant improvement of CO compared with RA-RV pacing.

Conclusions

RA-BiV pacing improves CO compared with RA-RV pacing in the early postoperative period following pediatric cardiac surgery. This improvement is related to a reduction in left ventricular dyssynchrony.     

Comparison between ETCO₂ values measured by the Smart Capnoline™ and the PACO₂ in intubated then extubated postoperative cardiac surgery patients

Objective

To compare the PaCO₂ with the ETCO₂ obtained with the Smart Capnoline™ in the postoperative setting of cardiac surgery during ventilation and after extubation

Type of study

Prospective, observational.

Patients

Twenty patients after cardiac surgery.

Methods

In the intensive care unit, arterial blood gases were measured concomitantly with ETCO₂, and difference between PaCO₂ and ETCO₂ were calculated. Three CO₂ sensors were utilized: Filterline H set for intubated patients, Smart Capnoline HO₂ (nasal version) and Smart Capnoline O₂ (bucconasal version) after extubation. Data were compared with Wilconson test and the intraclass correlation coefficient was calculated.

Results

The difference PaCO₂ - ETCO₂ was significantly larger in extubated patients compared to intubated patients, which is also confirmed for the bucconasal sensor (intubated patients: 6.6 ± 4.3 mmHg, nasal sensor: 9.3 ± 3.5 mmHg, bucconasal sensor: 15,4 ± 12.9 mmHg).

Conclusion

In the postoperative setting of cardiac surgery, ETCO₂ measurements allow a reliable estimation of PaCO₂ in intubated patients in contrast to measurements in extubated patients. The bucconasal CO₂ sensor does not show more reliable measurements compared to nasal sensors in the postoperative setting of cardiac surgery.     

Laparoscopic Surgery for Coeliac Artery Compression Syndrome: Current Management and Technical Aspects

Objectives

The study aims to assess the feasibility and midterm outcome of trans-peritoneal laparoscopy for coeliac artery compression syndrome (CACS).

Design

Retrospective chart review involving four European vascular surgery departments and two surgical teams.

Materials and methods

charts for patients who underwent laparoscopy for symptomatic CACS between December 2003 and November 2009 were reviewed. Preoperative computed tomography (CT) angiography and postoperative duplex scan and/or CT angiography were performed.

Results

Eleven consecutive patients (nine women) with a median age of 52 years (interquartile range: 42.5-59 years) underwent trans-peritoneal laparoscopy for CACS. All patients had a history of postprandial abdominal pain; weight loss exceeded 10% of the body mass in eight cases. Preoperative CT angiography revealed coeliac trunk stenosis >70% in all cases. One patient had additional aortitis and inferior mesenteric artery occlusion, while another patient presented with an occluded superior mesenteric artery. Two conversions occurred (one difficult dissection and one aorto-hepatic bypass needed for incomplete release of CACS). The median blood loss was 195 ml (range: 50-900 ml) and median operative time was 80 min (interquartile range: 65-162.5 years). Symptoms improved immediately in 10/11 patients (no residual stenosis) while one remained unchanged despite a residual stenosis treated by a percutaneous angioplasty. Symptoms reappeared in one patient due to coeliac axis occlusion. The mean follow-up period was 35 ± 23 months (range: 12-78 months).

Conclusion

Our study demonstrates that trans-peritoneal laparoscopy for treating median arcuate ligament syndrome is safe and feasible. Additional patients and a longer follow-up are needed for long-term assessment of this laparoscopic technique.     

Cancellations in ambulatory day surgery: Ten years observational study

Background

Reasons for cancellation of booked procedures in ambulatory surgery need a detailed analysis in order to introduce corrective measures to lessen them.

Methods

Cancellations occurring the day before operation without patient replacement and procedures cancelled on the day of operation in 10 500 patients scheduled to be operated on in a multidisciplinary ambulatory surgery unit were analysed. Data were obtained from the incident register sheets and the database of the unit.

Results

A total of 424 patients were cancelled (4%). Reasons for cancellation were: acute medical conditions in 23.3% of cases, personal decision of the patient to refuse programming in 22.2%, non-attendance in 2.1%, failure to follow pre-operative guidance in 23.3% and unavailability of resources in 29%. These causes were preventable or possibly preventable in 57.1% of cases, difficult to prevent in 29% and not preventable in 13.9%.

Conclusion

More than half the cases of cancellation could be prevented. A rapid response of surgical departments to substitute patients, campaigns to increase the awareness of the population about the cost of health services and the implementation of pre-operative assessment guidelines must be considered.     

Determinación de paratirina en suero como factor predictivo de hipocalcemia tras tiroidectomía total

Introduction

Postoperative parathyroid hormone (PTH) levels as a predictor of hypocalcaemia in patients subjected to total thyroidectomy is analyzed.

Matherial and method

Prospective study involving 67 patients who underwent total thyroidectomy due to a benign disease. Serum PTH and ionised calcium were measured 20 h after surgery. Sensitivity, specificity and predictive values of PTH and ionised calcium levels were calculated to predict clinical and analytical hypocalcaemia.

Results

A total of 42 (62.7%) patients developed hypocalcaemia (ionised calcium<0.95 mmol/l), but only 20 (29.9%) presented with symptoms. PTH concentration the day after surgery was significantly lower in the group that developed symptomatic hypocalcaemia (5.57±6.4 pg/ml) than in the asymptomatic (21.5±15.3 pg/ml) or normocalcaemic (26.8±24.9 pg/ml) groups (p=0.001). Taking the value of 13 pg/ml as a cut-off point of PTH levels, sensitivity, specificity, positive predictive value and negative predictive value were 54%, 72%, 76% and 48%, respectively. On the other hand, sensitivity for predicting symptomatic hypocalcaemia was 95% and specificity was 76%. The test showed a high incidence of false positives (11/30, 36%). Negative predictive value was 97% and positive predictive value was 65%. In multivariate analysis, PTH and ionised calcium were the only perioperative factors that showed an independent predictive value as risk indicators of symptomatic hypocalcaemia.

Conclusions

Normal PTH levels 20 h after surgery practically rule out the subsequent appearance of hypocalcaemia symptoms. On the other hand, low PTH levels are not necessarily associated to symptomatic hypocalcaemia due to the high number of false positives.     

Single-incision laparoscopic surgery in children: initial single-center experience

Background

In continued efforts to further improve the advantages of minimally invasive surgery to patients, surgeons have developed single-incision laparoscopic techniques. We report our initial experience in children with a variety of single-site procedures.

Method

A retrospective chart review was performed on patients who underwent a single-site procedure from April 2009 to April 2010.

Results

There were 142 consecutive procedures: 24 cholecystectomies, 103 appendectomies for nonperforated appendicitis, 2 splenectomies, 1 combined splenectomy/cholecystectomy, 8 ileocecectomies, 2 Meckel diverticulectomies, 1 small bowel duplication resection, and 1 jejunal stricture resection. There were 12 conversions to conventional laparoscopy: 10 during appendectomy and 2 during cholecystectomy. Mean operative time was 34 minutes for appendectomy, 73 minutes for cholecystectomy, 90 minutes for splenectomy, 116 minutes for combined splenectomy/cholecystectomy, 86 minutes for ileocecectomy, and 43 minutes for the small bowel procedures. The only complications were umbilical surgical site infections after appendectomy in 6 patients.

Conclusion

This institution's preliminary experience suggests that single-incision laparoscopic surgery in children has at least comparable outcomes to conventional laparoscopic surgery. However, prospective data are needed to prove that single-incision laparoscopic surgery is superior to conventional laparoscopy.     

Oral antibiotic therapy improves fat absorption in cystic fibrosis patients with small intestine bacterial overgrowth

Background

The aim of the present study was to assess the influence of antibiotic therapy on fat assimilation in cystic fibrosis (CF) patients with small intestine bacterial overgrowth (SIBO).

Materials and methods

Twenty six pancreatic insufficient CF patients with bronchopulmonary exacerbation and diagnosed SIBO (positive hydrogen-methane breath test) entered the study. ¹³C mixed triglyceride breath test was performed before and after antibiotic therapy. Sixteen subjects were treated intravenously (ceftazidime and amikacin), ten patients orally (ciprofloxacin).

Results

Cumulative percentage dose recovery changed significantly in the subgroup receiving antibiotics orally [median (mean ± SEM): 3.6% (4.5 ± 1.3%) vs. 7.2 (6.9 ± 1.6%); p = 0.019]. In the subgroup with intravenous drug administration, the tendency towards improvement was noted [2.7 (4.3 ± 1.5%) vs. 5.2 (5.7 ± 0.8%); p = 0.109].

Conclusions

Antibiotic therapy applied in CF patients with SIBO in the course of pulmonary exacerbation results in a significant improvement of fat digestion and absorption.     

Laparoendoscopic Single-site Partial Nephrectomy: A Multi-institutional Outcome Analysis

Background

Laparoendoscopic single-site surgery (LESS) has been developed in an attempt to further reduce the surgical trauma associated with conventional laparoscopy. Partial nephrectomy (PN) represents a challenging indication for LESS.

Objective

To report a large multi-institutional series of LESS-PN and to analyze the predictors of outcomes after LESS-PN.

Design, setting, and participants

Consecutive cases of LESS-PN done between November 2007 and March 2012 at 11 participating institutions were included in this retrospective analysis.

Intervention

Each group performed LESS-PN according to its own protocols, entry criteria, and techniques.

Outcome measurements and statistical analysis

Demographic data, main perioperative outcome parameters, and perioperative complications were gathered and analyzed. A multivariable analysis was used to assess the factors predicting a short (≤20 min) warm ischemia time (WIT), the occurrence of postoperative complication of any grade, and a favorable outcome, arbitrarily defined as a combination of the following events: short WIT plus no perioperative complications plus negative surgical margins plus no conversion to open surgery or standard laparoscopy.

Results and limitations

A total of 190 cases were included in this analysis. Mean renal tumor size was 2.6, and PADUA score 7.2. Median operative time was 170 min, with median estimated blood loss (EBL) of 150 ml. A clampless technique was adopted in 70 cases (36.8%), and the median WIT was 16.5 min. PADUA score independently predicted length of WIT (low vs high score: odds ratio [OR]: 5.11 [95% confidence interval (CI), 1.50–17.41]; p = 0.009; intermediate vs high score: OR: 5.13 [95% CI, 1.56–16.88]; p = 0.007). The overall postoperative complication rate was 14.7%. The adoption of a robotic LESS technique versus conventional LESS (OR: 20.92 [95% CI, 2.66–164.64]; p = 0.003) and the occurrence of lower (≤250 ml) EBL (OR: 3.60 [95% CI, 1.35–9.56]; p = 0.010) were found to be independent predictors of no postoperative complications of any grade. A favorable outcome was obtained in 83 cases (43.68%). On multivariate analysis, the only predictive factor of a favorable outcome was the PADUA score (low vs high score: OR: 4.99 [95% CI, 1.98–12.59]; p < 0.001). Limitations of the study were the retrospective design and different selection criteria for the participating centers.

Conclusions

LESS-PN can be safely and effectively performed by experienced hands, given a high likelihood of a single additional port. Anatomic tumor characteristics as determined by the PADUA score are independent predictors of a favorable surgical outcome. Thus patients presenting tumors with low PADUA scores represent the best candidates for LESS-PN. The application of a robotic platform is likely to reduce the overall risk of postoperative complications.     

Operating room nitrous oxide trace concentrations: a clinical study in ambulatory surgery

Purpose:

This blinded study evaluates the N₂O concentration variations in an ambulatory surgery centre using a small, simple on-line trace gas concentration monitor (GasFinder™ [Medair AB, Delsbo, Sweden]).

Scope:

Thirty-seven day surgical sessions using standardised anaesthesia with propofol/fentanyl induction and sevoflurane/N₂O with larynx mask. Five of 37 time-weighted averages (TWA) were greater than 25 ppm but less than 100. Peak registered concentrations reached 2000 ppm. Eleven sessions showed peak values higher than 100 ppm (range 13-1693).

Conclusions:

This simple, on-line N₂O monitor is a useful tool for detecting deviations from strict gas hygiene.     

Unexpectedly increased rate of surgical site infections following implant surgery for hip fractures: problem solution with the bundle approach

Introduction

Surgical site infections (SSIs) are the most common nosocomial infections after surgery. However, clinical guidance on how to handle any suspicious clusters of SSI in orthopaedic surgery is missing. We report on problem analysis and solution finding following the observation of an increased rate of SSI in trauma implant surgery.

Setting

Trauma unit of a university hospital.

Methods

Over a 2-year observation period, all patients (n = 370) following surgical stabilisation of proximal femur fractures in a trauma unit of a university hospital were consecutively followed using a standardised case report form. First, a retrospective cohort of 217 patients was collected for whom an increased SSI rate was detected. Based on risk analysis, new standard perioperative procedures were developed and implemented. The impact was evaluated in a prospective cohort of 153 comparable patients. Uni- and multivariable analysis of factors associated with the risk for SSI was undertaken.

Results

The intervention bundle resulted in a significant reduction of an initially increased SSI incidence of 6.9 (down) to 2.0% (p = 0.029). Multivariable analysis revealed four risk factors significantly associated with a higher risk of SSI caused by different bacteria: duration of surgery (p = 0.002), hemiarthroplasty (p = 0.002), haematoma (p = 0.004) and the presence of two operating room staff members (p < 0.001 and 0.035).

Conclusions

A standardised prospective SSI protocol and detection system offering the simultaneous use of data should guarantee every institution immediate alarm registration to avoid comparable problem situations. Detailed interdisciplinary analysis followed by the implementation of coherent interventions, based on a best-evidence structured bundle approach, may adequately resolve similar critical incidence episodes.     

A population-based analysis of temporal perioperative complication rates after minimally invasive radical prostatectomy

Background

Existing population-based reports on complication rates after minimally invasive radical prostatectomy (MIRP) did not address temporal trends.

Objective

To examine contemporary temporal trends in perioperative MIRP outcomes.

Design, setting, and participants

Between 2001 and 2007, 4387 patients undergoing MIRP were identified using the Nationwide Inpatient Sample.

Measurements

To examine the rates and trends of intraoperative and postoperative complications, transfusion rates, length of stay in excess of the median, and in-hospital mortality. We tested the effect of the late (2006-2007) versus the early (2001-2005) study period on all outcomes using multivariable logistic regression models controlled for clustering among hospitals.

Results and limitations

Intraoperative and postoperative complications decreased from 7.0% to 0.8% (p < 0.001) and from 28.5% to 8.7% (p < 0.001), respectively. Transfusion rates decreased from 3.5% to 2.1% (p = 0.3). Hospital length of stay >2 d decreased from 56% to 15% (p < 0.001). In multivariable analyses, intraoperative (odds ratio [OR]: 0.41; p = 0.002) and postoperative (OR: 0.65; p = 0.007) complications were less frequent in the late versus the early study period. Late study period patients were less likely to stay >2 d than early study period patients (OR: 0.34; p > 0.001). Limitations of these findings include the lack of adjustment for several patient variables including disease characteristics, surgeon variables including surgeon caseload, and the restriction to in-hospital events.

Conclusions

Our analyses demonstrate that in-hospital complication rates and length of stay after MIRP decreased over time. This implies that temporal differences specific to complication rates after MIRP must be considered when comparisons are made with other radical prostatectomy techniques.