全髋关节置换术患者延迟出院的危险因素分析

目的分析全髋关节置换术患者延迟出院的危险因素。方法回顾性分析2015年1月至2018年7月择期行单侧全髋关节置换术患者的临床资料,包括性别、年龄、BMI、ASA分级、手术时间、麻醉方式、术中失血量、术中输液量、术中阿片类药物用量、术中血管活性药物用量、PACU停留时间、术后随访静息疼痛评分、术前住院时间、术前合并症、术后并发症及转归情况。根据术后住院时间将患者分为两组:正常出院组(术后住院时间≤14 d)和延迟出院组(术后住院时间>14 d),采用单因素和多因素Logistic回归分析影响延迟出院的因素。结果共纳入908例患者。单因素分析显示,与正常出院组比较,延迟出院组的年龄明显偏高,术中失血量明显增多,手术时间、PACU停留时间、术前住院时间明显延长,术前合并症、术后并发症明显增多(P<0.05)。Logistic回归分析显示,年龄≥70岁(OR=2.075,95%CI 1.287~3.346,P=0.003)、手术时间>3 h(OR=1.997,95%CI 1.181~3.375,P=0.010)、术中失血量≥800 ml(OR=2.898,95%CI 1.449~5.794,P=0.003)、PACU时间>60 min(OR=1.745,95%CI 1.064~2.859,P=0.027)、术前住院时间≥7 d(OR=1.805,95%CI 1.114~2.924,P=0.016)、术前有合并症≥2个(OR=2.912,95%CI 1.513~5.825,P=0.003)是导致患者延迟出院的独立危险因素。结论患者年龄、术中失血量、手术时间、PACU停留时间、术前住院时间及术前合并症是全髋关节置换术后出院延迟的独立危险因素,针对危险因素进行有效干预是缩短住院时间改善患者预后的重要策略。     

腹腔镜胆道探查手术不良转归的预测指标

目的:研究腹腔镜胆道探查患者术前疾病指标与手术不良转归的相关性。方法:收集218例腹腔镜胆道探查患者的术前资料,采用多变量分析定义三个手术不良转归:中转开放手术,术后发生并发症,术后住院时间延长。结果:患者血清胆红素水平增高与中转开放手术有关[OR=1.01(CI=1.00-1.01),P=0.01]。66.5%的患者无任何术后并发症,16%的患者有轻度ClavienⅠ级并发症,1例死亡;年龄越高,发生ClavienⅡ～Ⅴ级并发症的几率越高[OR=1.03(CI=1.01-1.05),P=0.02]。术前胆总管直径增粗[OR=1.16(CI=1.08-1.25),P<0.001]、既往上腹部手术史[OR=4.89(CI=1.10-21.74),P=0.04]及血清胆红素值增高[OR=1.04(CI=1.01-1.88),P=0.02]是术后住院时间延长的预测指标。结论:腹腔镜胆道探查手术是安全的,但高龄、黄疸、胆总管直径增粗及既往手术史可增加手术风险,此类患者应考虑其他治疗方法,以获得更好的预后。     

Laparoscopic colorectal surgery – results from 200 patients

OBJECTIVE: Laparoscopic surgery is increasingly being performed for benign and malignant colorectal disease. This study examines the short-term results in a consecutive series of laparoscopic colorectal procedures performed over 2 years. METHOD: A prospective database was established for all elective patients undergoing laparoscopic colorectal surgery by one surgeon. The main outcome measures assessed were operative duration, conversion rate, length of hospital stay, morbidity and mortality and lymph node harvest. RESULTS: Two hundred and thirty-one consecutive patients were referred for elective colorectal surgery, with 18 patients excluded from laparoscopic surgery. Thirteen patients had nonresective laparoscopic colorectal procedures for endometriosis and have been excluded from the series. Of 200 patients who underwent a laparoscopic colorectal procedure, 114 (57%) were female, the median age was 67 years (inter-quartile range (IQR) 57-76), and there were 116 malignancies. The most common operations were anterior resection and sigmoid colectomy (n = 82), right hemicolectomy (n = 62) and left hemicolectomy (n = 12). The median operating time was 120 min (IQR 90-150) and 10 patients (5%) required conversion to open surgery. The median lymph node harvest in malignancies was 21 nodes (IQR 15-30) and no positive resection margins were found. There were two deaths and 29 significant complications (14.5%), with seven patients requiring re-operations because of postoperative complications. The median postoperative hospital stay was 4 days (IQR 3-6) and 13 patients (6.5%) were re-admitted within 30 days of hospital discharge. CONCLUSION: Laparoscopic colorectal surgery is possible for most benign and malignant conditions, with low conversion and complication rates, as well as short hospital stay.     

Laparoscopically assisted or open enterolithotomy for gallstone ileus

BACKGROUND: Gallstone ileus is associated with high morbidity and mortality rates. Enterolithotomy as a single procedure is recommended to minimize complications. The trauma could potentially be reduced further by using a laparoscopic technique. METHODS: Thirty-two consecutive patients with gallstone ileus operated by a laparoscopic or open approach between 1992 and 2004 were studied retrospectively. Demographic data, preoperative and postoperative hospital stay, duration of operation, complications and deaths were recorded. Median follow-up after surgery was 36 months. RESULTS: Nineteen laparoscopic procedures, with two conversions, and 13 open operations were performed. The median duration of operation was 60 min in the laparoscopic group and 58 min in the open group (P = 0.675). The median hospital stay was 7 and 10 days, respectively (P = 0.383). There were five minor and one major complications in the laparoscopic group, compared with one and four, respectively, in the open group. There were no deaths within 30 days. CONCLUSION: The overall morbidity rate was low after both laparoscopic and open enterolithotomy for gallstone ileus, especially in terms of major complications in the laparoscopic group. Laparoscopically assisted enterolithotomy can be recommended for both diagnosis and treatment.     

Factors predicting deviation from an enhanced recovery programme and delayed discharge after laparoscopic colorectal surgery

Aim The study aimed to identify factors that predict postoperative deviation from an enhanced recovery programme (ERP) and/or delayed discharge following colorectal surgery. Method Data were prospectively collected from all patients undergoing elective laparoscopic colorectal resection between January 2006 and December 2009. They included Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) variables, body mass index (BMI), sex, preoperative serum albumin, pathology, conversion from a laparoscopic to an open approach and postoperative length of hospital stay. Results There were 176 patients (90 women) of mean age 68 years. Fifteen (9%) operations were converted from laparoscopic to open. The remainder were completed laparoscopically. Fifty‐five (31%) deviated from the ERP, with most failing multiple elements. The most common reason was failure to mobilize, which often occurred in conjunction with paralytic ileus or analgesic failure. Factors independently predicting ERP deviation on multivariate analysis were pathology and intra‐operative complications. The median length of stay was 5 days. Sixty‐four (36%) patients had a prolonged length of stay that was predicted by age, number of procedures and ERP deviation. Conclusion Pathology and intra‐operative complications are independent predictors of ERP deviation. Prolonged length of stay can be predicted by age, multiple procedures and ERP deviation. Failure to mobilize should be considered as a red flag sign prompting further investigation following colorectal resection.     

Renal dysfunction after myocardial revascularization.

OBJECTIVES: In this study, we evaluate the incidence of and analyse the pre and intraoperative risk factors for the development of postoperative renal dysfunction (PRD), and the impact of such an event on perioperative mortality and on hospital length of stay. In addition, we sought to investigate the influence of a mildly increased serum creatinine (1.3-2.0 mg/dl) on perioperative mortality and morbidity. METHODS: The study included 2445 consecutive patients who had no pre-existing renal disease (creatinine or=2.1 mg/dl with a preoperative-to-postoperative increase >or=0.9 mg/dl. Univariate and multivariate analyses were performed where appropriate. RESULTS: Global 30-day mortality was 0.7%. The incidence of PRD was 5.6% (136 patients). Mortality for patients who experienced PRD was 8.8 vs. 0.1% for patients who did not (P<0.001). PRD increased the length of hospital stay by 3.4 days (7.6 vs. 11.0 days; P<0.001), and patients who needed haemodialysis (11%) had a perioperative mortality of 33.3% and a mean hospital length of stay of 16 days. Multivariable logistic regression identified the following variables as independent predictors of PRD: age (P=0.017; odds ratio (OR) 1.3 per 10 years), angina class III/IV (P=0.003; OR 1.7); cardiopulmonary bypass time (P=0.007; OR 1.01 per minute); preoperative serum creatinine levels: group 1 (1.3-1.6 mg/dl (P<0.001; OR 5.5)) and group 2 (1.7-2.0 mg/dl (P<0.001; OR 14.2)). Finally, a mild elevation of the preoperative creatinine level (1.3-2.0 mg/dl) increased significantly the probability of perioperative mortality, low cardiac output, haemodialysis and prolonged hospital stay. CONCLUSIONS: Although the likelihood of PRD in patients without pre-existing renal dysfunction is relatively low, it dramatically increases mortality, morbidity and length of stay after CABG. Mildly elevated (>1.2 mg/dl) preoperative serum creatinine level significantly increases the perioperative mortality and morbidity.     

结直肠癌患者ERAS方案和术后住院时间的相关性分析

［摘要］ 目的 研究结直肠癌患者实施ERAS流程后影响术后住院时间的相关因素。方法 收集2015年5月~2018年9月间广东省第二人民医院普外二科接受手术治疗的结直肠癌患者411例，将患者根据《结直肠手术应用加速康复外科中国专家共识（2015版）》方案，完成ERAS标准流程。观察术后住院时间与术前肠道准备、术前碳水化合物摄入、预防性抗生素使用、术中预防低体温措施、目标导向性液体治疗、硬膜外置管、术后早期活动、术后早期进食、非甾体镇痛药使用、早期拔除引流管、年龄、性别、体重指数、美国麻醉医师协会麻醉分级、贫血、手术部位、手术方式、手术时间、术后有无ICU监护、并发症发生情况之间的相关性。利用二分类Logistic回归分析各变量与术后住院时间之间的相关性。结果 年龄、性别、糖尿病、体重指数、新辅助化疗、术前贫血均与术后住院时间无显著相关性，其P值分别为0.705、0.563、0.078、0.674、0.323、0.782。而术前延长术后住院时间的因素为美国麻醉医师协会麻醉分级≥3分（P<0.001， OR=8.000， 95% CI 4.080~15.686）。手术相关因素如手术的方式、手术时间长于180 min与术后住院时间延长密切相关（P=0.025， OR=0.464， 95% CI 0.237~0.907；P<0.001，OR=15.370， 95% CI 7.828~30.175）。而术后的重症监护室监护治疗并不显著影响术后住院时间（P=0.645， OR=0.791，95% CI 0.291~2.148）；术后早期活动延迟与术后住院时间延长相关（P<0.001， OR=12.149， 95% CI 5.284~27.931）；而术前碳水化合物的摄入也对术后住院时间有影响（P=0.001， OR=0.343， 95% CI 0.179~0.658），当然其可使术后患者的住院时间缩短（相关系数为?1.050）。而硬膜外置管镇痛、术中液体平衡及术后早期进食及术后并发症与住院时间并无显著关联。结论 制定更加高效合理的结直肠癌围手术期ERAS方案可缩短患者住院时间，加速患者康复。     

手术联合介入栓堵大体肺动脉侧支治疗肺血减少型先天性心脏病的手术疗效分析(附151例报告)

目的 比较外科手术联合术前、术中(包括栓堵当日手术及同期Hybrid手术)及术后介入栓堵治疗合并大体肺动脉侧支(MAPCAs)肺血减少型先天性心脏病的手术疗效,探讨联合术式的时机.方法 1992年至2009年11月手术联合栓堵共151例,成功栓堵MAPCAs 252支.其中1992年至2007年7月28例,包括手术前栓堵3例(10.7%)、栓堵当日手术19例(67.9%)、术后栓堵6例(21.4%);2007年7月成立Hybrid手术室后行间期Hybrid手术115例(93.5%)、术前栓堵3例(2.4%)、术后栓堵5例(4.1%).一期矫治132例,姑息手术19例,其中7例再行二期矫治.结果 全组手术死亡11例(7.3%),其中成立Hybrid手术室后死亡5例(4.1%)明显低于2007年7月前的6例(21.4%),同期Hybrid手术死亡也由21.1%(4/19例)降至4.3%(5/115例).术前栓堵6例均无死亡,术后栓堵死亡2例均为2007年7月前死亡.术前、术中栓堵呼吸机使用时间、ICU住院时间、术后住院时间及住院费用均显著低于术后栓堵者(P=0.000、0.000、0.000).成立Hybrid手术室后病人住ICU时间及术后住院时间均显著低于2007年7月前(P=0.002及0.002);同期Hybrid手术的ICU住院时间由2007年7月前的8.38天缩短至5.37天(P=0.079),术后住院时间由18.74天减少至13.01天(P=0.059).结论 成立Hybrid手术室后同期Hybrid手术死亡显著下降,病人住ICU时间及术后住院时间缩短,手术疗效改善.术前、术中栓堵伴MAPCAs的肺血减少型先天性心脏病较术后栓堵者使用呼吸机、ICU及术后住院时间缩短,住院费用降低.术后栓堵作为补救措施可减少相关并发症的发生,是治疗MAPCAs的有益补充.     

后腹腔镜根治性肾切除术后并发症和住院时间延长的相关因素分析

目的探讨经腹膜后入路腹腔镜根治性肾切除术(laparoscopic radical nephrectomy,LRN)术后并发症和住院时间延长的相关因素。 方法回顾性分析北京安贞医院泌尿外科2010年8月至2021年8月期间,接受腹膜后入路LRN患者的临床资料,包括年龄、性别、体质量指数、合并症、美国麻醉医师协会(ASA)分级、既往腹部手术史、肿瘤大小、T分期、术中出血量、术中输血、术后并发症和术后住院时间等指标。采用Clavien-Dindo分级标准评价患者术后并发症情况,以术后住院时间的第75百分位数为分界点,术后住院时间>10 d定义为术后住院时间延长。应用单因素和多因素Logistic回归分析术后并发症和住院时间延长的危险因素。 结果本研究共纳入103例肾肿瘤患者,术后并发症Clavien-Dindo分级≥2级16例(15.5%);住院时间延长(>10 d)17例(16.5%)。多因素Logistic回归结果显示：手术时间≥240 min (OR: 5.17, P＝0.024)和术中出血量>300 ml(OR: 22.89, P＝0.001)与术后并发症独立相关;术中输血(OR: 9.94, P＝0.023)是术后延迟出院的独立危险因素。 结论腹膜后入路LRN术后并发症和住院时间延长与术出血量,手术时间和术中是否输血等因素有关。     

The impact of obesity on technical feasibility and postoperative outcomes of laparoscopic left colectomy

OBJECTIVE: To compare technical aspects and postoperative outcomes of laparoscopic left colectomy in obese and nonobese patients. SUMMARY BACKGROUND DATA: Obesity has been generally associated with increased surgical risk. The data regarding outcomes after laparoscopic colectomy in obese and nonobese patients are limited and quite controversial; however, most reports have suggested that obesity is associated with a greater technical difficulty as well as an increased risk for conversions and postoperative complications. METHODS: All patients undergoing laparoscopic left colectomy for any pathologic condition between January 2001 and January 2003 were analyzed. Patients with a body mass index (BMI) above 30 kg/m were defined as obese and patients with BMI below 30 kg/m were defined as nonobese. Data collected included age, gender, BMI, American Society of Anesthesiologists score, diagnosis, technical parameters of the procedure, operative time, conversion, pathology, length of hospital stay, and complications over a 30-day postoperative course. RESULTS: A total of 123 patients underwent elective laparoscopic left colectomy during the 2-year period. Twelve patients were excluded from analysis because missing data did not allow calculation of their BMI. Of the 111 patients analyzed, 23 (20.7%) were obese and 88 patients (79.3%) were nonobese. Patients' preoperative clinical characteristics were similar in obese and nonobese patients except for BMI (P > 0.001). There were no significant differences between the 2 groups with respect to intraoperative parameters, duration of the operation, resection margin, and number of harvested nodes as well as overall postoperative complication rates. There were no conversions in the obese patients, whereas 5 procedures in the nonobese group required conversion to open surgery (P = not significant). Obese patients had shorter hospital stays than nonobese subjects (7 +/- 2.5 days vs. 9.5 +/- 7 days; P = 0.018). CONCLUSION: In contrast with previously reported series of laparoscopic colectomy, our findings show that obesity does not have an adverse impact on the technical difficulty and postoperative outcomes of laparoscopic left colectomy. Our study supports the safety of using laparoscopic surgery for colorectal diseases in obese patients.     

Factors determining length of stay of surgical day-case patients

BACKGROUND: AND OBJECTIVE: Factors which lead to prolonged stay in the day-care unit and unplanned admission after day-case surgery are poorly understood. METHODS: Data sets of 3152 day-case patients were collected with a computerized online record keeping system (NarkoData). Predictors of prolonged postoperative stay including unanticipated admission were identified using univariate analysis. Charts of patients, who needed admission, were reviewed. RESULTS: 13.2% of day-case patients had a postoperative stay < or = 3 h, 55.3% 3-6 h and 26.2% > or = 6 h. The rate of unanticipated admission was 5.4%. Intraoperative haemoglobin concentration and blood loss were the best predictors of a prolonged postoperative stay. Other significant predictors were female gender, advanced age, longer duration of surgery, larger volume of infusions, intubation, spinal anaesthesia, intraoperative use of opioids and non-depolarizing muscle relaxants, high pain score, nausea and vomiting and prolonged preoperative waiting time. Chart review of patients admitted to hospital confirmed the validity of the statistically significant predictors. CONCLUSIONS: In day-case surgery, the predictors of prolonged stay in the day-care unit and unplanned Hospital admission are mainly related to the surgical procedure.     

Postoperative atrial fibrillation independently predicts prolongation of hospital stay after cardiac surgery

AIM: Postoperative atrial fibrillation (AF) occurs in up to 50% of cardiac surgery patients and represents the most common postoperative arrhythmic complication. A reduction of the length of hospital stay is a desirable goal in preventive strategies of postoperative AF. The aim of the present investigation was to determine whether prolonged postoperative hospital stay associated with AF after cardiac surgery surgery is attributable to the arrhythmia itself or to baseline characteristics of patients who develop AF. METHODS: Patients undergoing elective cardiac surgery in the absence of heart failure and significant left ventricular dysfunction (n = 253; average age 65+/-11 years) were recruited to the present prospective study. Midline sternotomy procedures with standard surgical techniques for normothermic cardiopulmonary bypass in coronary artery bypass grafting and valvular surgery were used. RESULTS: A total of 99 patients (39.1%) of the study population developed AF during the postoperative period. AF patients were older and more likely to have surgery for valvular heart disease and less likely to have antiarrhythmic drugs including beta-adrenergic blockers than patients without AF, but both patients with and without AF had similar body mass index and duration of surgery. Postoperative hospital stays were longer in patients with AF compared to those without AF (14.9+/-5.7 vs 10.6+/-3.6, respectively; P = 0.001). Multivariate analysis, adjusted for age and postoperative complications, demonstrated that postoperative hospital stay was 14.2+/-5.3 days in patients with AF and 10.8+/-3.8 days in patients without AF (P < 0.01). Treatment with oral antiarrhythmic drugs that reduce AF is associated with a reduction of postoperative hospital stay. CONCLUSIONS: Despite baseline characteristics differed between patients with and without postoperative AF, most of the prolongation of hospital stay can be attributed to the rhythm disturbance itself.     

Randomized clinical trial of laparoscopic versus open fundoplication: blind evaluation of recovery and discharge period

BACKGROUND: There is a widespread belief that introduction of the laparoscopic technique in antireflux surgery has led to easier postoperative recovery. To test this hypothesis a prospective randomized clinical trial with blind evaluation was conducted between laparoscopic and open fundoplication. METHODS: Sixty patients with gastro-oesophageal reflux disease were randomized to open or laparoscopic 360 degrees fundoplication. The type of operation was unknown to the patient and the evaluating nurses after operation. RESULTS: The operating time was longer in the laparoscopy group, median 148 versus 109 min (P < 0.0001). The need for analgesics was less in the laparoscopically operated patients, 33.9 versus 67.5 mg morphine per total hospital stay (P < 0.001). There was no significant difference in postoperative nausea and vomiting. On the first day after operation patients in the laparoscopy group had better respiratory function: forced vital capacity 3.2 versus 2. 2 litres (P = 0.004) and forced expiratory volume 2.6 versus 2.0 litres (P = 0.008). Postoperative hospital stay was shorter in the laparoscopic group, median (range) 3 (2-6) versus 3 (2-10) days (P = 0.021). No difference was found in the duration of sick leave. CONCLUSION: Laparoscopic fundoplication was associated with a longer operating time, better respiratory function, less need for analgesics and a shorter hospital stay, while no reduction in the duration of postoperative sick leave was found compared with open surgery.     

Hospital stay amongst patients undergoing major elective colorectal surgery: predicting prolonged stay and readmissions in NHS hospitals

Aim Reduced hospital stay confers clinical and economic benefits for patients and healthcare providers. This article examines the length of stay and consequent bed resource usage of patients undergoing elective excisional colorectal surgery in English NHS trusts. Method All patients undergoing elective colorectal resections for malignancy between 1996 and 2006 in English NHS trusts were included from the Hospital Episode Statistics data set. Unifactorial and multifactorial analyses were performed to identify independent predictors of prolonged stay and 28‐day readmission. Results Over the 10‐year period, 186 013 patients underwent elective colorectal procedures in 181 NHS trusts. About 2.893 million bed days were utilized for elective colorectal surgery. Admission stay was shorter following colonic surgery than following rectal surgery (median 11 vs 13 days, P < 0.001). A 2‐day decrease in median stay was observed over the 10‐year period for both colonic and rectal procedures. Readmissions within 28 days of discharge were higher following rectal excision than following colonic surgery (9.4 vs 7.6%, P < 0.001). Multiple logistic regression analyses revealed the following independent predictors of prolonged hospital stay: distal (vs proximal) bowel resection, benign pathology, open technique, increasing age, comorbidity, social deprivation and low provider volume status. Independent predictors of 28‐day readmission included distal bowel resection, benign diagnosis, young age, social deprivation and high provider volume status. Conclusion Patients of advanced age, with associated comorbidities, and those living in areas of social deprivation are at increased risk of prolonged stay. Targeted pre‐emptive discharge planning and enhanced use of laparoscopic surgery could improve bed resource utilization.     

Predictors of Prolonged Hospital Stay following Open and Laparoscopic Gastric Bypass for Morbid Obesity: Body Mass Index,Length of Surgery,Sleep Apnea,Asthma and the Metabolic Syndrome

Background: The number of weight reduction operations performed for type II and type III obesity is rapidly escalating. Risk of surgery has been infrequently stratified for patient subgroups. The purpose of this study was to identify patient characteristics that increased the odds of a prolonged hospital length of stay (LOS) following open or laparoscopic Roux-en-Y gastric bypass (RYGBP). Methods: The hospital records of 311 patients who underwent RYGBP in a 6-month period were retrospectively reviewed. Patient characteristics including the presence of significant obesity-related medical conditions were recorded. Analysis was based on intent to treat. Univariate and step-wise logistic regression analysis was used to identify the odds ratio (OR) and adjusted odds ratio (AOR) for predictors of an increased hospital LOS. Results: Datasets for 311 patients were complete. 159 patients underwent open vertical banded gastroplasty-Roux-en-Y gastric bypass (VBG-RYGBP) and 152 laparoscopic RYGBP (LRYGBP). 78% of patients were female. Median age was 40 years (range 18-68). Median BMI was 49 kg/m² (range 35-82). 17% of patients had sleep apnea, 18% asthma, 19% type 2 diabetes, 13% hypercholesterolemia and 44% hypertension. Median length of surgery for open VBG-RYGBP (64 minutes) was significantly faster than for LRYGBP (105 minutes). Median length of stay was significantly shorter for LRYGBP (2 days) than open VBG-RYGBP (3 days). Univariate logistic regression analysis identified 6 predictors of increased LOS: open surgery (0.4 OR); increasing BMI (60 kg/m² 0.38 OR; BMI 70 kg/m² 0.53 OR); increasing length of surgery (120 min 0.33 OR; 180 min 0.48 OR); sleep apnea (2.25 OR); asthma (3.73 OR); and hypercholesterolemia (3.73 OR). Subset analysis identified patients with the greatest odds for a prolonged hospital stay: women with asthma (2.47 AOR) or coronary artery disease (8.65 AOR); men with sleep apnea (5.54 OR) or the metabolic syndrome (6.67 – 10.20 OR); and patients undergoing a laparoscopic operation with sleep apnea (11.53 AOR) or coronary artery disease (12.15 AOR). Conclusions: Open surgery, BMI, length of surgery, sleep apnea, asthma and hypercholesterolemia all increased the odds of a prolonged LOS. Patients with the greatest odds of long LOS were women with asthma or coronary disease, men with sleep apnea or the metabolic syndrome, and patients undergoing laparoscopic surgery with sleep apnea or coronary artery disease. Patients at high-risk for prolonged hospital stay can be identified before undergoing RYGBP. Surgeons may wish to avoid high-risk patients early in their bariatric surgery experience.     

支架联合腹腔镜手术治疗梗阻性左半结肠癌的初步探讨

目的 探讨左半结肠癌并肠梗阻患者腔内支架置入后再行腹腔镜手术的疗效及手术时机的选择.方法 前瞻性将49例左半结肠癌并梗阻患者由计算机随机分入支架联合腹腔镜手术组（29例,其中支架后3 d手术15例、10 d后手术14例）和开腹手术组（20例）,对比分析3组患者一期手术吻合成功例数、中转开腹率、手术时间、住院时间、术中失血量、疼痛评分、永久造口率和术后并发症发生情况.结果 与开腹组比较,支架联合腹腔镜手术组患者一期手术吻合成功率高（62.1%比35.0%,P=0.004）,永久造口率低（6.9%比35.0%,P=0.024）,失血量少（15～200 ml比120～610 ml,P=0.000）,疼痛轻（术后疼痛评分2.5分、3.0分比8.0分,P=0.000）,相关并发症少（5例次比10例次）.支架联合腹腔镜手术两组之间,与3 d后手术组比较,10 d后手术组患者一期手术吻合成功率高（85.7%比40.0%,P=0.001）中转开腹率低（14.3%比46.7%,P=0.046）.结论 左半结肠癌并梗阻患者放置腔内支架后的腹腔镜手术是可行的,放置支架后10 d行腹腔镜手术较为合适.     

Predictors of Increased Length of Hospital Stay Following Laparoscopic Sleeve Gastrectomy from the National Surgical Quality Improvement Program

Background

Laparoscopic sleeve gastrectomy is the most commonly performed bariatric procedure in the USA. Identifying preoperative risk factors for prolonged postoperative hospital stay will help appropriately select patients for fast-track protocols and avoid costly readmissions. To date, there has been no large national database analysis of risk factors for prolonged length of stay following laparoscopic sleeve gastrectomy.

Methods

Laparoscopic sleeve gastrectomy procedures reported to the American College of Surgeons National Surgical Quality Improvement Program between 2009 and 2012 were reviewed. Open procedures and revisional procedures were excluded. Baseline patient characteristics and preoperative lab values were reviewed. Univariate analysis was conducted to identify patient factors that predicted prolonged hospitalization (defined as ≥?3 days). Multivariate logistic regression was used to identify factor associated with prolonged length of stay.

Results

We identified 11,430 patients who underwent laparoscopic sleeve gastrectomy. The median length of stay was 2 days and 18.4% required hospitalization ≥?3 days. Multivariate analysis revealed that female sex, age greater than 65, body mass index greater than 50, chronic obstructive pulmonary disease, hypertension, renal insufficiency, anemia, and prolonged operative time were significantly associated with prolonged hospital stay.

Conclusions

Preoperative patient characteristics as well as operative details predict prolonged length of stay following laparoscopic sleeve gastrectomy. As the utilization of fast-track protocols in bariatric surgery programs expands, these data may be used to assist in the selection of patients who may be inappropriate for rapid discharge from the hospital after sleeve gastrectomy as well as guide medical optimization strategies preoperatively.

     

Laparoscopic gastric and biliary bypass: a single-center cohort prospective study

PURPOSE: Relief of gastric outlet and distal biliary obstruction may be accomplished by open surgery or by minimally invasive techniques including endoscopic and laparoscopic approaches. We examined the feasibility and safety of laparoscopic gastric and biliary bypass in all patients with malignant and benign disease requiring surgical relief of obstructive symptoms. MATERIALS AND METHODS: Patients with benign duodenal stricture or inoperable malignancy underwent therapeutic laparoscopic bypass surgery. Prophylactic gastric or biliary bypass was added in selected patients with nonmetastatic malignancy. RESULTS: Twenty-eight patients (17 of them female) with a median age of 67 years (range, 26-81 years) underwent 29 laparoscopic bypass procedures for malignant (n = 23) or benign (n = 6) disease. One patient who underwent a Roux-en-Y gastrojejunostomy for non-steroidal anti-inflammatory drug induced ulcer disease developed stenosis of the stoma that required laparoscopic refashioning 2 months later, accounting for the 29th procedure reported herein in 28 patients. Surgery included the construction of a single gastric (n = 16) or biliary (n = 5) bypass or a double bypass (n = 8), and an additional prophylactic bypass in 5 of 23 cancer patients (21.8%). All procedures were completed laparoscopically. The median operative time was 90 minutes (range, 60-153 minutes) and mean postoperative hospital stay was 4 days (range, 3-6 days). Complications developed following 4 procedures (13.8%) and 1 patient died (3.4%). No complications occurred in patients with prophylactic bypass. One patient required laparoscopic revision of the gastroenterostomy 2 months postoperatively, for benign disease. No recurrence of obstructive symptoms was observed in cancer patients during follow-up. CONCLUSION: Laparoscopic bypass surgery for distal biliary and gastric obstruction in patients with benign or malignant disease results in low morbidity and mortality and short postoperative hospital stay. The addition of prophylactic bypass in patients with nonmetastatic unresectable malignancy appears safe and effective.     

Free triiodothyronine: a novel predictor of postoperative atrial fibrillation.

OBJECTIVE: Despite improved perioperative management, atrial fibrillation (AF) after coronary artery bypass grafting (CABG) remains a relevant clinical problem, whose pathogenetic mechanisms remain incompletely explained. A reduced incidence of postoperative AF has been described in CABG patients receiving IV tri-iodothyronine (T3). This study was designed to define the role of thyroid metabolism on the genesis of postoperative AF. METHODS AND RESULTS: Free T3 (fT3), free thyroxine (fT4), and thyroid stimulating hormone were assayed at admission in 107 consecutive patients undergoing isolated CABG surgery. Patients with thyroid disease or taking drugs known to interfere with thyroid function were excluded. A preoperative rhythm other than sinus rhythm was considered an exclusion criterion. Thirty-three patients (30.8%) had postoperative AF. An older age (P=0.03), no therapy with beta-blockers (P=0.08), chronic obstructive pulmonary disease (P=0.08), lower left ventricle ejection fraction (P=0.09) and lower fT3 concentration (P=0.001), were univariate predictors of postoperative AF. On multivariate analysis, low fT3 concentration and lack of beta-blocking therapy were independently related with the development of postoperative AF (odds ratio, OR, 4.425; 95% confidence interval, CI, 1.745-11.235; P=0.001 and OR 3.107; 95% CI 1.087-8.875; P=0.03, respectively). Postoperative AF significantly prolonged postoperative hospital stay (P=0.002). CONCLUSIONS: Low basal fT3 concentration can reliably predict the occurrence of postoperative AF in CABG patients.     

Laparoscopic adrenalectomy and splenectomy are safe and reduce hospital stay and charges

The proposed benefits of laparoscopy for certain surgical procedures have been decreased post-operative pain and hospital stay balanced against the proposed deficits of increased costs. We have reviewed our data to evaluate factors associated with patient, procedure, and hospital charges for patients undergoing open versus laparoscopic adrenalectomy and splenectomy during the same time period. Eighty-seven patients underwent adrenalectomy (n = 47) or splenectomy (n = 40) from October 30, 1995 to June 6, 2001 and were retrospectively reviewed. Patient and operative factors were analyzed by intent to treat; the major endpoints were operating room (OR) time in minutes, blood loss in cm3, length of hospital stay in days, and charges broken down by anesthesia/operation [OR/recovery room (RR)] and total charges in dollars x 1000. Comparisons of means were analyzed by unpaired t test; data are presented as mean +/- SEM, and significance is defined as P < 0.05. Median age of the group was 47 years (range 20-77). Forty-five patients underwent a laparoscopic approach of which two were converted to open (4%) as compared with 42 undergoing an open operation; one patient from each group was excluded from outcome analyses because of prolonged hospitalization (>3 weeks). Operative mortality of the whole group was one per cent. There were no differences between the groups with respect to age, gender, or comorbidity. The laparoscopic group had significantly longer operative times and OR/RR charges. However, the length of hospital stay and the total charges for the patient undergoing a laparoscopic approach were significantly less (P < 0.05). We conclude that a laparoscopic approach for adrenalectomy or splenectomy can be accomplished in approximately 95 per cent of patients selected for this procedure. Despite prolonged OR time and increased OR/RR charges the laparoscopic procedures resulted in significantly decreased length of hospital stay and overall patient charges. Laparoscopy is a safe and cost-effective approach and should be strongly considered in patients requiring adrenalectomy or splenectomy.