RESUMEN
Background Between the conflicting requirements of clinic organisation, the European Working Time Directive, patient safety, an increasing lack of junior staff, and competitiveness, the development of ideal duty hour models is vital to ensure maximum quality of care within the legal requirements. To achieve this, it is useful to evaluate the actual effects of duty hour models on staff satisfaction. Materials and Methods After the traditional 24-hour duty shift was given up in a surgical maximum care centre in 2007, an 18-hour duty shift was implemented, followed by a 12-hour shift in 2008, to improve handovers and reduce loss of information. The effects on work organisation, quality of life and salary were analysed in an anonymous survey in 2008. The staff survey was repeated in 2014. Results With a response rate of 95% of questionnaires in 2008 and a 93% response rate in 2014, the 12-hour duty model received negative ratings due to its high duty frequency and subsequent social strain. Also the physical strain and chronic tiredness were rated as most severe in the 12-hour rota. The 18-hour duty shift was the model of choice amongst staff. The 24-hour duty model was rated as the best compromise between the requirements of work organisation and staff satisfaction, and therefore this duty model was adapted accordingly in 2015. Conclusion The essential basis of a surgical department is a duty hour model suited to the requirements of work organisation, the Working Time Directive and the needs of the surgical staff. A 12-hour duty model can be ideal for work organisation, but only if augmented with an adequate number of staff members, the implementation of this model is possible without the frequency of 12-hour shifts being too high associated with strain on surgical staff and a perceived deterioration of quality of life. A staff survey should be performed on a regular basis to assess the actual effects of duty hour models and enable further optimisation. The much criticised 24-hour duty model seems to be much better than its reputation, if augmented by additional staff members in the evening hours.
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Actitud del Personal de Salud , Competencia Clínica/legislación & jurisprudencia , Satisfacción en el Trabajo , Centros Quirúrgicos/legislación & jurisprudencia , Tolerancia al Trabajo Programado , Carga de Trabajo/legislación & jurisprudencia , Alemania , Humanos , Estudios Longitudinales , Seguridad del Paciente/legislación & jurisprudencia , Garantía de la Calidad de Atención de Salud/legislación & jurisprudenciaRESUMEN
Approximately 7 % of melanomas have a BRAF mutation beyond codon 600. These mutations can be BRAF activating without being addressable by an approved BRAF inhibitor. The case of a patient with fulminant metastatic melanoma and a BRAF(L597Q) mutation is presented. It is demonstrated that the tumor shows an excellent response to the MEK inhibitor trametinib. This is an example for possible targeted therapy in a non-V600-mutated melanoma resulting in a 17-month overall survival.
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Melanoma/tratamiento farmacológico , Melanoma/secundario , Proteínas Proto-Oncogénicas B-raf/genética , Piridonas/uso terapéutico , Pirimidinonas/uso terapéutico , Neoplasias Cutáneas/tratamiento farmacológico , Neoplasias Cutáneas/secundario , Antineoplásicos/uso terapéutico , Humanos , Masculino , Melanoma/genética , Persona de Mediana Edad , Mutación/genética , Proteínas Proto-Oncogénicas B-raf/antagonistas & inhibidores , Neoplasias Cutáneas/genética , Resultado del TratamientoRESUMEN
BACKGROUND: Continuous application of local anaesthetics reduces postoperative pain after different approaches for laparotomy. In this randomized, blinded trial, we investigated the effect of continuous application of local anaesthetics after paramedian laparotomy either with subfascial or subcutaneous catheter in addition to a standardized systemic analgesia. MATERIALS AND METHODS: Patients with stage III/IV melanoma and indication for radical iliac lymph node dissection (RILND) were randomized to a continuous application of a local anaesthetic through either a subfascial or subcutaneous catheter. Participants and those assessing the outcomes were blinded. The main outcome criterion was the pain level on the first postoperative morning while exercising measured with a visual analogue scale. Minor criteria were the pain measured by the area-under-curve until the third postoperative day, the patient's satisfaction with analgesic treatment, the analgesic requirement, the overall complications and the day of discharge. RESULTS: Fifty-two patients were evaluated. Pain therapy was sufficient in both groups during the postoperative course while resting and during mobilization. There were no significant differences regarding the main and minor outcome criteria. Doses of additional analgesics did not differ between groups. No adverse events or side effects were observed. CONCLUSION: For patients who undergo paramedian laparotomy, none of the investigated techniques is superior to the other at a median pain level under visual analogue scale (VAS) 30 mm on the first postoperative morning. TRIAL REGISTRATION NUMBER: DRKS00003632 (German Register of Clinical Trials).
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Anestésicos Locales/uso terapéutico , Cateterismo Periférico/métodos , Laparotomía/efectos adversos , Escisión del Ganglio Linfático/efectos adversos , Dolor Postoperatorio/prevención & control , Adulto , Anciano , Método Doble Ciego , Femenino , Humanos , Masculino , Persona de Mediana Edad , Manejo del Dolor , Dolor Postoperatorio/etiología , Estudios Prospectivos , Adulto JovenAsunto(s)
Alelos , Cadenas HLA-DRB1/genética , Haplotipos , Pénfigo/etnología , Pénfigo/genética , Adulto , Anciano , Árabes , Estudios de Casos y Controles , Egipto , Femenino , Expresión Génica , Frecuencia de los Genes , Alemania , Cadenas HLA-DRB1/clasificación , Cadenas HLA-DRB1/inmunología , Humanos , Masculino , Persona de Mediana Edad , Pénfigo/inmunología , Pénfigo/patología , Población BlancaRESUMEN
BACKGROUND: Psoriasis vulgaris is a common chronic inflammatory skin disease. Development of early onset psoriasis is, to some extent, genetically determined and a strong association with the major histocompatibility complex HLA-Cw6 has been demonstrated. The use of genome-wide association studies has highlighted novel genes associated with the development of psoriasis as IL12B, IL23R, TNFAIP3 and IL13 for instance. The majority of these studies were performed on cohorts of European descent. OBJECTIVE: To determine whether inter-ethnic differences exist in the genetic susceptibility to psoriasis, we genotyped single-nucleotide polymorphism variations in the vicinity of candidate genes in 132 Egyptian patients and 175 healthy controls. METHODS: Blood samples of patients and controls were screened for nucleotide polymorphisms in four candidate genes by TaqMan single-nucleotide polymorphisms Genotyping Assays. RESULTS: We found a significant association between psoriasis and the single-nucleotide polymorphism rs610604, within the TNFAIP3 gene. The TNFAIP3 gene is involved in the TNF-α signalling cascade (P-value: 0.004952), a key step in the pathogenesis of psoriasis. Although there was no significant association found between rs610604 (IL12B) and rs11209026 (IL23R) in this population, the interaction of these two genes showed a significant association with psoriasis (P-value: 0.025). Moreover, when selecting the patients with early disease onset (less than 30 years), we also found that the association of IL12B and psoriasis was highly significant (P-value 1.14 × 10(-12)). No association between rs20541 (IL13) and psoriasis was observed in our Egyptian cohort. CONCLUSION: Replicating the association of single-nucleotide polymorphisms in the TNFAIP3, IL12B and IL23R genes with psoriasis vulgaris, in subjects from different ethnic backgrounds, underlines their importance in the pathogenesis of the disease. In contrast, the lack of any association between rs20541 (IL13) and psoriasis in our Egyptian cohort suggests the existence of important inter-ethnic genetic differences in psoriasis susceptibility.
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Proteínas de Unión al ADN/genética , ADN/genética , Regulación de la Expresión Génica , Subunidad p40 de la Interleucina-12/genética , Péptidos y Proteínas de Señalización Intracelular/genética , Proteínas Nucleares/genética , Psoriasis/genética , Adulto , Proteínas de Unión al ADN/biosíntesis , Egipto/epidemiología , Femenino , Frecuencia de los Genes , Predisposición Genética a la Enfermedad , Estudio de Asociación del Genoma Completo , Genotipo , Humanos , Subunidad p40 de la Interleucina-12/biosíntesis , Péptidos y Proteínas de Señalización Intracelular/biosíntesis , Masculino , Proteínas Nucleares/biosíntesis , Psoriasis/epidemiología , Psoriasis/metabolismo , Proteína 3 Inducida por el Factor de Necrosis Tumoral alfa , Factor de Necrosis Tumoral alfaRESUMEN
BACKGROUND: The development of modern videoendoscopy enables surgeons to perform laparoscopic resection of colonic cancer. AIM: This manuscript evaluated the literature concerning clinically relevant differences in the short and long-term course after laparoscopic or conventional resection of colonic cancer. METHODS: An investigation of meta-analyses from randomized controlled clinical trials comparing laparoscopic and conventional surgery for colonic cancer was carried out. RESULTS: The incidence of intraoperative complications was higher during laparoscopic surgery, the duration of surgery was increased and blood loss was less when compared to open surgery. Overall morbidity and the incidence of surgical complications were decreased after laparoscopic surgery. General morbidity and mortality were not different after laparoscopic or open resection of colonic cancer. Duration of hospital stay was shorter but was also associated with the type of perioperative care (i.e. traditional or enhanced recovery). Following minimally invasive or conventional resection, the incidence of tumor recurrence (local and distant) and the duration of survival (overall and disease-free) showed no differences. Wound implantations were rare after both operative techniques but with a tendency to occur more often after laparoscopic than open resection. CONCLUSION: Laparoscopic resection of colonic cancer has clinically relevant short-term benefits for the patients and long-term results are not different from open colectomy. However, most of the patients included in randomized controlled trials underwent right or left colectomy and sigmoid or rectosigmoid resections. Data with a high level of evidence concerning carcinomas of the flexures or the transverse colon do not exist. Suitable patients with colonic cancer should undergo laparoscopic resection by experienced surgeons.
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Neoplasias del Colon/cirugía , Medicina Basada en la Evidencia , Laparoscopía , Neoplasias del Colon/mortalidad , Neoplasias del Colon/patología , Estudios de Seguimiento , Humanos , Tiempo de Internación/estadística & datos numéricos , Ensayos Clínicos Controlados Aleatorios como Asunto , Tasa de SupervivenciaRESUMEN
Antiphospholipid syndrome features not only deep vessel thrombosis but also may have cutaneous manifestations such as Raynaud phenomenon, acral necrosis, livedo reticularis, subcutaneous nodules, and leg ulcers. A 72-year-old man presented with a rapidly progressing leg ulcer. He was already on anticoagulation with warfarin due to atrial fibrillation and disclosed a history of stroke with temporary paresis of the left leg. Histopathology of a biopsy of the edge of the ulcer revealed occlusive arteriosclerosis of medium-sized arteries. Serology showed autoantibodies against cardiolipin, ß2- glycoprotein I, and phosphatidylserine which led to the diagnosis of antiphospholipid syndrome. Therapy with low molecular weight heparin, dexamethasone, and azathioprine in combination with stage-adjusted wound care led to complete healing of the ulcer within 5 months.
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Antiinflamatorios/uso terapéutico , Anticoagulantes/uso terapéutico , Síndrome Antifosfolípido/diagnóstico , Síndrome Antifosfolípido/terapia , Úlcera de la Pierna/diagnóstico , Úlcera de la Pierna/terapia , Accidente Cerebrovascular/prevención & control , Anciano , Vendajes , Quimioterapia Combinada , Humanos , Masculino , Accidente Cerebrovascular/diagnóstico , Resultado del TratamientoRESUMEN
PURPOSE: The aim of this study was to investigate the effects of a restrictive vs. a liberal postoperative fluid therapy guided by intrathoracic blood volume index (ITBVI) on hemodynamic and pulmonary function in patients undergoing elective esophagectomy. Perioperative fluid therapy may influence postoperative physiology and morbidity after esophageal surgery. Definitions of adequate infusion amounts and evident rules for a fluid therapy are missing. METHODS: After esophagectomy, 22 patients were randomized either to a restrictive group (RG) with low range of ITBVI (600-800 ml/m2) or a liberal group (LG) with normal ITBVI (800-1000 ml/m2). Infusion regimen was modified twice a day according to transpulmonary thermodilution measurements until the 5th postoperative day. Primary endpoint was paO2/FIO2-ratio. Secondary endpoints were pulmonary function, fluid balance and hemodynamic as well as morbidity. RESULTS: Demographic and surgical details did not differ between both groups. The calculated sample size was not reached. There were no postoperative differences in paO2/FIO2-ratio, ITBVI, hemodynamic parameters, or morbidity either. Cumulative fluid uptake was 4.1 liter less in the RG on the 5th postoperative day (p = 0.01), and pulmonary function was better in these patients (area under curve day 2-7 for forced vital capacity (FVC), forced expiratory volume in one second (FEV1), peak expiratory flow (PEF) each <0.05). CONCLUSION: ITBVI guided restrictive infusion therapy yields a lower fluid uptake, but may not result in a difference of clinical relevant parameters. A fluid restriction after esophagectomy should always be combined with hemodynamic monitoring because additional infusions may be required.
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Esofagectomía , Pulmón/fisiopatología , Cuidados Posoperatorios , Anciano , Volumen Sanguíneo , Neoplasias Esofágicas/fisiopatología , Neoplasias Esofágicas/cirugía , Femenino , Fluidoterapia/métodos , Humanos , Masculino , Persona de Mediana Edad , Periodo Posoperatorio , Pruebas de Función RespiratoriaRESUMEN
BACKGROUND: Heart rate variability (HRV) is a sensitive marker of altered sympathetic-parasympathetic function and is reduced in inflammation, illness, and trauma. The effect of major abdominal surgery on the course of HRV parameters is still an issue requiring further investigation. MATERIALS AND METHODS: A prospective, observational study including 40 consecutive patients undergoing elective colorectal surgery under "fast-track" perioperative management. Time and frequency domain parameters of HRV were measured 1 day prior to operation and on days 1-5 postoperatively. General and surgical complications as well as the course of leucocytes and C-reactive protein (CRP) were documented and correlated to the HRV measurements. RESULTS: Time domain parameters of HRV showed a significant decrease compared to the preoperative values on postoperative day 1 and returned to baseline on day 2, demonstrating impaired autonomic regulation in the early postoperative period. No correlation to complications or course of leukocytes or CRP was significant in our study. CONCLUSIONS: Colorectal resections significantly influence the HRV course. The autonomic regulation is reduced in the early postoperative time and all parameters return to baseline until the third day.
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Arritmias Cardíacas/diagnóstico , Sistema Nervioso Autónomo/fisiología , Colectomía/efectos adversos , Neoplasias Colorrectales/cirugía , Electrocardiografía , Adulto , Anciano , Anciano de 80 o más Años , Arritmias Cardíacas/etiología , Bradicardia/diagnóstico , Bradicardia/etiología , Estudios de Cohortes , Colectomía/métodos , Neoplasias Colorrectales/patología , Procedimientos Quirúrgicos Electivos/efectos adversos , Procedimientos Quirúrgicos Electivos/métodos , Femenino , Frecuencia Cardíaca/fisiología , Humanos , Masculino , Persona de Mediana Edad , Periodo Posoperatorio , Valor Predictivo de las Pruebas , Cuidados Preoperatorios/métodos , Pronóstico , Estudios Prospectivos , Estadísticas no Paramétricas , Resultado del TratamientoAsunto(s)
Viruela Vacuna/complicaciones , Enfermedad de Darier/complicaciones , Aciclovir/uso terapéutico , Antivirales/uso terapéutico , Viruela Vacuna/diagnóstico , Virus de la Viruela Vacuna/aislamiento & purificación , Enfermedad de Darier/virología , Herpes Simple/complicaciones , Herpes Simple/tratamiento farmacológico , Humanos , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
BACKGROUND AND OBJECTIVE: The natural course of sigmoid colon diverticulitis during conservative therapy and the assessment of the perioperative morbidity after sigmoid colon resection are differently evaluated by surgeons and gastroenterologists. The "fast-track" rehabilitation accelerates the reconvalescence and reduces the rate of postoperative general complications after colorectal surgery. The results of the laparoscopic "Fast-track" sigmoidectomy should be examined within a quality assurance program to better evaluate the perioperative risks following surgical management of diverticulitis. PATIENTS AND METHODS: A prospective data collection within the voluntary quality assurance program "fast-track" Kolon II was performed. All participating clinics agreed on a multimodal, evidence-based standard perioperative treatment in terms of a "fast-track" rehabilitation for elective operations for sigmoid diverticulitis. RESULTS: Data from 846 patients undergoing laparoscopic "fast-track" sigmoid colon resection in 23 surgical departments in Germany were collected and evaluated. The mean age of the patients was 63 years (range 23 - 91). 203 patients (24 %) had severe co-morbidities (ASA classification III - IV). A conversion to conventional open surgery was necessary in 51 cases (6 %). Complications occurred in 93 patients (11 %). 76 patients suffered a surgical complication (8.9 %) and 32 patients (3.8 %) a general complication. Two patients died postoperatively due to multi-organ failure following anastomotic leaks. The patients took solid food in median on day 1 after surgery (range, 0 - 5) and passed stool on day 2 (range, 0 - 22). Predefined discharge criteria (free of pain on oral medication, normal oral feeding, stool) were met on day 4 (range, 1 - 58) and the patients were discharged on day 7 (range, 3 - 72). The 30-day re-admission rate was 3.9 %. CONCLUSION: Patients undergoing laparoscopic "fast-track" sigmoidectomy had a low rate of general complications and had a rapid reconvalescence with a short postoperative in-patient treatment as documented in a german quality assurance program.
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Colon Sigmoide/cirugía , Diverticulitis del Colon/cirugía , Complicaciones Posoperatorias/epidemiología , Sigmoidoscopía/normas , Adulto , Anciano , Anciano de 80 o más Años , Medicina Basada en la Evidencia , Femenino , Alemania/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Control de Calidad , Adulto JovenRESUMEN
BACKGROUND: Perioperative fluid therapy is controversially debated in surgery. In malnourished and hypovolaemic patients, a restrictive fluid regimen may lead to hypoperfusion and increased incidence of complications. The present prospective cohort study was performed to assess whether pre-operative i.v. fluid administration improves intraoperative cardiac preload in patients undergoing oesophageal resection. METHODS: Intraoperatively, the intrathoracic blood volume index (ITBVI) was monitored in 44 consecutive patients undergoing elective oesophagectomies with the transthoracic thermodilution technique. Twenty-two of these patients received a pre-operative i.v. fluid loading with a balanced crystalloid solution (1 ml/kg/h over 48 h). RESULTS: After induction of anaesthesia ITBVI was low but not different between the groups [767 (512-1314) vs. 775 (531-1200) ml/m(2), P=0.81]. In the intervention group, the extravascular lung water increased above normal levels during the operation. The groups did not differ in cardiac output, blood pressure, heart rate and central venous pressure. Post-operative morbidity was not different between the cohorts. CONCLUSION: Pre-operative i.v. fluid loading with crystalloid solutions could not be shown to improve the intraoperative volume status and cardiac function in this study. Randomised trials with other volume replacement techniques are recommended.
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Fluidoterapia , Cuidados Preoperatorios/métodos , Adulto , Anciano , Anciano de 80 o más Años , Sistema Cardiovascular , Soluciones Cristaloides , Enfermedades del Esófago/cirugía , Esofagectomía , Femenino , Humanos , Soluciones Isotónicas , Masculino , Persona de Mediana Edad , Complicaciones PosoperatoriasRESUMEN
INTRODUCTION: Laparoscopic (LAP) versus open (CON) colonic resection with traditional perioperative care has some short term benefits postoperatively regarding functional recovery. Whether these benefits may also occur when all patients are treated with multimodal "fast-track"-rehabilitation programs is questionable. METHODS: Patients undergoing elective left sided colonic surgery were prospectively non randomised observed. The "fast-track" program included patient information, thoracic peridural analgesia, forced mobilisation and oral intake, and stress reduction. Endpoints were duration of postoperative ileus and hospital stay, general- and local complication, and pulmonary function. RESULTS: 147 consecutive patients were operated on, 47 open and 100 laparoscopically. The time until oral intake was completed seemed to be shorter in the LAP-group (p=0.07) followed by a shorter hospital stay (p<0.01). The pulmonary function was postoperatively improved in the LAP-group compared to the CON-group (p<0,01). General complications (LAP 9% vs. CON 17%) were non significantly increased in the CON-group. Local complications increased in the CON-group (LAP 13% vs. CON 28%, p<0,05). CONCLUSION: Even with perioperative "fast-track"-rehabilitation programs short term advantages were found in laparoscopic compared with open colonic surgery in a non randomised population. The clinical relevance should be examined in controlled randomised trials.
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Colon/cirugía , Neoplasias Colorrectales/rehabilitación , Neoplasias Colorrectales/cirugía , Laparoscopía , Adulto , Anciano , Anciano de 80 o más Años , Colon Sigmoide/cirugía , Convalecencia , Interpretación Estadística de Datos , Diverticulitis/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Cuidados Posoperatorios , Complicaciones Posoperatorias , Recuperación de la Función , Recto/cirugíaRESUMEN
BACKGROUND: Capnoperitoneum (CP) compromises hemodynamic function during laparoscopy. Three therapeutic concepts were evaluated with an aim to minimize the hemodynamic reaction to CP: First, a controlled increase of intrathoracic blood volume (ITBV) by intravenous fluids; second, partially reduced sympathetic activity by the beta1-blocker esmolol; and third, a decrease in mean arterial pressure (MAP) by the vasodilator sodium nitroprusside. METHODS: For this study, 43 pigs were assigned to treatment with fluid and sodium nitroprusside (group A) or with esmolol (group B). In both groups, the pigs were assigned to head-up, head-down, or supine position, resulting in three different subgroups. Invasive hemodynamic monitoring was established including left heart catheter and cardiac oxygen lung water determination (COLD) measurements. Measurements were documented before CP with the animals in supine position, after induction of a 14-mmHg CP with the animals in each body position, after a 10% reduction in MAP by vasodilation, and after an increase in ITBV of about 30% by infusion of 6% hydroxyethylstarch solution. RESULTS: Increasing ITBV improved hemodynamic function in all body positions during CP. Esmolol reduced cardiac output and myocardial contractility. Sodium nitroprusside did not improve hemodynamic function in any body position. CONCLUSIONS: Optimizing volume load is effective for minimizing hemodynamic changes during CP in the head-up and in head-down positions. In general, beta(1)-blockers cannot be recommended because they might additionally compromise myocardial contractility and suppress compensatory reaction of the sympathetic nerve system. Vasodilation has not improved hemodynamic parameters during CP.
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Hemodinámica , Neumoperitoneo Artificial/efectos adversos , Medicina Preventiva/métodos , Antagonistas Adrenérgicos beta/uso terapéutico , Animales , Presión Sanguínea/efectos de los fármacos , Volumen Sanguíneo , Dióxido de Carbono , Fluidoterapia/métodos , Inyecciones Intravenosas , Nitroprusiato/uso terapéutico , Propanolaminas/uso terapéutico , Porcinos , Sistema Nervioso Simpático/efectos de los fármacos , Sistema Nervioso Simpático/fisiopatología , Vasodilatadores/uso terapéuticoRESUMEN
BACKGROUND AND AIMS: After rectal cancer surgery, postoperative general complications occur in 25-35% of all patients and postoperative hospital stay is 14-21 days. "Fast-track" rehabilitation has been shown to accelerate recovery, reduce general morbidity and decrease hospital stay after elective colonic surgery. Because the feasibility of "fast-track" rehabilitation in patients undergoing rectal cancer surgery has not been demonstrated yet, we demonstrate our initial results of "fast-track" rectal cancer surgery. PATIENTS AND METHODS: Seventy consecutive unselected patients undergoing rectal cancer resection by one surgeon underwent a perioperative "fast-track" rehabilitation. Demographic and operative data, pulmonary function, pain and fatigue, local and general complications and mortality were assessed prospectively. RESULTS AND FINDINGS: Thirty-six female and 34 male patients aged 65 (34-77) years underwent open (n=31) or laparoscopic (n=39) anterior resection with partial mesorectal excision (PME 27), anterior resection with total mesorectal excision and protective loop ileostomy (TME 29) or abdominoperineal excision with colostomy (APR 14). Overall, pulmonary function returned to >80% of preoperative value on day 2 (1-4) and the first bowel movement occurred on day 1 (0-3) after surgery. The incidence of local and general complications was 27 and 18%, respectively. Postoperative hospital stay was 8 (3-50) days overall, but shorter after PME [5 (3-47)] than TME [10 (5-42)] or APR [9 (5-50)] (p<0.01). INTERPRETATION AND CONCLUSION: "Fast-track" rehabilitation was feasible in patients undergoing rectal cancer resection. Local morbidity was not increased, while general morbidity and postoperative hospital stay compared favourably to other series with "traditional" perioperative care.
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Carcinoma/rehabilitación , Procedimientos Quirúrgicos Electivos/métodos , Laparoscopía , Neoplasias del Recto/rehabilitación , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma/mortalidad , Carcinoma/cirugía , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Tiempo de Internación , Masculino , Persona de Mediana Edad , Readmisión del Paciente , Complicaciones Posoperatorias/epidemiología , Estudios Prospectivos , Neoplasias del Recto/mortalidad , Neoplasias del Recto/cirugía , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND: After loop-ileostomy closure subcutaneous wound infection is the most frequent postoperative complication. Implantation of local antibiotics has been shown to reduce the incidence of wound infection after different surgical procedures, therefore, a subcutaneous application of a gentamycin implant may also decrease infection rate after ileostomy-closure. METHODS: We conducted a randomized, double-blind, placebo-controlled trial to evaluate the effectiveness of a subcutaneous gentamycin-collagen implant to reduce wound infection after loop-ileostomy closure. Patients had the same perioperative treatment and standardized anastomotic and closure technique. A collagen sponge with gentamycin was used in the treatment group and an identical collagen implant without antibiotics was used in the placebo group. RESULTS: Eighty patients (40 per group) were included. There was no difference between the groups with respect to demographics or in the postoperative course. The total wound infection rate was 10 percent with no difference between the gentamycin (n=4) and the collagen group (n=4) (P = 1.0). CONCLUSION: Subcutaneous implantation of a gentamycin sponge yields no clinically relevant reduction of the wound infection rate after loop-ileostomy closure so that routine use is not recommended in this procedure.
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Antibacterianos/administración & dosificación , Gentamicinas/administración & dosificación , Ileostomía/efectos adversos , Infección de la Herida Quirúrgica/prevención & control , Anciano , Profilaxis Antibiótica , Método Doble Ciego , Implantes de Medicamentos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infección de la Herida Quirúrgica/etiología , Resultado del TratamientoRESUMEN
PURPOSE: The aim of this study was to investigate whether brief psychologic interventions to reduce perioperative stress may improve the postoperative course of patients undergoing abdominal surgery. METHODS: We used a randomized, controlled, partially blinded trial to evaluate the differential effectiveness of two brief psychologic interventions (guided imagery and progressive muscle relaxation) on analgesic requirement, pain perception, pulmonary function, duration of postoperative ileus, and fatigue after conventional resection of colorectal carcinoma in elderly cancer patients. RESULTS: Sixty patients (20 guided imagery, 22 relaxation, 18 control) were evaluated. Acceptance of the brief psychologic interventions was high and 90 percent of the patients indicated that they would recommend it to other patients. Analgesic consumption (P = 0.6) and subjective pain intensity at rest (P = 0.3) and while coughing (P = 0.3) were not different between groups. Recovery of pulmonary function, duration of postoperative ileus, and subjective postoperative fatigue were also not influenced. When the data from intervention groups were pooled, again no benefits were detected compared with the control group. CONCLUSIONS: Brief psychologic interventions such as guided imagery and relaxation yielded a very positive patient response but did not show a clinically relevant influence on the postoperative physiologic course of elderly patients undergoing conventional resections of colorectal cancer.
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Colectomía/efectos adversos , Neoplasias Colorrectales/cirugía , Imágenes en Psicoterapia , Dolor Postoperatorio/prevención & control , Terapia por Relajación , Factores de Edad , Anciano , Colectomía/psicología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/etiología , Dolor Postoperatorio/psicología , Cuidados Preoperatorios , Método Simple Ciego , Estrés Psicológico/prevención & control , Resultado del TratamientoRESUMEN
BACKGROUND: Colorectal resections are common surgical procedures all over the world. Laparoscopic colorectal surgery is technically feasible in a considerable amount of patients under elective conditions. Several short-term benefits of the laparoscopic approach to colorectal resection (less pain, less morbidity, improved reconvalescence and better quality of life) have been proposed. OBJECTIVES: This review compares laparoscopic and conventional colorectal resection with regards to possible benefits of the laparoscopic method in the short-term postoperative period (up to 3 months post surgery). SEARCH STRATEGY: We searched MEDLINE, EMBASE, CancerLit, and the Cochrane Central Register of Controlled Trials for the years 1991 to 2004. We also handsearched the following journals from 1991 to 2004: British Journal of Surgery, Archives of Surgery, Annals of Surgery, Surgery, World Journal of Surgery, Disease of Colon and Rectum, Surgical Endoscopy, International Journal of Colorectal Disease, Langenbeck's Archives of Surgery, Der Chirurg, Zentralblatt für Chirurgie, Aktuelle Chirurgie/Viszeralchirurgie. Handsearch of abstracts from the following society meetings from 1991 to 2004: American College of Surgeons, American Society of Colorectal Surgeons, Royal Society of Surgeons, British Assocation of Coloproctology, Surgical Association of Endoscopic Surgeons, European Association of Endoscopic Surgeons, Asian Society of Endoscopic Surgeons. SELECTION CRITERIA: All randomised-controlled trial were included regardless of the language of publication. No- or pseudorandomised trials as well as studies that followed patient's preferences towards one of the two interventions were excluded, but listed separately. RCT presented as only an abstract were excluded. DATA COLLECTION AND ANALYSIS: Results were extracted from papers by three observers independently on a predefined data sheet. Disagreements were solved by discussion. 'REVMAN 4.2' was used for statistical analysis. Mean differences (95% confidence intervals) were used for analysing continuous variables. If studies reported medians and ranges instead of means and standard deviations, we assumed the difference of medians to be equal to the difference of means. If no measure of dispersion was given, we tried to obtain these data from the authors or estimated SD as the mean or median. Data were pooled and rate differences as well as weighted mean differences with their 95% confidence intervals were calculated using random effects models. MAIN RESULTS: 25 RCT were included and analysed. Methodological quality of most of these trials was only moderate and perioperative treatment was very traditional in most studies. Operative time was longer in laparoscopic surgery, but intraoperative blood was less than in conventional surgery. Intensity of postoperative pain and duration of postoperative ileus was shorter after laparoscopic colorectal resection and pulmonary function was improved after a laparoscopic approach. Total morbidity and local (surgical) morbidity was decreased in the laparoscopic groups. General morbidity and mortality was not different between both groups. Until the 30th postoperative day, quality of life was better in laparoscopic patients. Postoperative hospital stay was less in laparoscopic patients. AUTHORS' CONCLUSIONS: Under traditional perioperative treatment, laparoscopic colonic resections show clinically relevant advantages in selected patients. If the long-term oncological results of laparoscopic and conventional resection of colonic carcinoma show equivalent results, the laparoscopic approach should be preferred in patients suitable for this approach to colectomy.
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Colectomía/métodos , Neoplasias Colorrectales/cirugía , Laparoscopía/métodos , Pérdida de Sangre Quirúrgica , Femenino , Humanos , Laparoscopía/efectos adversos , Masculino , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
OBJECTIVE: A multimodal perioperative concept ("fast-track"-surgery) may decrease the incidence of general complications following elective colonic resections, accelerate rehabilitation and shorten postoperative hospital stay. During the introduction of this new "clinical pathway" several obstacles have to be overcome. This manuscript describes a practical way to establish "fast-track"-colonic surgery in the clinical routine. MATERIAL AND METHODS: After discussion of the many aspects of perioperative pathophysiology following abdominal surgery a "fast-track"-concept for colonic surgery was defined. Since 11.10.2001 the "fast-track" concept was applied to all patients treated by one attending surgeon. Experience with establishing this concept in the clinical routine was analysed. RESULTS: "Fast-track"-colonic surgery was established in close cooperation between surgeons, anesthesiologists and nurses. A written-down concept, the use of checklists and letters of information for patients, their relatives and general practicioners will simplify the introduction of the new perioperative treatment. Traditional practice (i. e. types of incisions, use of drainage, postoperative oral feeding) have to be modified. In 74 "fast-track"-colonic resections postoperative hospital stay was reduced to a median of 4 days, regardless of the way of access to the abominal cavity (laparoscopic or conventional). Postoperative morbidity was acceptable (local complications: 7 %; general complications: 7 %, but only 1 % without local complication). CONCLUSION: Establishing "fast-track"-colonic surgery requires close cooperation between surgery, anestehsiology and nursing personal. Most important is a surgeon prepared to overcome traditional concepts of perioperative care.
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Colon/cirugía , Neoplasias del Colon/cirugía , Convalecencia , Interpretación Estadística de Datos , Humanos , Tiempo de Internación , Cuidados Posoperatorios , Complicaciones Posoperatorias/prevención & control , Cuidados Preoperatorios , Factores de TiempoRESUMEN
BACKGROUND: EORTC-QLQ-C30 questionnaires and GIQLI questionnaires are used to evaluate post-operative quality of life (QoL). It was not clear whether results of both instruments are comparable. Therefore, the level of agreement between both QoL questionnaires was evaluated in patients undergoing elective colorectal cancer resection. METHODS: Pre-operatively, 7 and 30 days after surgery 116 patients answered the EORTC-QLQ-C-30 and the GIQLI questionnaires in random order. Individual questions with similar content from each questionnaire were compared. Data for global QoL, physical (PF), emotional (EF) and social function (SF) were linearly transformed to fit a scale from 0 to 100. Data from the two instruments were correlated and the level of agreement between them was calculated according to the method of Bland and Altman. RESULTS: A total of 308 data sets [(pre-op. n=116; 7th pod n=101; 30th post-operative day (pod) n=91)] were evaluated. Both instruments detected a reversible reduction of QoL after surgery and gave inferior results for patients with conditions known to impair QoL. EORTC-QLQ-C30 was more sensitive than GIQLI. The correlation between the two questionnaires for global QoL, PF and EF was good ( r=0.53-0.66, p<0.01), but no correlation for SF was detected ( r=-0.44, p=0.44). Linearly transformed scores from the two instruments differed considerably from -13 (95%CI -51 to 24) points (QoL) to 10 (-38 to 58) points (PF). CONCLUSION: Although EORTC-QLQ-C30 scores and GIQLI scores from patients undergoing elective colorectal cancer surgery did correlate well, the level of agreement between the two instruments was quite low. Perioperative QoL data from the two instruments cannot be compared with each other.