Asunto(s)

Desarticulación , Cadera/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Desarticulación/efectos adversos , Desarticulación/mortalidad , Desarticulación/estadística & datos numéricos , Humanos , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Resultado del Tratamiento

Asunto(s)

Absceso Abdominal/cirugía , Drenaje/efectos adversos , Anciano , Remoción de Dispositivos , Embolización Terapéutica , Femenino , Humanos , Plexo Hipogástrico , Procedimientos Quirúrgicos Mínimamente Invasivos , Choque Hemorrágico , Cirugía Asistida por Computador , Tomografía Computarizada por Rayos X

RESUMEN

BACKGROUND: In patients with chronic mesenteric insufficiency (CMI), traditional bypass surgery carries a high operative mortality. Endovascular therapy for reconstruction of the mesenteric vascular system has high technical success but poor long-term patency. Secondary procedures are often mandatory for recurrent disease. The purpose of this study was to evaluate an endovascular-first treatment strategy for CMI, reserving open reconstruction for complex disease patterns without an endovascular option. STUDY DESIGN: Data for consecutive adult patients (N = 107) initially treated with endovascular techniques for CMI were reviewed. The management algorithm consisted of postoperative and biannual ultrasound and clinical follow-up. RESULTS: A total of 107 patients with CMI were treated from April 2004 through June 2010. Technical success for endovascular reconstruction was 100%. Long-term follow-up data were available on 90% of patients. After the index procedure, 57% of patients (n = 55) had complete resolution of the preoperative symptoms. During the management phase, 83% of patients had elevated velocities on duplex evaluation. During this interval, 53% of patients required no further intervention after the index procedure, and the remaining patients required an additional 78 procedures. Five patients required open revascularization for recurrent disease, and only 2 patients died from complications of mesenteric insufficiency. CONCLUSIONS: Endovascular management for CMI has a high technical success rate with low morbidity and mortality. Regular follow-up is essential to optimize patient outcomes. Ultrasound findings alone are a poor predictor of recurrent disease. Long-term success requires adaptation of a management program to elicit recurrent symptoms and offer prompt treatment.

Asunto(s)

Procedimientos Endovasculares , Isquemia , Enfermedades Vasculares , Adulto , Anciano , Velocidad del Flujo Sanguíneo , Enfermedad Crónica , Estudios de Cohortes , Femenino , Humanos , Isquemia/mortalidad , Isquemia/fisiopatología , Isquemia/cirugía , Masculino , Isquemia Mesentérica , Persona de Mediana Edad , Estudios Retrospectivos , Stents , Resultado del Tratamiento , Enfermedades Vasculares/mortalidad , Enfermedades Vasculares/fisiopatología , Enfermedades Vasculares/cirugía

RESUMEN

The indications for open abdominal aortic aneurysm (AAA) repair have changed with the development of endovascular techniques. The purpose of this study is to clarify the indications and outcomes for open repair since endovascular aneurysm repair (EVAR) and to compare contemporary AAA repair with the pre-EVAR era. Patients undergoing open AAA repair were identified; the demographics, outcomes, and indications for open repair were reviewed. Outcomes were compared based on indication for open repair in the EVAR era and between the pre-EVAR and EVAR eras. Open indications in the EVAR era included: age younger than 65 years with minimal comorbidities (AGE, n = 24 [9.8%]), unfavorable anatomy (ANAT, n = 146 [59.3%]), aortoiliac occlusive disease (AIOD, n = 38 [15.4%]), and miscellaneous (OTHER, n = 38 [15.4%]). Mortality (30-day and 5-year) was affected by indication: AGE = 0 and 0 per cent, ANAT = 4.1 and 49.7 per cent, AIOD = 13.5 and 32.3 per cent, and OTHER = 5.3 and 41.8 per cent. Age, sex, race, coronary artery disease, and peripheral artery disease were similar between the pre-EVAR and EVAR eras. EVAR-era patients had more diabetes mellitus, hypertension, and hyperlipidemia and longer operative time. Mortality was not different, but complication rates were lower in the pre-EVAR era (23.7 vs 43.5%, P = 0.025). Patients undergoing open AAA repair in the EVAR era have more comorbidities, longer operative times, and more complications. Outcomes for EVAR-era patients are affected by the indication for open repair. A preference for open repair in younger patients with minimal comorbidities is justified.

Asunto(s)

Aneurisma de la Aorta Abdominal/mortalidad , Aneurisma de la Aorta Abdominal/cirugía , Factores de Edad , Anciano , Angioplastia , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Selección de Paciente , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia , Resultado del Tratamiento

RESUMEN

BACKGROUND: Vascular surgical education for general surgery residents is concerning as endovascular interventions increase and vascular surgery expands. The purpose of this study was to examine the effects these factors have on vascular surgery case numbers for general surgery residents and statewide surgeons and to report on former general surgery residents' perceptions of vascular surgery in training and practice. STUDY DESIGN: Case numbers for all general surgery residents graduating from the Greenville Hospital System from 1991 to 2007 and for the vascular surgery fellows graduating from 2003 to 2007 were obtained. A database identified case numbers and physician specialty for vascular procedures from 1997 through 2006. A survey gained perspectives of graduated general surgery residents on the vascular experience during residency and practice and on postresidency vascular caseload. RESULTS: There was significant decline in resident participation in open abdominal aortic aneurysm (22.4 versus 7.7), carotid endarterectomy (37.2 versus 31.1), aortobifemoral bypass (18.6 versus 5.5), and lower extremity bypass (42.8 versus 19.1). Numbers for dialysis access creation (49.0 versus 57.1) were maintained. Statewide, comparing 1997 with 2006, the percentages of procedures performed by vascular surgeons were: abdominal aortic aneurysm (29.3% versus 49%; p < 0.001), carotid endarterectomy (28.9% versus 45.5%; p < 0.001), and dialysis access (4.6% versus 12.3%; p=0.020). The survey of general surgery graduates revealed lower extremity bypass, carotid endarterectomy, abdominal aortic aneurysm, and dialysis access are important in training. Dialysis access was the most common operation performed by the general surgery graduates. CONCLUSIONS: There is a trend toward vascular surgeons and vascular residents performing most open vascular cases. Currently practicing surgeons believe there is value to vascular exposure for general surgeons in training, and vascular surgery should remain in general surgery training.

Asunto(s)

Becas , Cirugía General/educación , Internado y Residencia , Procedimientos Quirúrgicos Vasculares/educación , Adulto , Aneurisma de la Aorta Abdominal/cirugía , Derivación Arteriovenosa Quirúrgica/educación , Derivación Arteriovenosa Quirúrgica/estadística & datos numéricos , Implantación de Prótesis Vascular/estadística & datos numéricos , Becas/estadística & datos numéricos , Encuestas de Atención de la Salud , Humanos , Estudios Retrospectivos , South Carolina , Procedimientos Quirúrgicos Vasculares/estadística & datos numéricos , Procedimientos Quirúrgicos Vasculares/tendencias

RESUMEN

The StarClose (Abbott Vascular, Redwood City, CA) arterial closure device utilizes an extraluminal nitinol clip to establish hemostasis. The purpose of this study was to determine the safety and efficacy of StarClose from a prospective peripheral arterial disease (PAD) registry. Over an 18-month time interval, 500 StarClose devices were used in 378 consecutive patients with symptomatic PAD after diagnostic and/or therapeutic endovascular cases. Patient demographics along with objective criteria including duplex ultrasound images, common femoral artery flow velocities, and ankle-brachial indexes (ABIs) were analyzed before and after StarClose placement. All outpatients received prophylactic antibiotic (one dose), periprocedural heparin (without protamine reversal), and antiplatelet therapy. Aspirin and clopidogrel (Plavix) was used for all patients undergoing therapeutic intervention. There were 378 patients who underwent procedures for aortoiliac or infrainguinal PAD, 99 of which were bilateral. Of the 500 arteriotomy closures, 296 were therapeutic interventions with sheath sizes of 6-8 F in the common femoral artery. The diagnostic studies (n = 204 arteriotomies) were performed with a 5F sheath. The technical success in achieving hemostasis was 97.2%; only 14 devices had a deployment problem requiring prolonged manual compression. Median length of stay was 157 min for patients done on an outpatient basis. Eleven of 260 (4.2%) on duplex follow-up had a doubling of the peak systolic velocity, only one of which was symptomatic. Late follow-up showed 42 of 360 (11.7%) with a drop in ABI >0.10. Nine major complications (2.0%) were identified in follow-up. The StarClose closure device has a low major complication rate and is safe and efficacious in patients with PAD, although stenosis at the arteriotomy site may occur. The device has achieved rapid hemostasis without need for anticoagulant reversal and requires significantly less time to ambulation than manual compression.

Asunto(s)

Cateterismo Periférico/efectos adversos , Arteria Femoral , Hemorragia/prevención & control , Técnicas Hemostáticas/instrumentación , Enfermedades Vasculares Periféricas/diagnóstico , Enfermedades Vasculares Periféricas/terapia , Instrumentos Quirúrgicos , Anciano , Tobillo/irrigación sanguínea , Antibacterianos/uso terapéutico , Anticoagulantes/uso terapéutico , Aspirina/uso terapéutico , Presión Sanguínea , Arteria Braquial/fisiopatología , Clopidogrel , Constricción Patológica , Diseño de Equipo , Femenino , Arteria Femoral/diagnóstico por imagen , Arteria Femoral/fisiopatología , Hemorragia/etiología , Técnicas Hemostáticas/efectos adversos , Heparina/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Enfermedades Vasculares Periféricas/fisiopatología , Inhibidores de Agregación Plaquetaria/uso terapéutico , Punciones , Flujo Sanguíneo Regional , Sistema de Registros , Estudios Retrospectivos , Ticlopidina/análogos & derivados , Ticlopidina/uso terapéutico , Resultado del Tratamiento , Ultrasonografía Doppler Dúplex

RESUMEN

BACKGROUND: It is generally accepted that failed infrainguinal bypass with prosthetic material significantly compromises arterial run off, which may limit future revascularization. It is well known that the negative consequences of early vein graft thrombosis are limited, but the effect of failed peripheral angioplasty on the distal vasculature is poorly studied. The purpose of this study was to determine whether early failure after superficial femoral artery intervention influences subsequent revascularization options. METHODS: Between July 1, 1998, and June 30, 2006, 276 patients underwent endovascular intervention of the superficial femoral artery. A prospective analysis of angiograms done before the intervention and after early failure (

Asunto(s)

Angioplastia de Balón/efectos adversos , Arteriopatías Oclusivas/cirugía , Arteria Femoral/cirugía , Claudicación Intermitente/cirugía , Isquemia/cirugía , Extremidad Inferior/irrigación sanguínea , Anciano , Amputación Quirúrgica , Angioplastia de Balón/instrumentación , Arteriopatías Oclusivas/complicaciones , Arteriopatías Oclusivas/diagnóstico por imagen , Constricción Patológica , Femenino , Arteria Femoral/diagnóstico por imagen , Humanos , Claudicación Intermitente/diagnóstico por imagen , Claudicación Intermitente/etiología , Isquemia/diagnóstico por imagen , Isquemia/etiología , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Estudios Prospectivos , Radiografía , Recurrencia , Reoperación , Índice de Severidad de la Enfermedad , Stents , Factores de Tiempo , Insuficiencia del Tratamiento

RESUMEN

OBJECTIVE: It has long been evident that lifetime follow-up after endovascular aneurysm repair (EVAR) is necessary to identify late complications. The purpose of this study is to test the hypothesis that late follow-up rates for EVAR in routine practice are inferior to those reported from protocol-driven clinical trials, consequently contributing to avoidable events associated with poor long-term outcome. METHODS: From February 1999 to December 2005, 302 EVARs were performed and eligible for follow-up. Of these, 47 were performed as part of an industry-sponsored clinical trial (study patients). Responsibility for follow-up was assigned to a research nurse for study patients and to office clerical staff for nonstudy patients. Follow-up compliance was classified as either frequent (<1 missed scheduled appointment) or incomplete (>2 missed scheduled appointments). Overall survival and complication rates were analyzed. RESULTS: Of the 302 patients, 203 (67.2%) had frequent follow-up and 99 (32.8%) had incomplete follow-up. The mean follow-up was significantly better in the frequent follow-up group (34.7 +/- 22 months) vs the incomplete follow-up group (18.8 +/- 18.6 months, P < .001). The 5-year survival (63.9% frequent vs 64.0% incomplete), the 5-year reintervention rate (22.3% frequent vs 10.8% incomplete), and incidence of known endoleak (14.8% frequent vs 9.1% incomplete) were statistically similar in the two groups. The incidence of major adverse events, defined as events requiring urgent surgical intervention, was significantly increased in the incomplete follow-up group (6.1% vs 0.5%; P = .006), with nearly half of these patients dying perioperatively. There was no difference in measured outcomes for study patients compared with nonstudy patients. However, mean follow-up was significantly longer for study patients vs nonstudy patients (44.8 +/- 23.7 months vs 26.8 +/- 20.9 months; P < .001). CONCLUSIONS: Follow-up surveillance after EVAR is less intense in practice environments outside of clinical trials. Patients with incomplete follow-up have higher fatal complication rates than patients with frequent follow-up. These data expose a potential under-appreciated limitation of EVAR, questioning whether the findings in clinical trials defining the efficacy of EVAR can be routinely extrapolated to ordinary practice.

Asunto(s)

Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/métodos , Anciano , Aneurisma de la Aorta Torácica/diagnóstico , Aneurisma de la Aorta Torácica/mortalidad , Endosonografía , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Complicaciones Posoperatorias/epidemiología , Estudios Prospectivos , South Carolina/epidemiología , Tasa de Supervivencia , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del Tratamiento

RESUMEN

Abdominal wall reconstruction (AWR) is often required for hernias created after temporary abdominal closure (TAC). Demographic and clinical data from patients undergoing TAC and AWR between January 1, 1992, and December 31, 2002, were collected and univariate analysis performed. Temporary abdominal closure and AWR were performed in 21 patients. Complications developed in 12 patients (57.1%) after TAC; associated risk factors were mesh placement (P = .04) and skin grafting (P = .04). Successful AWR included mesh (n = 6), component separation (n = 6), primary repair (n = 4), and 3 combination techniques. Six patients (28.6%) developed intraoperative complications, and 14 (66.7%) developed postoperative complications. Intraoperative complications were increased in patients with tissue expanders (P = .01). Postoperative complications (P = .04) were less likely with component separation. The complication rate with TAC and AWR is high. Tissue expanders are associated with an increased risk of intraoperative complications with AWR, whereas component separation is associated with a reduction in postoperative complications.

Asunto(s)

Pared Abdominal/cirugía , Hernia Ventral/cirugía , Procedimientos de Cirugía Plástica/métodos , Adulto , Anciano , Femenino , Estudios de Seguimiento , Hernia Ventral/etiología , Humanos , Masculino , Persona de Mediana Edad , Procedimientos de Cirugía Plástica/efectos adversos , Estudios Retrospectivos , Mallas Quirúrgicas , Técnicas de Sutura , Resultado del Tratamiento

RESUMEN

BACKGROUND: The purpose of this study was to measure the extent of adhesion formation to ePTFE mesh (DualMesh, W.L. Gore & Associates, Inc, Flagstaff, AZ) and two composite prosthetic materials, ePTFE and polypropylene (Bard Composix, C.R. Bard, Inc, Murray Hill, NJ) and hyaluronic acid/carboxymethylcellulose and polypropylene (Sepramesh, Genzyme Corp, Cambridge, MA) after their intra-abdominal placement on an intact peritoneum, simulating laparoscopic ventral hernia repair, and to evaluate host tissue response to the prosthetic biomaterials. MATERIALS AND METHODS: Through a midline laparotomy, a 2 x 2 cm piece of mesh (n = 60) was sewn to an intact peritoneum on each side of a midline incision in 30 New Zealand white rabbits. Mesh adhesions were scored using a modified Diamond scale (0 = 0%, 1 = 1-25%, 2 = 26-50%, 3 >50%) at 1, 3, 9, and 16 weeks by serial microlaparoscopy (2 mm). All laparoscopic evaluations were videotaped for blinded scoring by three surgeons. Host tissue response was graded (1-4) for inflammation, tissue ingrowth, and mesothelialization. The predominant cell type (polymorphonuclear leukocytes versus foreign body giant cell) was recorded. Statistical differences (P value <0.05*) were measured using a two-tailed t test and Kruskal-Wallis test. RESULTS: The mean adhesion score was significantly (P < 0.001) less for ePTFE mesh at 1, 3, 9, and 16 weeks compared with the two composite prosthetic materials. There were no differences in the mean adhesion scores between the two biosurgical composite meshes at any of the time intervals. There were no differences in the mean score for inflammation, tissue ingrowth and mesothelialization between any of the prosthetic biomaterials. The predominant cell type on all histological evaluations was polymorphonuclear leukocytes. CONCLUSIONS: Placing ePTFE mesh (DualMesh) intra-abdominal against an intact peritoneum results in significantly fewer adhesions than the composite prosthetic meshes during a 4-month follow-up. The host tissue response is equivalent for the three prosthetic biomaterials. The long-term consequences of increased adhesion formation to the composite meshes and the ultimate biocompatibility of the nonabsorbable and absorbable barriers on the polypropylene mesh are to be determined.

Asunto(s)

Laparoscopía , Politetrafluoroetileno , Mallas Quirúrgicas , Adherencias Tisulares/prevención & control , Abdomen/cirugía , Animales , Materiales Biocompatibles/farmacología , Peritoneo/patología , Peritoneo/cirugía , Complicaciones Posoperatorias/patología , Complicaciones Posoperatorias/prevención & control , Conejos , Adherencias Tisulares/patología

RESUMEN

Splenic abscess is a rare clinical entity, and splenectomy remains the treatment of choice. We sought to determine the safety and efficacy of laparoscopic splenectomy in this setting. Using a prospective database of laparoscopic splenectomy, we identified 4 patients who underwent surgery for splenic abscess (3 male, 1 female). Mean age was 55.5 (range 42-78) years. Patient symptoms included: fever and abdominal pain in 4 patients, pleural effusions in 2, and nausea and leukocytosis in 1. Risk factors for splenic abscess included septic emboli from bacterial endocarditis in 2 patients and acquired immune deficiency syndrome in 1. All patients underwent successful laparoscopic splenectomy. Mean operative time was 200 (range 160-220) minutes, and blood loss was 220 (range 100-450) mL. There were no postoperative complications or deaths; postoperative length of stay averaged 14 (range 2-26) days. Despite the difficulty of the operation, the laparoscopic approach appears to be a safe and effective treatment of splenic abscess.

Asunto(s)

Absceso/cirugía , Esplenectomía/métodos , Enfermedades del Bazo/cirugía , Adulto , Anciano , Femenino , Humanos , Laparoscopía , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Resultado del Tratamiento

RESUMEN

BACKGROUND: The purpose of this study was to determine factors that influence postoperative IV analgesic use after colectomy. STUDY DESIGN: We retrospectively evaluated patients who underwent colectomy between January 1997 and December 2000 at our medical center and calculated the amount of postoperative IV narcotics needed in morphine equivalents. Statistical differences (p < 0.05 considered significant) were measured using the Wilcoxon rank-sum test. Correlations were performed using Spearman correlation coefficients, and linear regression analysis was also performed. RESULTS: Four hundred eighty-one patients (235 men, 246 women) underwent colectomy; patients had a mean age of 60.6 years (range, 17 to 96 years). Procedures performed included total/subtotal colectomy (10%, n = 49), right colectomy (42%, n = 200), transverse colectomy (3%, n = 12), left/sigmoid colectomy (40%, n = 195), and low anterior resection (4%, n = 17). Laparoscopic colectomy was performed in 53 (11%) patients. Mean postoperative morphine equivalent use was 160.2 mg. Narcotic analgesic use was significantly less for women (p = 0.02), diagnosis of cancer (p = 0.02), and laparoscopic colectomy (p = 0.0001). Patients undergoing a right colectomy required less postoperative narcotics than patients having other types of colectomies (p < 0.02). There was a positive correlation between postoperative narcotic use and operative time (r = 0.14, p = 0.007) and a negative correlation with patient age (r = -0.37, p = 0.0001). Linear regression analysis demonstrated that age (p = 0.0001), female gender (p = 0.04), and laparoscopy (p = 0.001) were independent predictors for decreased narcotic use. CONCLUSIONS: Postoperative IV narcotic analgesic use is affected by gender, patient age, indication for colectomy, operative time, type of procedure, and operative technique.

Asunto(s)

Analgesia/métodos , Colectomía/efectos adversos , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/etiología , Cuidados Posoperatorios/métodos , Adolescente , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Analgésicos Opioides/uso terapéutico , Colectomía/métodos , Colonoscopía/efectos adversos , Colonoscopía/métodos , Utilización de Medicamentos , Femenino , Humanos , Infusiones Intravenosas , Tiempo de Internación/estadística & datos numéricos , Modelos Lineales , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Dolor Postoperatorio/diagnóstico , Selección de Paciente , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Factores de Riesgo , Factores Sexuales , Factores de Tiempo

RESUMEN

Advanced laparoscopy in the morbidly obese patient is technically challenging. Having the proper instrumentation and equipment available is a major component of technical success. Items routinely used during surgery performed on patients of normal size must often be modified or substituted when morbidly obese patients undergo surgery. In this article, we review the specific tools necessary for the safe and proper completion of laparoscopic Roux-en-Y gastric bypass, in addition to various alternatives that can be helpful when other procedures are performed on morbidly obese patients.

Asunto(s)

Derivación Gástrica/instrumentación , Laparoscopios , Laparoscopía , Fuentes de Energía Bioeléctrica , Cateterismo , Humanos , Obesidad Mórbida/cirugía , Engrapadoras Quirúrgicas , Cirugía Asistida por Video

RESUMEN

Imaging of the vena vava prior to the insertion of an inferior vena vava (IVC) filter is mandatory to assess IVC diameter and patency, delineate anatomy and venous anomalies, and to direct filter placement for appropriate deployment and avoidance of complications. The standard imaging technique is vena cavography, although alternative methods to evaluate the inferior vena cava include carbon dioxide venography, transabdominal duplex ultrasound, and intravascular ultrasound. This manuscript will review the anatomical features, technique, and complications of pre-insertion inferior vena cava imaging and discuss alternative methods to evaluate the inferior vena cave prior to filter insertion.

Asunto(s)

Filtros de Vena Cava , Vena Cava Inferior/diagnóstico por imagen , Angiografía de Substracción Digital , Dióxido de Carbono , Medios de Contraste , Humanos , Flebografía/métodos , Vena Cava Inferior/anatomía & histología

RESUMEN

Inferior vena cava (IVC) filters offer a safe and effective means of preventing pulmonary embolus and have reduced complications when compared to earlier techniques of caval interruption. However, despite continued improvement in filters and insertion methods, complications still occur. Pneumothorax, hemorrhage, and vessel injury may result while obtaining vascular access. Filter misplacement, excessive tilt, and vascular injury have been reported with insertion, but preinsertion cavography is helpful in preventing these insertion-related complications. Attention to detail, proper use of guidewires, and preinsertion imaging are vital in preventing insertion-related complications as well. Long-term complications occur in a minority of patients and include recurrent pulmonary embolus, caval occlusion, and filter migration. Overall, the benefits of preventing pulmonary embolism far exceed the risks related to filter placement in properly selected patients.

Asunto(s)

Filtros de Vena Cava/efectos adversos , Humanos , Embolia Pulmonar/prevención & control , Factores de Riesgo , Trombosis de la Vena/prevención & control

RESUMEN

The purpose of this study is to determine risk factors associated with mortality in surgical patients with vancomycin-resistant enterococcus (VRE) infections. The hospitalizations of surgical patients with VRE infections from January 1998 to December 2001 were reviewed. Statistical analysis was performed using the Student's t test, chi square, and Fisher's exact test. Thirty-one surgical patients (male:female, 14:17) with a mean age of 51.9 years (range, 21-83 years) developed VRE infection. Infections included bacteremia (12), urinary tract (11), surgical site (seven), and soft tissue (five) infections and intra-abdominal abscess (one). Nine (29.0 per cent) patients received recent outpatient antibiotics and 20 (64.5 per cent) were on steroids. Fifteen (48.4 per cent) patients were treated with intravenous vancomycin before infection. Twelve (38.1 per cent) patients died with a trend toward advanced age (60.7 vs 46.5 years; P = 0.06). The incidence of VRE infection in kidney transplant patients was 1.8 per cent. Six transplant patients (five kidney and one kidney/ pancreas) developed VRE infections with four deaths. Hypertension (P = 0.04), coronary artery disease (P = 0.02), and the need for intra-arterial pressure monitoring (P = 0.04) were associated with mortality. Isolate location, gender, diabetes, renal dysfunction, respiratory disease, liver disease, and serum albumin were not associated with mortality. Kidney transplant patients have a high incidence of VRE infection. Surgical patients with VRE infections have a high mortality rate. Hypertension and coronary artery disease are risk factors for mortality.

Asunto(s)

Enterococcus/efectos de los fármacos , Infecciones por Bacterias Grampositivas/epidemiología , Infección de la Herida Quirúrgica/epidemiología , Resistencia a la Vancomicina , Adulto , Anciano , Anciano de 80 o más Años , Enfermedades Cardiovasculares/epidemiología , Comorbilidad , Infección Hospitalaria/tratamiento farmacológico , Infección Hospitalaria/epidemiología , Femenino , Infecciones por Bacterias Grampositivas/tratamiento farmacológico , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Infección de la Herida Quirúrgica/tratamiento farmacológico , Resultado del Tratamiento , Población Urbana

RESUMEN

Laparoscopy has become the preferred method for nephrectomy in many medical centers. We compared our experience with hand-assisted laparoscopic nephrectomy (HALN) and standard laparoscopic nephrectomy (LN). Data were prospectively collected on 119 consecutive patients undergoing laparoscopic nephrectomy between August 2000 and November 2002. Outcomes were compared for LN versus HALN using Wilcoxon rank sum test for quantitative outcomes and Fisher exact test and chi2 for qualitative outcomes. Thirty-nine patients underwent LN: 16 live donor, 16 radical, and 7 simple nephrectomies. Eighty patients were treated with HALN: 47 live donor, 32 radical, and 1 simple nephrectomy. There were no differences in mean age (49.2 years LN vs. 47.7 years HALN, P = 0.60) or weight (192.2 lb LN, 179.2 lb HALN, P = 0.12). Mean tumor size (4.77 cm LN vs. 7.12 cm HALN, P = 0.07) and length of extraction incision (8.37 cm LN vs. 7.87 cm HALN, P = 0.08) were similar. Total hospital charges (19,352 dollars vs. 18,505 dollars, P = 0.29) and length of stay (3.68 days vs. 3.72 days, P = 0.15) were equivalent for LN and HALN. Average operative time for HALN was significantly shorter (202 minutes vs. 258 minutes, P = 0.0001), and blood loss was less for HALN (71.7 cc vs. 113.1 cc, P = 0.007). Wound complications rates were similar (6.5% HALN vs. 13% LN, P = 0.34), but overall morbidity rates were higher after LN (28.2% vs. 6.3%, P = 0.001). Compared with pure laparoscopic nephrectomy, the hand-assisted approach reduces operative time and blood loss without increasing total hospital charges or length of stay. In our patients, HALN was also associated with fewer postoperative complications than standard laparoscopic nephrectomy. Hand-assisted laparoscopy may allow for the performance of increasingly complex procedures while maintaining the benefits of minimally invasive surgery.

Asunto(s)

Laparoscopía/métodos , Pérdida de Sangre Quirúrgica/prevención & control , Femenino , Precios de Hospital , Humanos , Laparoscopía/economía , Tiempo de Internación , Masculino , Persona de Mediana Edad , Nefrectomía/economía , Nefrectomía/métodos , North Carolina , Complicaciones Posoperatorias , Estudios Prospectivos , Resultado del Tratamiento

RESUMEN

INTRODUCTION: The development of new energy sources for hemostasis has facilitated advanced laparoscopic procedures. Few studies, however, have documented the strength of the vessels sealed or the extent of surrounding lateral thermal injury, two important factors in maintaining hemostasis while preventing injury to surrounding structures. This study compared the burst pressure and extent of thermal injury of vessels sealed with the 5-mm laparoscopic PlasmaKinetics trade mark sealer (PK) (Gyrus Medical, Maple Grove, Minnesota) and the 5-mm laparoscopic LigaSure trade mark sealing device (LS) (Valleylab, Boulder, Colorado). METHODS: Arteries in three sizes (2-3 mm, 4-5 mm, and 6-7 mm) were harvested from domestic pigs. Eight to 17 specimens from each size were randomly sealed with the PK, and the same number with the LS. Burst pressures were measured in mm Hg. The extent of thermal injury, determined by coagulation necrosis, was measured microscopically in millimeters after staining the transected vessels with hematoxylin and eosin. Descriptive statistics, including means and standard deviations, are reported. Student's t-test and ANOVA were performed to determine significance (P <.05). RESULTS: The mean bursting pressures of the PK and the LS were equal in the 2-3 mm vessels (397 vs. 326 mm Hg, P =.49). The PK bursting pressures were significantly less than the LS in the 4-5 mm (389 vs. 573 mm Hg, P =.02) and the 6-7 mm groups (317 vs. 585 mm Hg, P =.0004). As vessel size increased, the PK was associated with significantly lower burst pressures, while the LS was associated with progressively higher burst pressures (P =.035). Thermal spread was not significantly different between the PK and the LS in the 2-3 mm (1.5 vs. 1.2 mm, P =.27), the 4-5 mm (2.4 vs. 2.4 mm, P =.79), or the 6-7 mm vessel size groups (3.2 vs. 2.5 mm, P =.32). Increasing vessel size, regardless of instrument used, was associated with increased thermal injury (P <.0001). CONCLUSION: The LS produces supraphysiologic seals with significantly higher bursting pressures than the PK in vessels ranging from 4 to 7 mm. The PK seals become progressively weaker while the LS seals increase in strength as the vessel size increases. Although thermal spread increases with vessel size, the degree of lateral thermal injury is no different between the two instruments.

Asunto(s)

Técnicas Hemostáticas/instrumentación , Laparoscopios , Laparoscopía , Procedimientos Quirúrgicos Vasculares/instrumentación , Animales , Arterias/anatomía & histología , Diseño de Equipo , Porcinos