RESUMEN
To examine, if case series considered together with observational studies tend to produce similar results as randomized-controlled trials (RCTs), on recurrent hernia repair. A systematic literature review and meta-analysis between 1990 and 2013 revealed 46 nonrandomized studies (NRCTs) and 5 RCTs including 25,730 patients. A direct comparison of the summary estimates between RCTs and NRCTs is presented. Outcomes, within or across studies, were compared. Comparisons of all outcomes in NRCTs and RCTs failed to show statistical significance. Prospective/retrospective cohort studies, case series, and RCTs did not differ significantly in their estimates. Adjusted testing for metaregression disclosed that rerecurrence among NRCTs was independent of the study design. The number of included patients and study setting were independent predictors of outcome. Our proposed methodology for a systematic review could potentially give answers where level I evidence is missing or could be a tool for optimization of a RCT design.
Asunto(s)
Hernia Inguinal/cirugía , Herniorrafia/métodos , Humanos , RecurrenciaRESUMEN
During the initial assessment of trauma patients they usually undergo a Focused Assessment with Sonography for Trauma (FAST) in which there are occasionally incidental findings of other surgical conditions. In this audit we discuss the incidence, demographics, and implications of these findings and we propose a management algorithm. Within 2 years we managed 6041 trauma patients in the emergency department based on the Advanced Trauma Life Support protocols, 95 per cent of which underwent a FAST ultrasound. Incidental findings were reported in 468 patients (7.8%), whereas in a further 11.2 per cent of these patients there was a second finding. The mean age of these patients was 57.55 years (15-105), and most of them were men (51.1%). The vast majority of the findings were related to the liver and biliary tree (52.1%) followed by the urinary track (27.1% + 8%). In multivariate analysis only the age was a significant factor associated with incidental findings (P < 0.001) whereas in univariate analysis both the gender [men (54.1%) vs women (45.9), P = 0.013] and the mechanism of trauma (P < 0.001) were as important as the age (P < 0.001). The patients who had incidental findings were 15 years older than the rest. The detection of unknown surgical conditions in FAST may lead to managerial and possible medico-legal issues rendering the development of a proper algorithm mandatory.
Asunto(s)
Hallazgos Incidentales , Heridas y Lesiones/diagnóstico por imagen , Heridas y Lesiones/epidemiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Algoritmos , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/epidemiología , Comorbilidad , Femenino , Enfermedades Urogenitales Femeninas/diagnóstico por imagen , Enfermedades Urogenitales Femeninas/epidemiología , Enfermedades Gastrointestinales/diagnóstico por imagen , Enfermedades Gastrointestinales/epidemiología , Humanos , Incidencia , Modelos Logísticos , Masculino , Enfermedades Urogenitales Masculinas/diagnóstico por imagen , Enfermedades Urogenitales Masculinas/epidemiología , Persona de Mediana Edad , Ultrasonografía , Enfermedades Urológicas/diagnóstico por imagen , Enfermedades Urológicas/epidemiología , Heridas y Lesiones/clasificación , Adulto JovenRESUMEN
BACKGROUND: The purpose of this study was to identify which age-related groups of hemodynamically stable blunt trauma patients will present a positive cost-to-benefit ratio, in regard to the screening of incidental findings on Focused Assessment with Sonography for Trauma (FAST). METHODS: We conducted a prospective study using retrospective data taken from the trauma registry of 6,041 consecutive hemodynamically stable blunt trauma patients who underwent FAST at our Level I urban trauma hospital during the year 2009. A receiver operating characteristic curve was used to determine whether age level is useful in detecting organ-/system-specific incidental findings in trauma patients undergoing FAST and to establish the required diagnostic cutoff value of this selected test. A cost-benefit analysis was then performed for the age-specific cutoff values of each organ/system evaluated by FAST. RESULTS: We found 522 incidental findings in 468 patients (7.8%). Further diagnostic workup was instructed in 35% (168 of 468) of patients with incidental findings. The cost-benefit analysis for the age-specific cutoff values found in the receiver operating characteristic curve analysis showed that the project of screening for incidental findings on FAST was viable only when the ultrasound operator additionally searches the liver/biliary tree (≥43 years) and the kidneys (≥56 years). CONCLUSIONS: A systematic examination of the liver and biliary tree and both kidneys of specific age groups during FAST screening of hemodynamically stable blunt trauma patients may disclose a potentially unknown pathology with a positive cost-to-benefit ratio.
Asunto(s)
Costos de la Atención en Salud , Hallazgos Incidentales , Ultrasonografía Doppler/economía , Heridas no Penetrantes/diagnóstico por imagen , Traumatismos Abdominales/diagnóstico por imagen , Traumatismos Abdominales/economía , Traumatismos Abdominales/cirugía , Adolescente , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Análisis Costo-Beneficio , Femenino , Grecia , Hemodinámica/fisiología , Humanos , Técnicas In Vitro , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Sistema de Registros , Medición de Riesgo , Estadísticas no Paramétricas , Resultado del Tratamiento , Ultrasonografía Doppler/métodos , Heridas no Penetrantes/economía , Heridas no Penetrantes/cirugía , Adulto JovenRESUMEN
The objective of this study is to assess transanal endoscopic microsurgery (TEM) as a surgical strategy for stage I rectal cancer. The literature lacks level I and level II evidence of the oncologic competence of TEM. Three randomized controlled, one prospective, and seven retrospective comparative studies were evaluated. End-points included perioperative outcomes, margin involvement, disease-free and overall survival, and recurrence. The number of patients with major (odds ratio (OR) = 0.24, 95% confidence interval (CI) 0.07-0.91) and overall postoperative complications (OR = 0.16, 95% CI 0.06-0.38) were significantly lower in TEM. The disease-free survival was higher in standard resection (SR) group compared with TEM (OR = 0.46, 95% CI 0.24-0.88). The number of patients with positive margins were less in the SR group (OR = 6.49, 95% CI 1.49-24.91), which was associated with lower local recurrence (OR = 4.92, 95% CI 1.81-13.41) and overall recurrence rate (OR = 2.03, 95% CI 1.15-3.57). No survival advantage was observed in favor of either procedure. TEM had lower rate of positive margins and longer disease-free survival when compared with transanal excision (TAE). TEM seems to be superior to SR concerning morbidity whilst less effective in obtaining negative surgical margins, and it is associated with higher local and overall recurrence. No survival advantage was observed in favor of either procedure. Unfavorable tumor preoperative histology does not seem to influence the selection between TEM and SR. TEM is more effective than TAE in obtaining negative surgical margins and shows a greater disease-free survival.
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Neoplasias del Recto/cirugía , Canal Anal/cirugía , Supervivencia sin Enfermedad , Humanos , Microcirugia/métodos , Recurrencia Local de Neoplasia/epidemiología , Estadificación de Neoplasias , Oportunidad Relativa , Neoplasias del Recto/mortalidad , Neoplasias del Recto/patología , Análisis de Regresión , Resultado del TratamientoRESUMEN
This prospective randomized study aimed to evaluate the impact of hernia sac laparoscopy on the morbidity and mortality in cases with a spontaneous reduction of the strangulated hernia content before the assessment of its viability. Ninety-five patients underwent operation owing to incarcerated hernia. Forty-one patients, whose strangulated indirect inguinal hernia spontaneously reduced before the viability of the content was assessed, were included in this study. They were randomly assigned to 2 groups: group A (21 patients managed using hernia sac laparoscopy) and group B (20 patients managed without laparoscopy). The median hospital stay was 28 hours for group A and 34 hours for group B. Four patients of group B had major complications whereas there was none observed in the group A. Two unnecessary laparotomies and 2 deaths occurred in group B. Hernia sac laparoscopy seems to be an accurate and safe method allowing to prevent unnecessary laparotomy and especially in high-risk patients it contributes to decrease major morbidity.